1. Teaching Medical Students in the Community Practice Setting: Applying Teaching and Learning Styles
An orientation module developed by the
Office of Regional Medical Education
The University of Texas Medical Branch
School of Medicine
The University of Texas Medical Branch at Galveston (UTMB) is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education to physicians.
The University of Texas Medical Branch at Galveston designates this educational activity for a maximum of two (2) AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with extent of their participation in the activity.
This module on applying teaching and learning styles in the community practice setting is designed for physicians who teach medical students in their practice. Click on the arrow button at the bottom left of each slide to progress to the next slide. Some slides will contain links to downloadable documents. Upon completion of the module please complete and submit the post assessment quiz and module evaluation to the UTMB Office of Regional Medical Education.
Estimated Study Time: 2 hours Medium Used: CD and web-based access
Click on this button to advance to the next slide 
Version 1.0
Original Release Date November 1, Expiration Date July 1, 2010

2. Teaching and Learning Styles Goals
Identify teaching and learning styles and methods as appropriate to medical student education.
Apply effective teaching methods in the community practice setting.
Upon completion of this module participants will be able to identify teaching and learning styles and methods as appropriate to medical student education and apply effective teaching methods in the community practice setting.

3. Speaker
Ingrid Bowden, M.Ed., R.N. is the administrative manager for the East Texas Area Health Education Center (AHEC) at UTMB.  She has over 12 years experience in recruiting community preceptors and coordinating the placement of medical students in community rotations throughout East Texas AHEC’s 111-county region.  Ms. Bowden serves on the UTMB School of Medicine Ambulatory Community Selective Committee, and manages all activities associated with the Public Health ACS.  She is also a member of the UTMB School of Medicine’s Community Faculty Development Coordinating Committee.
In accordance with the Accreditation Council for Continuing Medical Education (ACCME) standards and the policy of the University of Texas Medical Branch at Galveston, presenters are asked to indicate if they have any relationship which, in the context of their presentation, could be perceived as a real or apparent conflict of interest, (for example, ownership of stock, honoraria, or consulting fees). Any such relationship will be disclosed to the audience and consideration will be given to possible influences of their presentations. Dr. Michael Ainsworth has no relevant financial relationships with any commercial interest to the provider (UTMB).

4. Teaching and Learning Styles Objectives
Identify student learning styles and describe how to apply them in the community practice setting.
Identify teaching styles and methods appropriate for teaching medical students in the community practice setting.
Apply appropriate teaching methods for medical students in the community practice setting.
The module is divided into 3 sections. The first section contains information on adult learning styles. Teaching styles and methods appropriate for medical students in the practice setting will be discussed in the second section. The third section will address applying appropriate teaching styles and methods when teaching medical students in your practice.

5. Learning Styles Student roles and behaviors Types of learners
Learning components
Principles of adult learning
For learning styles we will look at 4 areas: roles and behaviors that students may exhibit; the different types of learners; the three components of learning, and the principles of adult learning.

6. Roles and Behaviors Compliant student Anxious-dependent student
Independent student
Sniper student
Let’s take a look at some roles and behaviors that students may exhibit.
Compliant students are typically good learners who work hard, are task oriented, show little emotional turmoil, and are primarily concerned with understanding the material and complying with teacher requests and course requirements.
Anxious students are more dependent on the teacher for knowledge and support and show concern for their evaluation. Feelings of anxiety and incompetence may block these students from actively learning and make them more concerned about grades than actual learning. These students can be difficult to engage in discussion.
Independent students are confident and unthreatened by the teacher. They favor peer relationships with the teacher and approach the material calmly, objectively, and often creatively.
Sniper students are generally uninvolved due to a low level of self-esteem and high level of pessimism concerning their ability to form productive relationships with authority figures. They can be hostile or elusive when confronted with a particular issue. They tend to complain and make excuses about mediocre efforts and performance.
Teachers should identify what behavior or behaviors that each individual student exhibits and modify teaching activities accordingly.

7. Learning Styles Inventory
Types of Learners
Visual learners
Auditory learners
Kinesthetic learners
Individual students may differ significantly in their preferred learning styles. Some students are highly visual and learn best from written or graphic presentations. Others are auditory learners who absorb information most easily when they hear it. A third group, called kinesthetic learners, prefers active learning with their hands and bodies. Many students are good at learning in multiple styles and may benefit most from a combination of several teaching approaches.
Identifying learning characteristics serves as a relatively stable indicator of how learners perceive, interact with, and respond to the learning environment. When a student first arrives at your practice, you may find it helpful to give them a quick one-page learning styles inventory to identify individual students’ learning characteristics. Click on the link to download, save, and print the learning styles inventory.
Learning Styles Inventory

