Transcript has been lightly edited for clarity and readability.
Kerry Whittemore: Welcome to M.ED: Medical Education for the Practicing Clinician. I'm your host, Dr. Kerry Whittemore, a pediatrician with the University of Utah Health. And this podcast is brought to you by The University of Utah, School of Medicine. The theme of today's episode is adult learning theory and how it applies to teaching medical students in residence.
With us today, is Dr. Kathleen Timme. Dr. Timme, is a pediatric endocrinologist at the University of Utah, and Primary Children's Hospital, as well as the Director of Educational Development for graduate medical education, and the Associate Program Director for fellow education and the pediatric education enterprise at the University of Utah. Dr. Timme also has her own podcast, entitled Teaching in Medicine, that you should all check out.
KW: Welcome, Dr. Timme. Why don't you tell me a little bit about your background and how you became interested in medical education?
Kathleen Timme: Thanks so much for having me on today. I'm originally from Buffalo, New York, I attended medical school there as well, and then afterwards I went to Yale for Pediatric Residency and stayed there for endocrine fellowship. I moved to the University of Utah after completing fellowship, and I've been here for about two years.
My interest in medical education really started in residency, having residents or having interns and medical students on the team and being able to teach them, was always sort of my favorite part of the clinical day. I really gravitated towards sharing the knowledge that I was finally obtaining. And then within our program, a couple of opportunities came up, so I sat on a faculty subcommittee for the LCME review. I really got to know some of the leaders in medical education at my former institution, and took on a couple other roles from there, and really loved the idea of, "How do we plan to teach graduate medical learners?" And so during fellowship, I decided to focus my scholarly project on a program called Fellows as Medical Educators, which was a curriculum for pediatric sub-specialty fellows to improve their teaching skills. It was really through that, that I got into curriculum development and became really enthusiastic about how we teach people how to teach.
And during fellowship is also when I started my Master's of Education, which I hope to finish up next year.
KW: When I think of adult learning theory, I think of adults learning, instead of kids. Do you want to tell us a little bit more about what adult learning theory actually is and how it applies to medical education?
What is adult learning theory and how does it apply to medical education?
KT: We often think of pedagogy, which is the practice of teaching in general. Andragogy is the practice of teaching adult learners. The whole premise is that teaching adults is very different from teaching primary and secondary education learners. In adults, one of the main things to keep in mind is that they come with their own experiences, they come with their own preferences for how they like to learn, and their own bubble of baseline knowledge, and all of that has to really be respected and taken into account when teaching them. Adult learning theory in general is recognizing the adult as a unique type of learner that needs to be approached in a different way than you would approach a child learner.
KW: One thing I found as a resident and now as an attending is, no one really taught me how to teach adults. In your experience in both residency and fellowship, do you feel like you were equipped with how to teach people who were also adults?
KT: I think in general, in the medical training system, we don't do the best job at teaching each other how to teach. Oftentimes, we learn based on experiences in our own education that went well, trying to emulate our best mentors, our best preceptors, and then also looking at those negative examples and thinking about, "Well, I didn't really like that teaching experience. This is how I would do things differently." Fortunately, a lot of programs are now having more formalized opportunities for residents and even for students to develop teaching skills early on, which I think is really important. For me, it was just a lot of mentorship and figuring out what worked well, what didn't work well, then also being very reflective about my own experiences and thinking about, “This was a really thoughtful approach in how this attending taught me this part of a physical exam," so maybe I would start to teach in that way as well.
KW: So, in medicine, more informal learning on how to be a teacher, versus a formal program, which hopefully, we're starting to do more of now?
KT: Yes, and with the Master's of Education, I've started to think about it more as a formal process.
KW: Why don't you tell us a little bit about the program you're hoping to do for the medical students doing rotations in the State of Utah?
How do we help trainees learn more effectively?
KT: When I first came to the University of Utah, I was working with the students as teachers program as co-director, which was an early experience for first and second year students, to help them gain those valuable teaching skills early on in their training and then have the opportunity to practice them later on.
In our current environment and with Gen Y and Gen Z learners, there's definitely more of a focus on bringing technology into curricula, and so I had this idea to start a completely online, asynchronous trainee as teacher program, and really make it broad so that it could be useful for student learners, for resident or fellow learners.
I've been discussing with the RUUTE team, and hopefully with other audiences as well, developing an online trainee as teacher program. The current vision is four online modules that they would complete, and these would include podcast episodes, videos to watch, and that's based on a needs assessment and student feedback as to how they like to receive their learning. I think it would be more effective than a Zoom lecture or an article to read, they really like on-demand, more technologically savvy modalities of education.
