There was an overall improvement in CET’s knowledge, skills, attitude, and behavior
in relation to the domains of communication, PBL, professional engagement, and SBL.
Although we enrolled 10 CET, data saturation was reached by the sixth trainee. Persistence
of changes, post CET rotation, were less pronounced for PGY-2 CETs. We observed consistent
use of new behaviors and skills in 4/8 CETs. The primary outcome demonstrated a behavioral
change towards embracing and repetitively demonstrating use of the theoretical frameworks
in support of a learner-centered approach to teaching. MS perception confirmed the
observed behavioral and skill changes described in the CET group.
The most frequent three codes prior to the initiation of the CET rotation were “practice
of teaching” (11.8%), “critical thinking” (9.7%), “reflective practice” (8.1%) in
the CET group; “practice of teaching” (14.9%), “reflective practice” (10.2%), “challenges
to teaching” (8.4%) in the control group. In contrast, the MS groups’ top three codes
were “reflective practice” (22.1%), “practice of teaching” (7.2%) and “education”
(7.1%). Refer to Table 4, for examples of codes and correlating quotes. To identify
relationships between the codes, a network map, based on the pre/post-survey and focus
group interviews, showed a robust increase in post-rotation interconnectivity and
proximity of codes to the practice of reflection. In both pre and post assessments,
mentoring showed similar connectivity and proximity to reflective practice, see Figure
Eight (27%) IM residents enrolled as CETs and the remaining, 22 (73%) residents participated
as controls. The CET group included 2 PGY-2 and 6 PGY-3 residents. A total of 17/20
(85%) of the MS enrolled in the study. The eight CETs (100%) completed at least two
weeks clinical-educator rotation with three residents completing three weeks. Among
the residents who elected to rotate for three weeks, one resident completed the population
health module and another the patient-centered medical home (PCMH) module. The deliverables
for these modules included a Grand Rounds presented by the resident on the topic,
the second resident delivered a detailed document describing implementation requirements
for a PCMH practice in the resident outpatient clinic.
The most common identified codes were ‘clear and concise communication’ followed by
‘feedback’, and ‘coaching’, see Table 4.
Faculty comments: From the focus group discussion, faculty stated that the CETs developed
new understanding in relation to professionalism, patient care, teaching process and
planning. Communication between CET and stakeholders, including patients, MS, staff,
and faculty, was noted to be clear and organized when compared to the control group.
CETs made use of verbal and non-verbal cues. They learned how to communicate effectively
with all stakeholders to plan educational sessions.
“During the [morning discussion] article there was more discussion compared to before.”
“ So he is now involving the residents to be part of the conversation rather than
him just talking so he will ask more questions and listen to them.”
Evaluation tools: Using the morning huddle survey, the mean values for all questions
combined were similar in both the CET and control groups with a mean of 4 correlating
to ‘agree’ on the 5-point likert scale indicating a similar improvement in both groups.
Residents: From post-survey and focus group discussion, the residents reported that
CETs showed consistency in ensuring knowledge transfer to learners.
“Facilitating the morning group and feeling/sensing that I was listening and being
listened to. I felt effective and that the whole group participated.”
The CET group also used their communication skills to provide constructive feedback,
coach learners, and ask questions at different levels of the Bloom taxonomy . At the beginning of the clinical-educator rotation, CETs anticipated communication
skills as a major challenge which was not the case after the rotation.
“Communication skills were challenging, now I know how to effectively communicate
our thought process.”
“I feel empowered as an educator and feel I am able to conduct more thought-provoking
“...I think I am better at giving feedback now that I have practiced multiple times
and have received feedback on my feedback. I feel more comfortable with it.”
Students: From focus group discussion, the MS also indicated an agreement with the
CETs’ improvement of communication between stakeholders. In comparison, the controls
were much less likely to communicate with learners through pre-planning or clarifying
learning objectives when leading an educational activity.
“...it is interesting when he first started teaching us he was kind of timid and disorganized
when we first started. I gained a lot from the cases working with him but he made
a lot of improvement just from the second time he was with us as a CET. Toward the
end he was very proficient very organized in teaching us.”
The most common identified codes were ‘reflective practice’, ‘objective oriented’,
and ‘efficiency’. See table 4.
Faculty comments: From focus group discussion, the faculty stated that the CET group
demonstrated effective use of reflective skills and providing feedback to learners.