8. Learning Components Cognitive ~ what the student should learn
Affective ~ motivate the student to learn
Metacognitive ~ how to learn, identify and correct areas of deficit
Next let’s take a look at 3 learning components.
Guidance in the cognitive component of learning will help the students identify learning goals and find relevant information. The teacher’s capacity to reflect on his or her own approach to clinical practice will enhance the student’s cognitive learning component. Mature independent learners are capable of self regulation supported by teachers who know how to facilitate and reinforce learning.
A motivating factor for students to learn is by demonstrating the relevance of the basic sciences in dealing with clinical problems. Constructive feedback and reinforcement are important motivational tools, as students strive to emulate their teachers.
For the metacognitive component students should recognize their own thinking and learning strategies to develop and organize a knowledge base. Metacognition can be assessed and facilitated by good quality feedback and by encouraging reflection. With the teacher’s guidance, students should be able to identify areas of deficit and correct them efficiently. Learners should be able to identify and select the learning media that works best for them.

9. Principles of Adult Learning
Apply what is learned shortly after learning it.
Emphasize learning concepts and principles over facts.
Students participate in setting own learning objectives.
Students use feedback to evaluate their own performance.
Adult learners are most willing to learn if they are given an active, creative role in the learning process. They respond best to self-directed learning methods. In general, adult learners prefer applied learning which has immediate relevance to real world tasks. As a teacher of adult learners, your efficacy will be enhanced by your ability to use facilitative techniques of instruction, serving as a mentor rather than a director of your students’ learning.

10. Teaching Methods in the Community Practice Setting
Teacher-centered and learner-centered instruction
Communication
Attentive silence
Cooperative negotiation
Persuasive confrontation
Levels of competency
In this next section we will examine teacher-centered versus learner-centered instruction, communication strategies, and teaching appropriate to individual students’ level of competency.

11. Teacher-Centered and Learner-Centered Instruction
Teacher-Centered ~ Topics are broken down into units of instruction. Emphasis is on the accumulation of facts.
Learner-Centered ~ Students answer their own questions and solve their own problems. Emphasis is on application of knowledge and skills.
In the traditional teacher-centered instruction the teacher has an active role in presenting information to students. Students accumulate facts in a passive manner. Through repetition and reinforcement, students learn the correct answers to questions. Students progress through units of instruction until they learn the whole subject.
The notion that adults should be responsible for their own learning has led to an approach known as learner-centered instruction. With the teacher serving as the facilitator, students answer their own questions and solve their own problems. In the clinical setting, learner-centered instruction emphasizes the application of knowledge and skills learned.

12. Communication Strategies
Attentive silence
Cooperative negotiation
Persuasive confrontation
Depending on the teaching activities at hand and the student’s level of performance, teachers should select from 3 different communication strategies when interacting with students. Each of these strategies will be discussed further in the slides to follow.

13. Attentive Silence Silence Observation Purposeful eye contact Tracking
Open-ended encouragement & advocacy
Surface paraphrasing & exploration
By remaining silent when the learner pauses, a teacher can communicate that he/she understands what the learner has said. The silence provides the student time to think and to continue to talk. The teacher should indicate attentiveness through non-verbal behavior such as nodding.
Observation is important because nonverbal messages frequently differ from verbal statements. The degree of congruence of discrepancy between the two can give further clues about the learner’s emotional and cognitive states. Observing behaviors and non-verbal cues can help plan further teaching.
The teacher who uses purposeful eye contact is silent and attentive while purposefully staring at the learner. The teacher may want to indicate receptivity to what the learner is saying, suspicion or concern about what was just said, or encouragement if the learner wishes to reveal something important. Because this technique may make some learners uncomfortable it should be used infrequently.
Tracking consists of using noncommittal words or nonverbal messages such as nods and grunts to convey interest and keep the person talking. By saying “I see” or “OK” the teacher can communicate that he or she understands, or approves of, what the learner is saying or doing.
General supportive statements build rapport, create a reservoir of goodwill, and encourage the learner to work harder and learn more. Restating or reflecting a learner’s thought shows understanding and encouragement.
Surface paraphrasing and exploration is used when the teacher wants the student to delve deeper without the teacher taking a major negotiating position or requesting in-depth discussions.

14. Cooperative Negotiation
Self-disclosure
Active listening
Intense paraphrasing
Open-ended questioning
Feedback
Negotiation between teacher and learner suggests the coming together of equals in which the teacher and learner each have needs and expectations that are worthy and require negotiation if discrepant. One of the easiest techniques with which to effectively deal with learners as equals is for the teacher to disclose personal information such as feelings, professional attitudes, past experiences, and mistakes.
Active listening is a more dynamic probing whose purpose is clarification, expansion, justification, and correlation. The teacher uses something the learner has just said or done as a starting point and with mild questioning attempts to expand the learner’s thinking.
As opposed to surface paraphrasing, intense paraphrasing suggests that the intent is more aggressive or assertive, that the purpose is more defined, and that the desired response or information is more specific.
Open-ended questioning may seem a less confrontational or assertive technique than intense paraphrasing, but actually is more stimulating.
When using open-ended questions, the teacher usually wishes to expand the learner’s thinking rather than narrow it to one or a few choices or ideas.
Feedback is the process of giving learners information about current performance so that they may improve in the future. Keep in mind that feedback should be descriptive, specific, appropriately timed.