What does the program cover?
The four modules are quick clinical teaching, teaching at the bedside, learning how to teach other team members, and how to teach students. Another module would be focused on teaching patients, and then the next module would be on principles of adult learning and finally, how to give effective feedback. I'd also like to build in some experiential encounters, so having the students or the trainees teach a patient and obtain some feedback from that experience and also having them teach their preceptor and any other learners who are in their clinical setting, and then really just have some reflection and some feedback after those encounters. They start with the modules, get a basic foundation in teaching, and then they practice through the experiential encounters. And then to wrap things up, they would do a reflective written assignment just to kind of tie in everything that they learned and give an opportunity for me as a course director, to provide some direct feedback on their learning.
KW: Cool, that sounds really interesting. For those of us who don't know, and I didn't know this until about six months ago, what exactly is asynchronous learning?
What is asynchronous learning?
KT: Unlike in-person learning where you're all doing the work together at the same time, asynchronous learning means that you engage with the content on your own schedule. For example, a video taped lecture or podcast or whatever that educational material is, can behoused somewhere, such as a learning management system, and then the learner can access it at any time that's convenient for them. The teaching and the learning don't necessarily have to take place with the teacher and the learner in the same room, at the same time. So a lot of online programs are asynchronous.
KW: Is that tied at all into adult learning theory and how that differs from children?
KT: I think it's very respectful to the needs and interests of adult learners. Adult learners often have their own life outside of education, and whether that's family responsibilities that they have or just variations in work schedule, that asynchronous approach really allows people to access learning when it's convenient for them.
Also with adult learning theory, adults come to the table with a readiness to learn, to achieve a specific end. With the online program, I hope to have very relevant topics, and this is all based on student and resident feedback of what they would like to learn, and I think that's something really important to keep in mind with adults: learning has to be tailored to what they need to accomplish right now. And so giving them the skills to teach effectively to interact with patients, those will all have very immediate rewards and they should be motivated to obtain those skills.
KW: When I was preparing for this, I was thinking about the different types of adult learning theory, so I just thought it really meant that adults learn different than kids and as you've given us some examples, it's definitely true. Do you want to tell us a little bit more about the different adult learning theories, and if there are any in particular that you think apply to medical student education more so than others?
Are there adult learning theories that apply to medical education more so than others?
KT: I think when we talk about adult learning theory, the main person that comes to mind is Malcolm Knowles, and he's really one of the masterminds behind andragogy. Knowles identifies six assumptions of adult learners:
- Self-concept. Your learners are capable, they're self-directed and they kind of have their own set of beliefs about who they are and what they want to accomplish.
- Experience. Adult learners come with past learning experiences. They may already have teaching experience, clinical experience, etc. Meeting your learner where they're at, and tailoring your instruction to their needs is really important. It acknowledges that every adult learner is a unique individual.
- Readiness to learn. Adults also come with a readiness to learn, so they're really eager to learn what they need to do in order to achieve X, Y and Z.
- Orientation to learning. If we think back to residency, we were very eager to learn pediatrics because we knew, in just a few short years with would be pediatricians and would absolutely need to know this information, so we were ready to learn it. And then they also have practical reasons for learning, so even outside of medicine, learning turns to problem-solving. If your car isn't working and you're trying to do some troubleshooting, you may watch a YouTube video or try to learn something because it has a practical, immediate application.
- Motivation to learn. Adults are also internally motivated, so they are often motivated for maybe a new job or more opportunities, and so if you think about an elementary school learner who maybe doesn't love math and still goes to math class and goes through the day, adult learners are usually very motivated for the topic that they're learning about.
- The "Why." The final assumption is that adults need to know why. I think this is very important with medical student learners in particular to highlight why what you're teaching them is relevant. Especially if you're in a specialty that the student doesn't think they're going into, they might not really realize why what you're teaching them is important. But as we all know, it's important to be a well-rounded physician. And so if I have somebody with me in clinic, in pediatrics who I know, for example, wants to go into surgery, maybe I would highlight some of the aspects of the physical exam or patient presentations that might be relevant for somebody going into that field, down the line. Really highlighting why what you're doing is important will allow your learner to tune in a little bit more strongly.
Malcom Knowles is the main theorist that I think of. With adult learning theory.
KW: And I can think of maybe with that student, if you have a poorly controlled diabetic, their wound from surgery isn't going to heal as well, or something like that.
KT: Exactly. You have to find those little pearls to keep it relevant for that learner.
