Journal of Mind, Brain and Education Volume 8, Issue 1 March 2014, pp. 3-5.
Teachable Moments, Learnable Moments: Medical Rounds as a Paradigm for Education
Vincent P. de Luise MD, FACS (1,2)
Corresponding author: 1. Harvard University 2. Yale University School of Medicine
The medical profession has for almost a century employed various types of “Rounds” as pedagogical tools to engage physicians, physicians-in-training, and their health care teams, in the clinical diagnosis and treatment of patients. This validated paradigm of medical rounds (MR) has recently been extended to the field of education, where it is being used as an effective strategy for administrators to better understand their own domain. There are four distinct types of MR which can be further analyzed to find commonalities and parallels with the domain of education. The four types of MR are (1) Morning Rounds, (2) Chart Rounds, (3) Grand Rounds, and (4) Ongoing Collaborations—each have unique pedagogical characteristics and serve different functions. They are, however, unified by common threads of dynamic and interpersonal interactions wherein teacher (physician) and learner (physician-in-training) share leathe now outmoded theory of the “empty vessel” and corroborate the concerning and fluidly exchange roles in the pedagogy. MR models supplant pt of the teaching brain. A formal analysis of MR underscores its ongoing utility in education both for its pedagogical innovations and for the Interactive and inherently human attributes that are required between teacher and learner for its efficacy.
For almost a century, the medical profession has employed various types of “rounds” as pedagogical tools to engage physicians and physicians-in-training in the diagnosis and treatment of patients, and in the learning and teaching of medicine and surgery. The older, static notion of the physician “doctor” (Lat. doceo, docere = “to teach”) as teacher and the physician-in-training as the “empty-vessel” learner has been supplanted by Dynamic Systems Theory (DST) (complexity) models extended to education and brain development and the synchrony and synergy between teacher and learner and the teaching brain (Rodriguez, 2012). It has been discovered that, as a function of the interrelationship between teaching and learning, the development of the teaching brain occurs in spurts, with each cluster of spurts producing a new level of skill and understanding (Fischer et al., 2007), a development that also occurs in medical rounds (MR). In recent years, the validated paradigm of MR has been extended to the field of education, where it is being used as an effective strategy for administrators to better understand their own domain (City, Elmore, Fiarman, & Teitel, 2009). Are there deeper insights that can be gleaned from an analysis of MR that can be extended to education? Are there parallels between the two disciplines that are foundational and that exemplify aspects of the teaching brain? Is it even possible to tease out those aspects of MR that are distinct from education, when MR is itself, in its essence, a consummate pedagogical exercise?
Answering these questions requires an analysis of the four types and functions of ME which can be translatable to education. Each of these types of MR represents a unique opportunity for teaching and learning, and provides insights into the teaching brain.
Morning Rounds (“Walking” Rounds)
Morning Rounds, the archetypal MR, are the daily episodes of teaching and learning that occur in virtually all hospital settings. An attending physician or hospitalist (hospitalists are physicians specialized in hospital-based medical care)—a more experienced physician or surgeon who has the ultimate medical responsibility for the team's patients—is accompanied by a group of physicians-in-training which includes interns (Post Graduate Year 1, PGY 1), residents (PGY 2–4), and medical students. Morning rounds is a community effort: it also includes nurses, social workers, pharmacists, and quality improvement specialists, all of whom play an ever-increasing role in patient care and resource utilization (Cooper & Elnicki, 2011).
The team “walks” the floor of the medical unit, surgical unit, or specific area of the patients for which they are responsible. The team goes to the bedside of each patient on that team's watch, where each patient represents a “classroom episode” of teaching and learning pedagogy. One of the physicians-in-training, usually the intern or resident, presents to the team that patient's history, laboratory testing and diagnostic imaging results, as well as a differential diagnosis of possible disease entities that could explain the patient's illness and reason for admission. At one time, these presentations had to be delivered from memory, to underscore to the physician-in-training that they had to have complete mastery of knowledge and understanding of the patient's condition before they could opine a treatment strategy. A discussion then ensues, often in the presence of the patient and in the form of a dialectic using the Socratic method, of the most likely diagnoses and best treatment options. If there are pertinent physical findings (e.g., a mass lesion, a heart murmur, a skin rash), the attending physician will identify and discuss them, ask permission of the patient to examine them, and then lead the physicians-in-training in the physical exam by palpation or auscultation of those physical findings as appropriate. This experiential, heuristic model of pedagogy inures not only to informing the physicians-in-training, but continually shapes and transforms the teacher's mind in response to the dialectic.
Within the Morning Rounds model, there are not only distinct differences between teacher and learner, but also, as a result of the fluidity of the dialectic at any given moment, the teacher may become the learner and the learner a teacher. As the attending physician teaches an aspect of the patient's condition, or describes a particular clinical sign or finding, the physicians-in-training also participate in the pedagogy by asking deeper questions about those findings. This fluidity has parallels to the concept of synchrony in the DST model of the teaching brain (Rodriguez, 2012). A recent study has found that physicians-in-training (medical students in this particular study) actually learn differently, depending upon who is doing the teaching. At times, medical students acquire and understand a topic more fully if the intern or resident is doing the teaching than if the attending physician is doing so (Bodnar, Fowler, & Saint, 2013).
