In many clinical settings, multiple trainees work alongside a single preceptor. Not surprisingly, there is great variability in the knowledge and skills of medical students, residents, fellows, and other health professions trainees. In such settings, it can be challenging to engage the entire team while avoiding teaching that any particular trainee would perceive as too elementary or too complex. Thus, great clinical teachers employ strategies to develop different learners’ clinical skills and independence. Unfortunately, not much information is available on this topic, and clinical teachers may only find effective teaching strategies for such multilevel learner (MLL) groups by trial and error.1,–4
A quick assessment of learners’ needs and educational levels forms the foundation of teaching MLLs. When joining an inpatient team or starting a day in the outpatient clinic, the great clinical teacher finds out who are the medical, physician assistant, nursing, or therapy students and who are the interns, senior residents, or fellows. Experienced preceptors seek opportunities to talk with learners one-to-one, ask about their interests, and work with them to develop 1 or 2 specific learning goals. Great teachers ask skillful questions to gain insight into each learner’s unique experiences, knowledge base, and adeptness with clinical reasoning.5 The reporter-interpreter-manager-educator framework may provide a useful approach to assessing a learner’s sophistication with clinical reasoning and patient care.6
In this article from the Council on Medical Students in Pediatrics series on great clinical teachers, we offer specific strategies for teaching learners who are at different levels. The ENGAGE mnemonic (Everyone teaches, Novel topics, Guide, Ascend the ladder, Groups within the group, Empower learners for autonomy) provides preceptors with a toolbox for engaging all levels of learners (Fig 1). Throughout this article, we provide examples for teaching through an illustrative case of a 4-year-old boy presenting with symptoms of Kawasaki disease (KD).
E: Everyone Teaches
Great clinical teachers set the expectation that all learners will contribute to teaching, often relating opportunities for teaching to each learner’s individualized learning goals.7 The clinical teacher can guide learners to present succinct, clinically relevant teaching points that fill knowledge gaps for those on the team. Topics can be assigned or learners may volunteer insights from their own studying. Interprofessional staff offer unique perspectives, and patients and family members can teach about their experiences with diagnosis, treatment, and advocacy.
In our example, the 4-year-old boy initially presents to clinic. The intern, interested in pediatric rheumatology, has never cared for a child with KD. The great clinical teacher, aware of the learner’s interests and that this patient may have KD, asks the intern to evaluate the patient and review the diagnostic criteria with other learners. After the encounter, the students may teach features of incomplete KD. During the hospital admission, the inpatient team may ask pharmacy staff to teach about side effects of intravenous immunoglobulin (IVIg) and nursing staff to discuss monitoring parameters during IVIg administration. Families may provide a narrative of the natural history of KD in their child.
N: Novel Topics
Clinical teachers can introduce recent publications, hospital protocols, clinical guidelines, and new understandings of disease mechanisms or treatments. By teaching novel topics, the clinical teacher models “keeping up to date” throughout one’s career.
In our patient encounter, the teacher can compare new KD guidelines with previous versions. Junior learners could present the rationale for revisions or other aspects of the new guidelines keyed to their level of learning. During a time set aside for teaching, senior learners can analyze how the coexistence of KD and viral infection can lead to diagnostic uncertainty.
Role modeling is a powerful teaching strategy for MLLs, particularly for harder-to-teach competencies such as professionalism and humanism. Clinical teachers might assume learners notice the way they interact with a patient, but learners, who are not primed to notice these actions, may miss them. Saying, “I said [this] to the patient because…” often helps learners notice and internalize the learning point.
For example, the clinical teacher could model family-centered care. When hearing a parent’s concerns about the risks of IVIg treatment, the clinical teacher may take an extra moment to understand and address the parent’s concern rather than quoting data on the effectiveness of IVIg. Afterward, the teacher can lead a reflective discussion of the encounter. The teacher could ask the medical student to identify the differing perspectives that emerged from the conversation, the interns to reflect on how the varied perspectives converge or conflict, and/or a senior resident to walk the team through ways to reassure the worried parent, all without compromising treatment.7
A: Ascend the Ladder
Questioning by ascending “up the ladder”8 helps the clinical teacher target specific learning objectives for each team member. The teacher asks developmentally appropriate questions of each learner based on their needs. Initially, the teacher may ask students foundational questions, such as questions about disease pathophysiology. Building on this discussion, the clinical teacher may prompt a more experienced learner to address diagnostic and treatment options. To conclude the discussion, the most experienced learner may be asked to describe a higher-order concept, such as case synthesis.5 Questioning requires special attention, and many recommendations for skillful questioning appear in a previous Council on Medical Students in Pediatrics article.5
In our example, the clinical teacher may ask a medical student to discuss the pharmacotherapy of KD, whereas an intern may be asked to review the rates of IVIg treatment failure. A senior resident could review treatment options available should IVIg and aspirin fail.
G: Groups Within the Group
Establishing small groups (pairs or trios) within the larger clinical team, with each group focusing on a task, promotes collaboration, teamwork, and leadership. Pair a senior resident with a medical student to create a coaching dyad for feedback on history and physical examinations and documentation or to staff patients in clinic. During group teaching, generate discussion and build consensus. For example, when faced with clinical uncertainty, as in refractory KD, pair learners to debate treatment options. After a brief discussion, join pairs to make a group of 4 and so on until 2 groups remain to debate and recommend treatment.
E: Empower Learners for Autonomy
Physicians and other health care providers are expected to develop increasing autonomy in caring for patients. Opportunities for autonomy are more apparent for senior learners, although there are ways to encourage autonomy among junior learners. Delegate duties appropriate to each learner’s level and skill set. For example, allow the intern in the clinic to call the inpatient team to admit the patient with KD while the senior resident coordinates bed placement. Ask junior learners to lead discussions. Remind them to speak up with concerns about patient care. Support senior learners leading rounds with and without an attending physician present.9,10 Recognize that readiness for autonomy does not necessarily correlate with the learner’s level in their program, and encourage learners to follow their individual trajectories.
ENGAGE strategies for MLLs apply to both inpatient and ambulatory settings and will enable the great clinical teacher to meet the needs of individual learners while ensuring that patients and families receive timely and excellent care. After incorporating these strategies, the clinical teacher will find that any setting with learners at multiple levels can become a dynamic environment in which everyone learns.
Dr Quigley conceptualized the ENGAGE mnemonic, drafted the initial manuscript, revised the manuscript, and developed Fig 1; Dr Potisek conceptualized the ENGAGE mnemonic, drafted portions of the initial manuscript, and revised subsequent versions; Dr Barone conceptualized the ENGAGE mnemonic and reviewed and revised the manuscript; and all authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.
FUNDING: No external funding.
We thank Janice Hanson, PhD, and Robert Dudas, MD, for their thoughtful reviews of the manuscript. Dr Hanson also helped to conceptualize Figure 1.
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.