Their questioning styles changed based on Bloom’s taxonomy of questions and teaching
was more learner-oriented. Although CETs practiced verbal and written reflection,
they struggled to align their reflections according to Mezirow’s hierarchies for reflective
“So before he started the rotation he was more of a talker where he would share the
knowledge he knows and he will keep going on regarding what he knows but after doing
the rotation and during it he learned the skills and abilities of how can he get most
out of the learners where he is now adapted the roll of a teacher and not just somebody
that gives a lecture.”
Evaluation tools: Based on the Reflective Journaling Rubric, most reflective practices
ranged between affective through judgmental reflectivity according to Mezirow’s levels.
Occasionally, a CET practiced reflection at the conceptual, psychic, or theoretical
levels. The content and personal growth based on the Reflective Journaling Rubric
were rated as 9% “basic”, 50% “proficient”, and 41% “outstanding”, in the CET group.
Residents: From post-survey, the CETs found reflective practice to be an effective
tool to help them understand their role as an educator and enhance their professional-based
“Reflective practice helped me recognize the caveats and gaps in my practice and interactions
and taught me how to find remedies by self-reflection”
“One big part of the clinical-educator, there is actually a big mindfulness component
to it so there is daily journaling and reflection in that aspect.”
Students: From focus group discussion, MS stated that reflection practice demonstrated
by the CETs was consistent with the residents and faculty’s findings and noted deeper
sense of reflection.
“...to be a teacher you have to lead by example, and I think it is one of the aspects
that I want to improve on,”
“Reflection is a sort of personal feedback for me where I can sit back and figure
out where I could have been better and next time, I will try to implement that and
that is what [the CET] successfully did”
The most common identified codes were ‘practice of teaching’, ‘patient care’, and
‘precepting’. See Table 4.
Faculty comments: From focus group discussion, the faculty stated that the participants
in the CET group had improved their professional interactions with their patients,
colleagues, and MS. This was evident through deliberately addressing patients and
learners by name, actively organizing and planning teaching activities, and providing
feedback in a facilitative and non-judgmental manner.
“[Another clinical-educator] gave me feedback after I gave a lecture. She video taped
it, as an attending you never get this opportunity where you get feedback from peers
or from other attendings or from anybody. So that was helpful because by doing this
rotation she developed the skills on how to give feedback without hesitation no matter
if its a peer, attending, or student.”
Evaluation tools: Using the presentation rubric, the CETs and controls showed similar
improvement in presentation skills with a mean value of 3 correlating to ‘proficient’
in the 4-point Likert scale.
Residents: From post-survey and focus group discussion, the CETs demonstrated their
understanding of concepts of adult learning theories, group dynamics, personal values,
personal learning inventory and reflection.
“Explaining my expectations to new students, sometimes we work together only for a
couple of weeks, understanding their expectations as many MS are too new to the clinical
“It is difficult to evaluate somebody and be able to add to that picture unless you
are paying good attention and you are following them along as now I am able to look
at the picture and see what I can bring more to the table as my perception changes
you are not there to be in the room or be a part of it and say yes to what has been
but your job is to make sure that how this process is taking place and where it is
going and if we are going together or not.”
Students: From focus group discussion, the MS stated that CETs demonstrated a higher
level of professionalism when interacting with learners. There were noticeable changes
in behavior that the MS were able to recognize as a different professional behavior
when compared to the controls.
“[Clinical-educators] let me be a reporter and take charge and when I present the
patient to the attending, they didn't interrupt me and let me do my job as a reporter”
“[Clinical-educators] were very professional, they called me by name, rather than
‘medical student,’ everyone calls me medical student, but they used my name. They
were attentive, listen to us, and keep eye contact.”
The most common identified codes were ‘knowledge/education’, ‘critical thinking’,
‘technology use in teaching’. See Table 4.
Evaluation tools: CETs were able to demonstrate proficiency in SBL through the use
of QNOTE. CETs were more inclined to identify gaps in notes with an average QNOTE
score of 80.6, while controls were more inclined to give a higher score to the same
clinical notes with an average score of 91.2, indicating a lack in identifying gaps
in EHR note quality.
Residents: From post-survey and focus group discussion, the CETs were able to use
their newly acquired skills in different clinical settings including precepting in
the outpatient clinic and bedside coaching in the inpatient service. CETs engaged
different systems by working as a team leader and facilitating the use of resources
available in the hospital to engage the learners.
“Implementation of a variety of teaching strategies appropriate to learners, engage
in critical thinking and create opportunities to do so, using information technology
to support the learning process, role model.”
