Teaching Junior Learners in Rheumatology

Teaching junior learners, such as medical students and residents, is increasingly important in rheumatology. Given the antici­pated shortage of rheumatologists, attracting more trainees to our field and enhancing knowledge of the rheumatic diseases among physicians in other fields are critical to meeting the needs of our patients.^1,2

In addition, clinical reasoning is a vital skill for junior learners, but as medical student and resident autonomy has decreased over time, so may have the opportunity to practice clinical reasoning. Rheumatology is an optimal setting for the deliberate practice of clinical reasoning, and rheumatologists are in a particularly strong position to teach it.

Working with junior trainees poses many challenges. Few medical students and residents pursue careers in rheumatology, which may create the perception of less robust learner engagement. Junior learners tend to be less familiar with rheumatology than they are with medical subspecialties that receive more exposure.

Moreover, time and space are significant barriers to effective teaching, particularly in the outpatient setting. Junior learners may take more time than a fellow to indepen­dently assess a patient and often require more preceptor time with the patient to provide effective care. In addition, faculty working with junior learners may not have multiple exam rooms to enable trainees to see patients independently.

In this article, we present frameworks and tools to use in teaching junior learners. These are organized into three phases (i.e., pre-patient encounter, encounter and post-encounter). We discuss the importance of the learning contract in the pre-encounter phase, using active teaching techniques during the visit and feedback and asynchronous learning following the encounter.

Before the Encounter

Principles of adult learning theory (ALT) provide a helpful framework for effective teaching (see Table 1).³ ALT posits that adults learn best in situations relevant to their current work or anticipated career, situations that build on their prior experiences and situations in which learning is problem centered and practical. The pre-encounter period, which includes the beginning of the learner’s rotation, as well as the time before each clinic session, is critical to setting the stage for teaching in the ALT framework and to the develop­ment of a relationship between preceptor and learner.

Studies have demonstrated that today’s learners value relationships with their teachers and that effectiveness of feedback is dependent in part on the relationship between the student and preceptor.^4,5 An understanding of the learner’s interests and background gives the preceptor the ability to connect subsequent learning points to the learner’s interests or to draw parallels with topics they already know well. Making these connections is a valuable educational strategy, but it also reinforces relationship building with the learner.

A key step in the pre-encounter period is the development of a learning contract between learner and preceptor, wherein goals, roles and logistics of the rotation or clinical encounter are agreed upon. Asking the learner what they would like to learn and how they learn most effectively helps set expectations for both parties and brings structure to an experience that can otherwise be plagued by uncertainty for the learner. Importantly, the learning contract should include the expectation that the learner will have an active role in the clinical experience—the specifics will likely vary with each learner and clinical scenario and are discussed in more detail below.

Table 1: Adult Learning Theory