Just Because I Am Teaching Doesn’t Mean They Are Learning: Improving Our Teaching for a New Generation of Learners

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The first thing I noticed when I walked into our conference room was that half the residents who were supposed to be attending our small-group session were missing. “Anyone know where the rest of our group is?” I asked.
“Bridget and Tom had to work,” explained Micah, one of the second-year residents. (The names of all the residents have been changed.) “The schedule has changed and we need to start our shift at 2:00 instead of 3:00. Maria’s in the ICU and can’t leave for conference. Ed was on last night and had to go home to sleep; he wanted me to record the session. Is that okay?” I knew about the resident duty hours restrictions and supported the need for residents to get adequate sleep. And I agreed with taping our sessions to make them available for those who could not attend. Nonetheless, it was frustrating to prepare a session for the residents and then not have half of them attend. Although I had heard about the need for more resident coverage to improve our clinical services, I had thought that our conference time would be protected.
“Okay, sure, we can record the session. Has everyone read the article I sent out last week?” I got some awkward stares. “Did you all receive it?”
“Yes,” said Micah, “but I haven’t had time to read it yet.”
“How about the rest of you?” There was silence, which I interpreted as a negative response. “All right. Well, the article is not too long. Why don’t you pull it up now on your computers and read through it for the next 10 minutes? That way, we can all be on the same page when we’re discussing the case.” I had recently written an article about systems-based practice1 with a resident case from our institution, and since that was the topic for today, I thought the residents would appreciate the timeliness of the article and how I had organized the literature around the case.
As I sat and watched the residents reading I began to feel my enthusiasm ebb. The small-group session was part of a course I had been teaching for many years. The course included many topics that I feel are critically important for a resident physician, topics often neglected in the resident curriculum, like professionalism, medical error, health policy, malpractice, wellness, and narrative medicine. All these areas now connect to various core competencies that all residents are expected to attain by graduation, but they are difficult to teach, assess, and test. A case-based discussion was one of the ways I could usually tell whether residents understood how to approach problems in the health care system. I had looked forward to the energy of an engaged and motivated group in the discussion. And yet … I sensed that they did not share my enthusiasm. I knew these residents well from working with them clinically. They were all excellent clinicians, motivated to learn and succeed. None of them was lazy or irresponsible. So what was the problem?
While the residents read my article, and also after the session was over, I scanned some of the medical literature to find out whether I needed a different educational approach and what the literature might tell me about current challenges to teaching. The first article I came across was by Pratt et al.2 They described five alternative perspectives on good teaching: transmission, developmental, apprenticeship, nurturing, and social reform. Each perspective had a set of concepts about learning and methods for reaching the learning goals.
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