Academic veterinarians balance many roles (Kochevar and Peycke, 2008; Magnier et al., 2014; Smith and Lane, 2015). When asked to rank the characteristics that the best clinical teachers exhibit, both students and other clinicians ranked enthusiasm (energetic, positive attitude, enjoys their job), competence/knowledge (competent in case management, professional skills, knows literature, engaged in continuing professional development), and clarity (answers questions clearly, summarizes important points, able to explain difficult topics) as the top three characteristics (Bolt, Witte, and Lygo-Baker, 2010; Smith and Lane, 2015; Sutkin et al., 2008). Other important skills were availability, positive relationship with students, being nonjudgmental, feedback skills, being a role model, professionalism, sincerity, being organized, being well prepared, demonstrating evidence-based practice, scholarly activity, and listening skills (Bolt, Witte, and Lygo-Baker, 2010; Sutkin et al., 2008).

Recent attention in the medical literature has focused on defining the model of the clinical teacher as an individual who can “multiply,” rather than “diminish,” the intelligence of the clinical team (Wiseman, Bradwejn, and Westbroek, 2014). As medicine has become more of a team effort, the brilliant lone clinician has become less effective than the clinician who can use the skills of their entire team to produce an outcome that is better than that achieved by any one individual (Reader et al., 2009). The Multiplier (Wiseman, Bradwejn, and Westbroek, 2014) makes sure that decision-making and responsibility are spread among the team, with each member taking on tasks that are important. In this way, each level of the team is contributing to the overall outcome. Each time the team functions in this way, learning happens, new ideas and expertise are incorporated, and the ability of the team to work together to achieve a better outcome is enhanced. In contrast, the Diminisher (Wiseman, Bradwejn, and Westbroek, 2014) is directive, making all the important decisions, relying on their expertise. The team members are good at executing orders, but do not contribute in a meaningful way to the knowledge or the plan that is used to manage the case. Learning is stifled and the case outcome may be poorer, because the team members have little incentive to stretch their knowledge or to take responsibility for the safety and welfare of the patient.

The first step in making the hospital accessible and friendly to students is to develop clear policies and procedures. The functioning of the hospital may seem self-evident to the experienced clinicians who live and breathe the clinic’s formal and informal rules, but having written policies clarifies the environment for the novice. Some examples would be:

• Dress code.
  
• Treatment responsibilities and times.
  
• Drug-dispensing protocols.
  
• Medical record navigation and policies.
  
• Client communication expectations.
  
• Interprofessional communication expectations.
  
• Service schedules.

The physical layout of the hospital should include spaces that allow discussion outside the main work flow. These can be “nooks” that allow the clinician to confer quickly with team members, or they can be rounds rooms with doors that can be closed (Lane and Cornell, 2013). If the work flow is constant in the service rounds room, it may be necessary to find a space elsewhere. Since the majority of information will be recorded in electronic format, a projector and screen will also be needed. Focusing the learner’s attention on one main screen will help prevent the multitasking that occurs if many small screens are open.

The service atmosphere that encourages learning is one in which each student is encouraged to speak, there are no “stupid” questions, and “I don’t know” is regarded as an opportunity to learn. The information flow is multidirectional (Lane and Cornell, 2013). The team practices self-care and notices if any member is getting overwhelmed or needs help. Everyone on the team is reflecting on and working on their learning issues. When an individual masters a concept or skill that has been difficult, the team celebrates.

Learning outcomes set the teaching goals for each clinical rotation. Writing these outcomes will help determine if the rotation activities allow each student to accomplish the outcomes or if additional resources are needed. Writing outcomes that include the development of noncognitive skills helps focus students on the acquisition of key skills that they might otherwise ignore. Teachers should also encourage students to produce their own individualized rotational learning goals, recorded on an index card or a personal computer (Lane and Cornell, 2013). Checking these goals on a daily basis helps both the student and the teacher devise learning practice that actually happens in the distracting clinical environment.