15. Persuasive Confrontation
Summarizing & interpreting
Information giving & prescribing
Critiquing, correcting, & closed questioning
Persuasion, challenge & confrontation.
Summarizing and interpreting are the least confrontational of this last set of behaviors. It can be an effective way to close a stimulating discussion.
When providing information to the student, consider the following:
Give the most important facts first.
Stress the importance of instructions or information to the learner’s needs.
Avoid jargon.
Relate information clearly to the problem at hand.
Use repetition for emphasis.
Make instructions specific, behavioral, and measurable.
Present alternately acceptable treatments or procedures.
Giving feedback is a type of formative evaluation used for the purpose of improving future performance, while critiquing and correcting the learner and asking closed questions to elicit short answers is a type of summative evaluation that is primarily a judgment of competence.
Persuasion, challenge, and confrontation are useful where learners are intransigent in learning new knowledge, attitudes, or skills; seem resistant or unmotivated; or have ineffective learning habits.
Click on the link on the slide to download examples of the three types of communication strategies that have been discussed.
Communication Strategies

16. Competency Levels 1. Unconsciously Incompetent Introductory Phase
“See one.”
2. Consciously Incompetent
Practice Phase
“Do one.”
3. Consciously Competent
Learners progress through four levels of sophistication as they learn new skills. Teachers must be aware of the level of sophistication at which a learner is currently functioning and match their teaching to that level. Most learners start at level 1, where they do not even know what they do not know. Most teachers are at level 4, where they can “do it in their sleep”. As an example, in teaching a junior medical student (who is unconsciously incompetent) how to draw a venous blood specimen, the teacher would first make the learner aware of the technique’s existence, the equipment required, and the indications and contraindications. The learner would then know what he does not know and be consciously incompetent. After demonstration and practice the student learns to perform the procedure correctly, albeit with hesitation, and moves to the consciously competent level. Then after numerous correct performances, anxiety decreases and the learner becomes unconsciously incompetent. In moving from level 1 to level 4, the learner moves through 3 phases which are discussed in the slides to follow.
Perfecting Phase
“Do one more.”
4. Unconsciously Competent

17. Introductory Phase 5 Steps
State objective of skill
Explain rationale
Describe equipment, materials, and skills needed
Explain sequential steps
Demonstrate entire skill
Students will primary observe as the physician progresses through 5 steps in the introductory phase.
State the objective of the skill teaching about to be done and the specific performance that is expected at the conclusion of teaching.
Explain the rationale and importance of the skill
Present a description of the necessary equipment and materials, and an overview of the skill’s basic sequential steps.
Explain how each sequential step is done.
Demonstrate the entire skill step by step.

18. Practice Phase Give specific instructions Close observation
Generous feedback
Allow independent practice time
“Certify” student on the skill
As the learner progresses to level 2, consciously incompetent, proceed with the practice phase.
Give specific instructions on what to practice and how.
Observe and practice closely and give frequent brief promptings about how the student is doing.
Provide generous quantities of feedback. Solicit self evaluation from the student and feedback from peers if appropriate.
Allow a period of independent practice time.
Observe the student performing the entire skill.

19. Perfecting Phase Provide precision practice Give feedback infrequently
In the perfecting phase opportunities for practice under realistic stress situations should be provided. Provide feedback less frequently as the student perfects his or her skills. Click on the link to download examples of statements that can be made in each of the 12 steps.
Competency Levels

20. Learning Vector Diagram
Independence
Dependence
assisting
monitoring
TEACHER’S STRATEGIES
supervising
This diagram demonstrates the sequence that teachers may use with their students.
Demonstrate the skill, providing the learner an opportunity to observe an “expert in action.” The student is in a passive role.
Supervise the learner, who is now given the opportunity to practice the skill under the teacher’s watchful eye. The learner is more actively engaged, but still highly dependent.
Monitor the learner by allowing him or her to perform the skill with as little interference from you as possible. This is known as “performance on a leash”.
Assist the learner in perfecting the skill. Allow the student to work independently while still remaining available.
demonstrating
Performance on a leash
Performance with a parachute
observation
practice
Low
LEARNER’S COMPETENCE
High

21. Applying Teaching Methods
Teaching action plan to monitor and facilitate progress
Learning objectives for students in the community practice setting
Pearls for effective teaching
In this final section we will discuss applying various teaching methods as appropriate for the type and clinical experience of the learner in the community practice setting. Individualized student action plans, objectives for the learner in your practice, and some tips for effective teaching.

