Reviews, Notes, and Listings: Teaching during Rounds: A Handbook for Attending Physicians and Residents

Teaching during Rounds: A Handbook for Attending Physicians and Residents Donn Weinholtz, Janine C. Edwards, and Laura M. Mumford. 127 pages. Baltimore: The Johns Hopkins University Press; 1992. $15.00. I was recently asked by a premedical student if medical school faculty received any formal training in teaching. I answered that, although most did not, faculty members were concerned about the quality of their teaching and that teaching awards were highly coveted. The student's question brought back memories of attending rounds over the past decade during which, in various roles, I have been intimidated, bored, cynical, challenged, and excited. I remember attendings who created an atmosphere in which the team learned easily and eagerly; others brought out passive-aggressiveness, and rounds were interminable. Some physicians have enormous talent as educators, and others do not. Regardless of natural ability, any physician can acquire skills which will improve teaching. How can the motivated physician improve his or her teaching? The most accessible source is self study in the principles of adult education as they apply to teaching clinical medicine. This new volume by Weinholtz and colleagues has the stated goals of providing a practical handbook for attending physicians and residents and of encouraging further educational research. One problem with the book is that these goals do not work together easily. Although passages that review the existing literature on education in clinical settings may be useful to researchers in adult education, this information is less valuable to the physician-educator. They read more like a grant application or a thesis than a handbook. Although the lengthy explanations of the roles of medical student, intern, resident, and attending physician may be a necessary introduction to the non-physician researcher, much of this information is too basic for physicians who have spent their entire professional lives in teaching hospitals. Similarly, the book has numerous vignettes intended to provide examples of good or bad teaching in clinical settings. These are far less useful for the clinician than the summary statements and recommendations about teaching in various settings. Each chapter addresses a major task of the teaching attendingstarting the rotation, teaching in the conference room, teaching at the bedside, providing feedback, and finishing the rotation. Additional chapters on the roles of the members of the medical team, allocating time for teaching, and involving other health professionals are also included, as is a summary chapter. For the teaching attending, the most valuable chapters are those on starting the rotation and on providing feedback, as well as the summary chapter. Making clear one's expectations to the medical team and taking time to understand the goals and expectations of team members at the beginning of the rotation are important and often overlooked acts. Providing feedback is another key responsibility of the teaching attending, but many faculty members do little more than fill out the forms required by the residency program director. The authors, leaning heavily on the work of Jack Ende, provide guidelines to enable the attending to give useful feedback. Scattered throughout the book are helpful recommendations about other aspects of teaching, along with important reminders of potential problems such as the differing perspectives of intern and attending physician and the lack of communication between the clerkship director's office and teaching attending. Unfortunately, the book often loses clarity because of the overuse of vignettes. The summary chapter is a brief and valuable review, which I will reread before my next month as an attending physician. The book has many limitations. Several important issues are not addressed. The problem of attracting students to one's specialty, an area of increasing importance for internists, is not discussed. Although the authors devote a chapter to allocating time for teaching, ways of creating this time are not described in detail. The problem of the resistant learner is not discussed; elaboration of the authors' recommendation to negotiate learning agreements with team members might have addressed this. The tensions that can exist between attending physician and resident are acknowledged, but the problem is oversimplified. When the book does function as a handbook, it is far more appropriate for attending physicians than for residents; the recommendations for residents seem to be tacked on. The authors should also have provided an annotated bibliography, which would be more useful than the heavily referenced text. The physician-educator for whom teaching is a major career focus will do well to attend an intensive faculty development course such as that established by Dr. Kelley Skeff at Stanford University or the annual course in teaching medical interviewing sponsored by the Society of General Internal Medicine. These courses are highly valued by past participants and serve as important means of disseminating educational concepts. For those unable to attend such a course, self study remains the mainstay of learning about teaching. This book by Weinholtz and colleagues is just over 100 pages and can be read in a few hours. Despite its many shortcomings, it also has strengths and can provide a framework for improving one's teaching. We still need, however, a true handbook, preferably one written by a clinician-educator for the clinician-educator.