There is increasing evidence that breaking complex tasks into smaller component (micro) skills that can be mastered individually is a more efficient method of teaching than trying to teach an entire task all at once (Neher et al., 1992; Razavi et al., 2010). Cognitive task analysis, a formal method of determining component skills, looks at each decision point in a procedure and determines how experts navigate these points (Wingfield et al., 2015). A less formal method involves having at least three experts write down the steps of a procedure or process, followed by a consensus session in which they discuss why they do what they do. Regardless of how one gets to the component skills, the task for the busy clinician-teacher is to identify which component skills a student needs to practice and to devise a method that enables the student to practice within the clinical environment.

Before focusing on the skills the student needs, the teacher should focus on what skills they need to teach in the hospital. Because the clinic is so distracting for both teachers and students, a number of systems have been developed to help learning occur within the normal flow of a busy practice. These systems break the task of clinical teaching into manageable steps that are easy to remember and master (Baker et al., 2015; Lane and Cornell, 2013; Neher et al., 1992; Pascoe, Nixon, and Lang, 2015; Wolpaw et al., 2012; Wolpaw, Wolpaw, and Papp, 2003). All concentrate on assessing where the student is in their reasoning and helping them to progress. Perhaps best known is the “one-minute manager” or “five microskills” system (see Box 12.2), which can be used at any step of the decision-making process (Neher et al., 1992; Wolpaw et al., 2012).

Getting a commitment starts with asking the right questions (“Which diagnosis do you think is most likely?” “What treatment option are you going to pick?” “What do you think the results of this test are going to be?”). As an example, a student has committed to a tentative diagnosis of neoplasia regarding a young indoor–outdoor male cat presenting with an enlarging painful mass over the right shoulder and a body temperature of 102.9 °F. Once the student has committed to a likely diagnosis, diagnostic plan, treatment plan, or opinion about the case, the teacher then asks for supporting evidence.

The second step should be limited to a few encouraging questions, rather than “grilling” the student to the bottom of her knowledge base. For the teacher, it is a diagnostic step to determine the student’s reasoning. The teacher must guard against using this step to get enough data to solve the problem. In our example, the student thinks that neoplasia is most likely because the rapid enlargement of the mass and pain the cat is displaying are most likely to indicate neoplasia. When the clinician asked if the student had any thoughts regarding the body temperature, the student indicated that she thought that it was within normal limits for a painful cat in an exam room.

Once the student has explained her reasoning, the teacher moves to the third step, which is to take the student’s specific reasoning and relate it to a more general rule or treatment principle. This is a good place to indicate to the student that we are all learners. In our example, the clinician might say: “The most likely neoplastic cause of a rapidly enlarging mass over the shoulder in a young cat is vaccine-induced fibrosarcoma, but I believe that recommended vaccine sites are more distal. I can’t remember the exact recommendations, so you might want to look these up and report back to the group.”

The next step is specifically to praise what was done right. In this case the student has conducted a very thorough history, so the clinician might say: “You used your funnel technique very effectively. You went from open-ended questions to close-ended questions. You listened quietly and reflected the client’s answers back to him to ensure that you heard correctly.”

The final step is to correct mistakes. The best way to correct a mistake is to get the student to correct herself, so the teacher might say: “Can you think of any other conditions that might cause fever, pain, and swelling?” In this case, the teacher has reframed the complaint into a sequence that might help the student remember that infection causes heat, pain, and swelling. If the student says an abscess, then the teacher can say: “Good thought. What can we do to tell these two conditions apart?” If the student remains puzzled, the teacher can say: “What would you like to do to determine if this mass is neoplastic?”