KW: And do you think it differs when you're interacting with a medical student, versus a resident or a nursing student, or in what way, or do you think it's all kind of the same, because they're all adults?
Are there differences between disciplines?
KT: I think the general approach should be similar and not assuming what past experiences are and really taking the time to get to know your learner and say, "We're going to see a patient with diabetes today. Have you ever seen a patient with diabetes before. What do you know about diabetes?" For all we know, the student might have diabetes and you would have a very different conversation based on what their own past experiences are.
I think the one big difference as you sort of move up the chain in medical education, so moving from student, to resident, to fellow, to a junior attending, is that you become a little bit more differentiated and a little more specialized. So when a medical student is in clinic, it's even more important to highlight the relevance and importance of what you're doing and why they're learning it, whereas if I have a pediatric resident with me in clinic, they more immediately see the relevance of what they're doing.
I spend a little bit less time obtaining buy-in for the educational experience. But yes, I think all of those principles are important for any adult learner, whether it's medical student or resident, just really meeting them where they're at, valuing that they come to the table with their own experiences, and highlighting the reason why you're teaching them what you're teaching.
KW: And since you've gotten feedback from students, and I'm guessing residents, throughout your fellowship here, and then also to back in Yale, what do you think people have told you about what's worked and what hasn't worked, in terms of their experiences as a learner?
KT: In terms of a clinical teaching?
Making it personal is paramount.
KT: I think people just value when you take the time to learn about them and to learn about their interests. Even just taking two minutes before clinic to tell them a little bit about yourself, try to figure out what they're interested in, and then tailoring the experience to their needs, I think people really appreciate that. And then taking those couple extra minutes, a little bit of extra time to explain what you're doing and give them the opportunity to ask questions and provide feedback. Even if you're really busy, I think you could, sometimes I'll do this with resident notes is, if I notice maybe something in the assessment or plan showed that there was a lack of, maybe I didn't explain things clearly, or there was an opportunity for more teaching there, you can always email or follow up with the learner later on, and I think it's just about doing that little bit of extra effort that goes a long way.
KW: And many physicians and hopefully, some of the people who are listening to this podcast don't work in an academic setting and they don't have time built into their schedule, for teaching, but yet they have learners in their practice. What are some quick pearls or take home points that busy clinicians working with adult learners can use, to better teach students?
What are some quick tips busy clinician educators can use to better teach students?
KT: It can be really difficult when you have a full clinic schedule and patients every 15, 20 minutes, and then you've got two learners by your side and trying to figure out how to juggle it all. There are some approaches.
One is called the One-Minute Preceptor. There's five steps to One-Minute Preceptor. One, is getting a commitment. After a learner maybe sees a patient and is presenting to you, just pick one aspect of their presentation and ask a question about it and have them commit to an answer. Whether that's, "What medication would you use to treat this patient?" The next step is to probe for supporting evidence. For example, follow that up with, "Why do you think that's a plan?" And then you teach a quick general principle, so you could say, "Yes, that's the right choice. This antibiotic class works for these reasons." And then the last two steps are reinforcing what was done well and correcting any mistakes, and that whole encounter can take 60 seconds and really provide them with one quick clinical teaching pearl.
My advice would be, if somebody saw a patient, for example, with asthma, you don't need to teach them everything you've ever learned about asthma, but maybe just focus on one small aspect of asthma care or a physical exam, and just take that one tiny pearl and highlight it. And then the next patient you see with asthma, you'll highlight a different pearl, so you don't necessarily need to sit down for a half hour.
I think there's also a lot of power in observation, which is one of the things I feel like we don't have a whole lot of time for, but even if you're with a learner for the first time, taking two minutes to watch a physical exam or a couple of minutes to listen to how they introduce themselves to the family, how they start obtaining a history, can give you a little bit of a sense of their baseline and then opportunities for giving direct feedback later on. So I would just focus on these things that you can do in one or two minutes, and then I'd say the follow-up email after clinic, I think is very valuable.
If I had a very busy clinic day, and I felt like I didn't get a whole lot of teaching in, sometimes I'll just send out, "These are the guidelines for hypothyroidism management," and just email it to them, so at least they have something that they can take away from the experience. But I agree, it's very hard.
KW: Yes, and not just in an non-academic setting. Within academics, it's hard too, for everyone, basically. That's a good idea about watching them at the beginning, and I probably don't do that enough. One thing that I find challenging is, you mentioned having more than one learner at the same time, especially if they're at different levels. How do you go about clinic if you have a fellow and a resident and a medical student, all there? Do you have them work together and see the same patients, or see separate patients, or how do you guys do that? Or does it depend on the attending?