The syllogism that the physician-in-training represents the student, that the attending physician/hospitalist is the teacher, and that the patient is the object of the “teachable moment”—comparable in the educational setting to a classroom learning experience such as a book chapter reading or a science experiment—is far too simplistic. The pedagogical episodes in Morning Rounds are both top-down and bottom-up, as the data that are initially presented to the team by the physicians-in-training are then evaluated and modified not only by the attending physician, but by the whole team. Thus, the dialectic in MR is not just dyadic but rather remarkably fluid; observations and inquiries by the physicians-in-training, and the changes in laboratory test and imaging results over the course of the patient's hospital stay, modify the original diagnostic hypothesis and, as a direct consequence, alter suppositions about therapy.
Afternoon Rounds (“Chart” Rounds)This episode of learning/teaching usually occurs at the nurses' station, or in a private room or a quiet area, away from patients. In these episodes of learning/teaching, the attending physician, hospitalist, or resident usually leads a discussion of each patient's lab test results and imaging results obtained during the day (i.e., since the end of the Morning Rounds). The “on-call” intern and/or resident are present to ensure that they understand each patient's diagnosis and current status for their responsibilities on the evening shift, as the other physicians go off-duty.
“Grand” RoundsGrand Rounds are a form of top-down pedagogy which almost invariably take place in an auditorium venue, away from the patient bedside. The venue is physically located in the teaching hospital itself, or at the medical school with which the teaching hospital is affiliated. With the dramatic changes in health care delivery that have occurred, the auditorium maybe at a distance from the teaching hospital. Tele-videoconferencing allows members of the patient care team associated with that Grand Rounds case to be present in real-time, even if physically distant from the teaching hospital at the time of the presentation, as well as allowing physicians and physicians-in-training from satellite locations to participate.
In Grand Rounds, the pedagogy is usually delivered by a physician from a podium to a receptive audience of physicians and physicians-in-training, one of the latter of whom begins by presenting a patient case. Following the presentation, a physician expert in that patient's illness, discusses the case, bringing in relevant peer-reviewed data and literature. There is then an open forum of questions, answers, and alternative opinions exchanged between the physician expert and the physicians and physician-in-training in the audience, providing another example of the fluidity of MR pedagogy.
Technology now allows the archiving of Grand Rounds presentations, which then make these pedagogical episodes available as online videos. These can be viewed by physicians and physicians-in-training at a later date, enabling them to improve their knowledge and patient care, while accreting to one of the core ideals of the Hippocratic Oath: Medical education should be transparent and open, and physicians should actively share their knowledge without compensation in order to improve patient care (http://classics.mit.edu/Hippocrates/hippooath.html).
Ongoing CollaborationOngoing collaborations between physicians and basic science researchers are a separate yet crucial aspect of the teaching hospital–medical school model. These daily, ongoing teaching/learning episodes are harder to quantify, but which could be classified as a form of rounds. In these episodes of pedagogy, often taking place within the cafeteria or lounge of a teaching hospital, physicians and researchers tackle ongoing scientific challenges. These informal “chat” sessions have become essential as incubators for the cross-fertilization and transfer of ideas, so much so that a number of medical schools have purposely built common spaces easily accessible to both researchers and physicians to convene and discuss topics of mutual interest and inquiry. A result of these interactions and chats is often the birthing of a scientific breakthrough.
While these four identifiable types of MR are distinguishable based on either geographic or temporal grounds, the overarching aspect that unites them is that each is characterized by both dyadic as well as more complex and fluid interactions between teacher and learner. These are the synchronous, synergistic, and mutually beneficial relationships within the process of MR that inform the teacher as much as they impart knowledge to the learner.
Educators in general tend to have autonomous ideas about educating. In the domain of medicine, there are numerous disparate teaching styles in different pedagogical venues, the top-down lecture format of Grand Rounds being a prominent example. However, these individual styles of pedagogy are all subsumed in the context and structure of MR.
Teaching systems can be stratified into those capable responses: instinctual, higher-order student-centered teaching, or using more complex teaching brain teaching. At this most complex level, exemplified by the various types of MR, the teacher and student engage in a synchronistic teaching flow that achieves an optimal teaching and learning experience (Kent, 2013; Rodriguez, 2013). MR activities are inherently synchronistic and demonstrate teaching flow in the dynamic and complex interchange of teacher as teacher/student and student as student/teacher (Rodriguez, 2012, 2013).
The teaching brain is not subordinate to the learning brain; rather, the two are in a dynamic cycle of synergy and synchrony with each other (Rodriguez, 2012). The ultimate measure of effective teaching is not to assess whether an individual has learned a specific piece of knowledge, but rather to evaluate whether the learner and teacher come closer together in thought and skill, that they should flow together successfully within each other's context (Rodriguez, 2013). MR are pedagogical episodes that exemplify this point. MR maintain physicians, physicians-in-training, and researchers in a constantly engaged and challenged environment, continually pushing them to refine their understanding of their patients' condition by being informed by the most recent medical knowledge that supports their diagnosis and care. In an increasingly technological world, with laptops and PDAs at once essential to education (as learning tools, not as teachers) but also serving as further barriers to direct human contact, MR remain the most human and enduring of pedagogical activities. At the core of all of these dynamic pedagogical episodes is the observation that MR hinge upon, indeed require, face-to-face interactions between physicians, physicians-in-training, researchers, and their teams, and conversely, without these critical human interactions, that would be little if any pedagogy (Yano, 2013) and suboptimal patient care.
MR are not just about learning; they are also very much about teaching and about the synergies and effective outcomes that result. Educators need to employ many of the strategies found in MR to enhance their own ability to diagnose the problems that occur in their areas of responsibility and expertise, and in a collaborative fashion find the most effective solutions. These teachable moments and learnable moments need to become as essential in education as they have been in medicine.