There was an overall improvement in CET’s knowledge, skills, attitude, and behavior in relation to the domains of communication, practice-based learning, professional engagement, and systems-based learning. Of the 10 residents who enrolled in the CET group, 8 completed the rotation. Data saturation was observed by the sixth trainee after which no new themes emerged. In addition, we observed that stakeholder (students, residents, and faculty) comments were similar suggesting triangulation of data. 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. Medical student perceptions confirmed the observed behavioral and skill changes described in the CET group.
The most frequent three codes in the CET group prior to the initiation of the CET rotation were “practice of teaching” (11.8%), “critical thinking” (9.7%), and “reflective practice” (8.1%). In the control group, the most frequent three code prior to the initiation of the rotation were “practice of teaching” (14.9%), “reflective practice” (10.2%), and “challenges to teaching” (8.4%). In contrast, medical students’ top three codes were “reflective practice” (22.1%), “practice of teaching” (7.2%) and “education” (7.1%). Refer to Table 5, 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 1.
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%) medical students enrolled in the study. 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. 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 codes derived were ‘clear and concise communication’ followed by ‘feedback’, and ‘coaching’, see Table 4.
Faculty comments: From the focus group meeting, faculty commented that the CETs developed new understanding in relation to professionalism, patient care, teaching process, and planning. Communication between CET and stakeholders, including patients, medical students, 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. Residents 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 Bloom’s 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 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 the focus group meeting, medical students indicated an agreement with the CETs’ improvement of communication between stakeholders. In comparison, 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. I gained a lot from the cases [patient care] 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 codes derived were ‘reflective practice’, ‘objective oriented’, and ‘efficiency’. See table 5.
Faculty comments: From the focus group meeting, faculty commented that the CET group demonstrated effective use of reflective skills and were able to provide quality 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 practice.
“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 has 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 the post-survey, the CETs found reflective practice to be an effective tool to help them understand their role as an educator and enhance their practice-based learning.
“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: During the focus group meeting, medical students commented that reflection practices demonstrated by the CETs were consistent and deliberate. Similar comments were echoed during resident and faculty focus group meeting.
“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 codes derived from qualitative data analysis were ‘practice of teaching’, ‘patient care’, and ‘precepting’. See Table 5.
Faculty comments: From the focus group meeting, the faculty commented that the participants in the CET group had improved their professional interactions with their patients, colleagues, and medical students. 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 CET] 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 medical students are too new to the clinical setting.”
“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 medical students stated that CETs demonstrated a higher level of professionalism when interacting with learners. There were noticeable changes in CET behavior that medical students recognized as a different professional behavior when compared to controls.
“[CETs] 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”
“[CETs] 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 codes derived from qualitative data analysis were ‘knowledge/education’, ‘critical thinking’, ‘technology use in teaching’. See Table 5.
Evaluation tools: CETs were able to demonstrate proficiency in systems-based learning 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, 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. By acting as team leaders, CETs engaged a variety of hospital systems and utilized available resources to create and enhance learning opportunities.
“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 the focus group discussion, medical students commented that CETs’ behavior change was evident during bedside teaching sessions 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. Furthermore, medical students had a unique opportunity to recall their theoretical knowledge and reflect on observed practices of clinical care to help them transition from theory to the practice of medicine.
“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 CET, he has always been very inquisitive and always asks good questions. He is always thinking deeper and thinking; well, what would you do in this scenario”
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 I need to prepare for it so we always had that discussion. I knew what my expectations were…”
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 medical students. In comparison to the control group, medical students reported that CETs were clear and concise in communicating teaching objectives for teaching activities, and professionally conducted the bedside teaching sessions. All medical students 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.”