It should be noted that the fifth skill (correct mistakes) was deliberately placed last by the developers of the one-minute manager/five microskills technique. It is common for busy clinicians to use a student as an information conduit to solve clinical problems efficiently (Wolpaw, Wolpaw, and Papp, 2003). Once the information is gathered, the clinician may ask a question or two of the student regarding the case and rapidly correct any misconceptions. This is considered to be teaching on the fly. The good news is that the student does get rapid feedback and, if delivered nonjudgmentally, the feedback is likely to be effective. The problem is that the student has no opportunity to practice framing an idea, supporting that idea, receiving wisdom on how to tie the specific case to general knowledge, receiving feedback on what was done well, correcting herself, and then moving to the next step. Sticking to the five skills reminds the busy clinician to help the student teach herself first and to correct the student second.

In order to be able to teach clinical reasoning, it helps to understand how expert clinicians solve diagnostic and other clinical problems. There is a developing body of research regarding expert diagnosis and how it differs from novice diagnosis (Bordage, Grant, and Marsden, 1990; Custers, 2015; Harasym, Tsai, and Hemmati, 2008; Norman, 2005; Sutkin et al., 2008). The expert uses a highly nuanced “illness script,” which is a mental description of the prototypical case with neural connections to memories of exceptions, things to watch out for, and individual case features. This description is temporally sequenced according to the usual information flow and management sequence of the case. The memory of the case is stored in long-term memory and mental processing is very rapid. The diagnosis is often being refined by the expert early in the history-taking process. If the case has no key distinguishing features or there are features that do not fit, the expert goes to a search pattern based on a schema or algorithm, which is still very rapid. If needed, the expert can go to the slower, hypothesis-based reasoning pattern that allows for testing of each case feature against what the expert knows about the pathophysiology of the disease process. The expert primarily uses the illness script to get the diagnosis, but rapidly switches between the other two modes as needed. Experts who use illness script and algorithm-based reasoning to solve diagnostic problems have been shown to be much faster and more accurate than those who use hypothesis-based deductive reasoning for clinical problem-solving.

In contrast, most students come out of their preclinical years reliant on using pathophysiology as the starting point for an undifferentiated list of disease entities and their features (Harasym, Tsai, and Hemmati, 2008; Sutkin et al., 2008). Depending on the curriculum, the “mental storage boxes” for the various disease entities may be based on discipline, system, disease feature, or clinical presentation. The goal of students’ teaching hospital experience is to help them build appropriate prototypical illness descriptions and to link them to previous knowledge (Bowen, 2006). This process will allow students to develop rapid, accurate diagnostic abilities and, if needed, “backward” processing to access previously learned basic knowledge. Locating where a student is in their development of diagnostic reasoning requires that the clinician have a system for assessing a student’s processing (Baker et al., 2015). Using the five microskills approach in combination with the assessment portion of the Problem-Oriented Medical Record (POMR; Weed, 1968) will quickly give the clinician an idea of whether the student needs to work on basic knowledge (“I don’t know anything about this disease presentation or its pathophysiology”), to develop schemes to manage and use their knowledge (“I do know, here’s all of my knowledge, help me prioritize it”), or is at the stage of developing generalized illness descriptions that incorporate pertinent clinical details and relative likelihood of disease.

Once the teacher knows the student’s processing level, the challenge is to give the student a learning task that will enable them to move toward the next stage and to bring value to the group processing of the case. The temptation for the expert, who rapidly processes complex case details, is either to bypass the student and teach general knowledge in a rounds session, or to overwhelm the student with rapid details and orders, putting them into a “fetch and do paperwork” role. If the teacher and student have already determined rotational and individual learning goals, these goals can be used to focus learning. The student with a weak knowledge base can be assigned specific “look-up” tasks to report back to the group. The student who needs algorithms or organizational schema can be tasked with finding them and explaining them to the group. All students benefit when the clinician takes a specific case presentation and converts it into a more generalized description. It is much easier for the student to retain the generalized illness description if the teacher uses a contrast-and-compare method when converting a specific case to the general case (Bowen, 2006). As an example, if the case involves a large breed of dog presenting for lethargy and collapse, with a large spleen and a low packed cell volume, whose diagnosis is splenic torsion, the clinician would review the clinical features used to differentiate splenic torsion from hemagiosarcoma or immune-mediated anemia.