How do you manage multiple learners at one time in the clinical practice setting?
KT: I really think it depends on the attending. Sometimes, if I have a more senior learner, like a resident or a fellow, and a more junior learner, like a medical student, especially in their first few days rotating with us, I might have the student sort of shadow of the resident, see how they obtain a history and physical before I divide them up to do their own things. If clinic is busy enough, I will then often try to split them up and have a student see one patient, a resident see another patient, or maybe a resident with a patient and I'm talking to the student about, "Okay, this is what I'm going to be listening for in the presentation. We're going to do the thyroid exam together." I think there's a lot of ways to integrate two people.
Even the little things are a learning opportunity.
And then really, anything that you're doing in your clinical day is a learning opportunity, so even if you're going on up-to-date and you're trying to remember what's the appropriate dose of this medication, and you have somebody sitting next to you, you always say, "Hey, this is how I look up medication dosing, this is where I find this information." So even things that don't necessarily seem like true clinical learning, really anything that you're doing during those clinic hours, is an opportunity to show somebody how to do it.
KW: Right. And even to show them how you write a note, because as you know, we spend lots of time in front of a computer, and I feel like we don't necessarily learn that as well, as a medical student, as maybe we should too.
KT: Yeah, there's a lot to be said about learning efficiency in an EMR, that is probably just as important of a survival skill as some of our clinical teaching.
KW: Absolutely. I remember, as a resident, learning how to teach medical students was kind of empowering, because you realize that you actually know something and that you can impart knowledge to another learner. What are you doing with the residents in education, at the University of Utah, to help with that?
What is currently available at U of U Health?
KT: Here at the University of Utah, we have over 900 residents and fellows. So while it would be great to offer one centralized resident as teacher program, it's not really feasible or realistic. So what I'm doing is helping support all the individual resident as teacher efforts.
What we're aiming to do is create a repository of information that individual programs can pull from. We have articles on a learning platform called Accelerate, which are really quick lessons that clinician educators can go through, that hopefully help them with their teaching skills. I also have the podcast, so we're going to have a series this fall, specifically focused on different teaching skills and how to build those up, and hopefully, those will be relevant for resident as teacher programs. And then I'd like to start a resident as teacher workshop series. So maybe a couple of times a year, having interested residents get together and focus on a specific clinical teaching topic, and fortunately, Zoom will allow us to have many learners access these opportunities.
And then I do provide some consultations to individual programs, trying to think about what they might want to do differently with their resident as teacher programs, and work with them one-on-one, to help build a program that meets their specific needs. We also spend time thinking about how you might assess the impact of a curriculum, to contribute to their educational scholarship, and also make sure that they're building curriculum that's useful, that they can continue to iterate and improve.
KW: Is that more for residents how to teach medical students, or how to teach patients and their families, or both?
What about teaching patients?
KT: So both. It's a little more focused on teaching students or senior residents teaching interns, peer teaching, but I think that teaching patients is also a really important skill, so we do have some activities built around that.
KW: And do you find, as being a pediatric specialist, do the adult learning theories come in to play at all in how you teach parents, versus the kid with diabetes? I don't really think about that, to be honest, when I'm working with families. But your diseases are so specialized and kind of complex, I think that maybe that would be applicable to you.
KT: Yes, definitely. For kids newly diagnosed with diabetes, they spend two plus days with us in the hospital, just focused on diabetes education. I've definitely revamped how I approached that teaching, over time, and a lot of it has been informed by adult learning theory. I made plenty of mistakes early on when explaining what is glucose and what is insulin, and just getting very granular and basic, and then you take the time to get to know the family and find out the parents are microbiologists with PhDs and they already know this stuff like the back of their hands. Just recognizing that everyone is unique and their baseline knowledge is different. Now I always start the conversation with, "What do you already know about diabetes?" and then try to meet them where they're at, without assuming anything.
KT: I think a lot of it is experiential learning, and that's how we've built our diabetes education program. So most of their education actually happens with the nurse at the bedside, hands-on practice with using a glucometer, how to drop insulin, how to give insulin, working with the pharmacist on holding a glucagon kit, how would you use that. And so it's a lot of practice and repetition, which also aligns with how adults learn best.
KW: Anything else you think we should know about adult learning, today?
KT: I would just say get to know your learner and really highlight why what your teaching is relevant to them and I think those are the best things you can do for adult learners.
KW: Awesome. Well, thanks for joining us today. We really appreciate it, Dr. Timme.
KT: Thank you so much for having me.