“...my opportunity to look at myself from a different point of view. Looking forward
to discover what are the challenges that a teacher faces while trying to meet the
needs of different people who may be very different from each other in the way they
learn, yet have the same objective.”
CETs were also able to master the use of QNOTE to assist learners in identifying their
gaps in clinical notes.
“ I also had another CET and she went over my notes using QNOTE and I noticed a lot
of errors so now I am looking at everything deeper.”
Students: From focus group discussion, MS stated that CETs’ behavior change was evident
through the bedside teaching where their actions manifested in a patient and learner-centered
approach. Patients were enthusiastic to participate in the teaching session as it
provided them with a deeper insight about their case and the MS had a unique opportunity
to reciprocate their theoretical knowledge into practice.
“When going through review of systems and physical exam, systems-based learning allows
the student to compartmentalize the teaching and ensuring all aspects of patient care/differential
diagnosis are addressed. At the same time, providing a method to draw from to develop
a "bigger picture" mentality with patient care.”
In addition to collecting data on these four constructs, we aimed to assess if the
clinical educator rotation met its objectives from the perspective of students, residents,
and faculty. Faculty and study participants observed significant behavioral changes
in the CET group after the completion of the rotation.
"In my opinion I think that this was a really good effort. I have seen significant
changes, and these changes are lifelong. It’s like you developed the muscles and you
keep working and those that learn and retain it if they practice it.”
The most noticeable behavioral changes included the ability to conduct well-structured,
concise, and focused feedback to learners. For example, when precepting or leading
small groups, CETs used a mix of higher order questions that engaged the learners
in analysis and evaluation rather than the predominant use of low order questions
such as knowledge or comprehension based. CETs provided learners with space to work
through problem solving and focus on their clinical reasoning skills.
“One thing about CE he has always been very like inquisitive and always ask good questions
he is always thinking deeper and thinking well what would you do in this scenario
and always think that he was a person that showed that if he wanted to share something
with you then he asks what do you think about this”
“... what I want for both of us to critically think and then I try to direct the question
in a way where it is learner-centered so if they are struggling to provide me with
the answer I stop and reframe my mode of questioning in a way that it may benefit
the learner to kind of see where I am trying to lead them, because sometimes what
we try to do as a teacher is to give all my knowledge but don't have time to answer
Other behavioral changes that were acquired and used by CETs included: facilitating
skills, concise and clear communication while coaching, improved patient communication,
and the overall novel approach to teaching.
“With CET they were very clear and able to tell me what they wanted and communicate
with me how they wanted me to do something and what the expectations were.”
In contrast, the control group asked more knowledge-based questions and usually provided
the answer to the questions without providing the opportunity for the learner to process
the question and respond.
“...some other [control residents] were a little more all over the place. You wouldn't
know what the expectations from day-to-day or what you are going to get or how things
are going to go. If they assign you a topic, you don't know if you are going to discuss
it that day, five days later, or never. So that was something I knew with CET I knew
if they assign me something to read, they will ask me the next day and need to prepare
for it so we always had that discussion. I knew what my expectations were…”
“In regard to other residents, the experience is not the same it depends on the senior,
I had four different seniors, and each was very different some took the role on. I
didn't know who is my go-to to teach me. Sometimes the interns teach more, sometime
the senior. I Don't know the hierarchy, but I think the seniors have more free time
to teach us and go over our notes.”
Through direct and indirect assessments, the most impactful observed change was the
strength of association between concepts related to clinical education, especially
reflective practice, feedback, mentoring, precepting, and teaching (Figure 1).
We also assessed the progression of the CET group through focused group discussion
with the MS. In comparison to the control group, MS reported that CETs were clear
and concise in communicating teaching objectives for teaching activities, and professionally
conducted the bedside teaching sessions. All MS concurred that the CET group conducted
teaching in a standardized fashion, while some residents in the control group demonstrated
similar organization in their teaching, they were not consistent with significant
variability between residents.
“It has created structure in how to approach bedside teaching and improve my knowledge
of various forms of bedside teaching, how to effectively give feedback, and how to
reflect with more organization.”
“Last week I feel you weren't as prepared as far what you wanted us to do but this
week you had it laid out what you wanted us to do, how you wanted the structure to
go, and that was better. This week you came in with a game plan before we saw the
“[A control resident] particularly spent extra time with us to help teach us, I think
it kinda came natural to him, without going through this process he is good at teaching....it
varies, depends on characters. Some teach spontaneously and others need to develop