22. Action Plan Pre clinic assignments Assign specific patients
Formal and informal feedback
Plan for achieving course objectives.
When the student first begins the rotation develop a mutually agreed upon action plan and timeline for the student while learning in your practice.
Prior to having the student see patients in the clinic, provide the student research and reading assignments relevant to the patients and clinical problems that will be seen in the clinic.
When in the clinic, assign patients for the students to assess, provide appropriate medical care, and follow-up. It is not necessary or most times even feasible for the student to provide care for all the patients in the clinic.
Schedule formal and informal times for feedback and evaluation. Adjust student learning activities and assignments as appropriate.
Finally, assist the student in development of a plan to achieve other specific course objectives such as learning about practice management, health care systems, or community service activities.

23. Learning Objectives
Evaluate patients and follow up as diagnostic and therapeutic maneuvers unfold.
Develop an ongoing patient relationships.
Understand the natural course of illness.
Participate in management decisions.
Some general learning objectives can be applied to any medical student rotating in your practice.
Evaluate new patients and follow them up as diagnostic and therapeutic maneuvers unfold.
Develop an ongoing relation with patients so as to understand the psychosocial milieu in which the patient lives and works.
Supervise the patient’s care on continuing basis and understand the natural course of illness.
Participate actively in management decisions that might require urgent or elective invasive tests or hospital admission.

24. Pearls for Effective Teaching
Plan schedule in advance
Assign focused tasks
Provide feedback
Provide alternate learning activities
Introduce the student to your medical colleagues
Finally, while applying appropriate teaching methods to students’ learning styles here are some concepts to enhance your teaching effectiveness.
It’s a good idea to plan the student’s schedule in advance and review it with the student.
The student should be assigned the focused tasks for the day.
Feedback is an important part of teaching and learning. The goal of feedback is the enhancement of student’s awareness and self-understanding, which facilitates learning.
Have alternate learning activities available. For example, so that the student can develop an understanding of the business aspects of the practice, the student could spend some time working with your practice manager.
Introduce the student to your medical colleagues. This will help the student feel welcome in the community.

25. Summary
The ability to select and apply appropriate teaching techniques relevant to an individual student’s learning style and level of competency will maximize the effects of your teaching efforts.
Student Evaluation
of Course
When students complete their community rotation and return home they are asked to complete an evaluation of their experience and of the community faculty preceptor. Click on the Student’s Evaluation link to view an example of such an evaluation.
Thank you for reviewing this module. Please click on the link at the bottom of the slide for a list of references. Move forward to the final slide to access the tutorial evaluation and post-assessment quiz.
Student Evaluation
of Preceptor

26. References
Baldwin CD & Niebuhr VN. Teaching Skills for Preceptors in the Community Setting: A Self-Directed Continuing Education Package. Developed for the Robert Wood Johnson Generalist Physician Initiative at the University of Texas Branch. 1996, re-edited in 2004.
Cassidy S. (2004). Learning Styles: An overview of theories, models, and measures. Educational Psychology. 24 (4),
Davis MH & Harden RM. (1999). AMEE Medical Education Guide No. 15: Problem-based learning: a practical guide. Medical Teacher 21 (2),
Gordon J et all. (2000). Strategic planning in medical education: enhancing the learning environment for students in clinical settings. Medical Education. 34 (10),
Hein T & Budny D. Teaching to Students’ Learning Styles: Approaches That Work. 29th ASEE/IEEE Frontiers in Education Conference. 12c1-7.
Middlesex Community College. Modality Preference Inventory. Middletown, CT. Website:
O’Sullivan M, Martin J, & Murray E. (2000). Students’ perceptions of the relative advantages and disadvantages of community-based and hospital-based teaching: a qualitative study. Medical Education. 34 (8),
Whitman N & Schwenk T. The Physician as Teacher. Salt Lake City, Utah: Whitman Associates, 1997.

27. Teaching Medical Students in the Community Practice Setting: Applying Teaching and Learning Styles
A teaching skills module developed by the
Office of Regional Medical Education
The University of Texas Medical Branch
School of Medicine Galveston, TX
Please print the links below to share evaluation feedback and request CME credit. 
Credits
Pam Hentschel, M.S.
Members of the UTMB Community Faculty Development Coordinating Committee
Link to Presentation Evaluation Form
Link to Post-Test and CME Credit Request Form
Michael Ainsworth, MD
Associate Dean for Regional Medical Education
301 University Blvd Galveston TX,
(409)
End Show