Diagnostic reasoning is only one aspect of a clinician’s cognitive task. A diagnostic and treatment plan also need to be developed. Again, the temptation when the hospital gets busy is to use rapid mental processing to develop the list of necessary tests or treatments and assign the student to making them happen. Using the five microskills approach regarding diagnostic and treatment plans will help the student own the clinical tasks and will allow the teacher to devise an appropriate learning task. The student with little knowledge is encouraged to review testing details and to report back. The student who already knows the common testing algorithms can be assigned to look at evidence-based treatment options or to consult with other specialists, expanding the knowledge of the entire group. Management decisions can be compared with evidence for efficacy, and the specific choice for the patient can be used as a focal point to discuss how one takes evidence and applies it to a specific case.

The POMR is an essential tool in teaching clinical reasoning (Weed, 1968). By having the student identify each problem and complete Subjective observations, Objective observations, Assessment of, and a Plan for each problem (SOAP), the clinician can identify the student’s ability to delineate problems, to process each problem, and to propose methods for diagnosis and/or treatment. With the transition to electronic medical records, some teaching hospital services have converted to a medical/legal record, while others maintain the traditional POMR (Friedman, Sainte, and Fallar, 2010; Peled et al., 2009). The most valuable aspect of the SOAP format is the assessment field, which allows the student to discuss their reasoning regarding the specific problem and their rationale for choosing specific diagnostic tests or treatments. If the POMR is to have teaching value, daily, specific, constructive written feedback must be provided to the student regarding their thought processing. Making sure that the electronic record allows student case notes with feedback is critical for students to practice reasoning through cases.

Surgical planning and execution, during which the student is part of a large surgical team, is a common treatment scenario in the teaching hospital. In order to ensure that students’ learning needs are addressed in this process, the BID (Brief, Intraoperative teaching, Debrief) method was developed (Roberts et al., 2009, 2012). In the Brief session, the surgeon asks the learner about their learning goals for the surgery. Once the goals are established, they guide the teaching within the Intraoperative phase. After the surgery, the Debrief occurs. This has four parts: reflection, rules, reinforcement, and correction (see Box 12.3). Using this system, the surgeon can quickly establish different learning goals for the resident and the student, allowing the teaching to be focused on the individual learner’s needs.

Other practices (Zundel et al., 2015) that students, residents, and surgeons identify as helpful for learning when the student is not the primary surgeon include the following:

• Familiarize the student with the operating room environment and its rules.
  
• Talk about team function in the operating room and relate how it contributes to the outcome.
  
• Make sure that the student has detailed procedural information and time to prepare for a given surgery.
  
• Assign one person to be in charge of teaching so that the student knows to whom to address questions.
  
• Talk through the procedure before and while doing it.
  
• Make sure that the student knows their expected role in the operating room.
  
• Ask questions of the student.
  
• Show enthusiasm for student learning in the operating room.

When teaching psychomotor skills in the clinic, there must be a balance between giving the students experience, patient welfare, and the efficiency of the clinic. Clinicians need to establish what skills are to be practiced or demonstrated on the rotation. Rules for patient welfare and efficiency (typically, X tries or X minutes) need to be explained and enforced. As with cognitive skills, the most efficient way to develop expertise is to practice the component skills and then put the entire task together (Razavi et al., 2010; Wingfield et al., 2015). Having a skills video library available allows the clinician/technician to direct the student to the video before performing the task. This step ensures that the student reviews the steps, without taking up the teacher’s time. The teacher can then ensure content knowledge and observe the student as the entire task is performed. After the task is finished, the student is asked to self-critique, the teacher gives praise on the specific things the student did well, and the teacher offers tips for getting to the next level of mastery. If needed, the student is directed to practice of specific component parts of the skill.

There are innumerable opportunities to teach communication in the teaching hospital (Adams and Kurtz, 2012). Developing communication policies and protocols within the hospital ensures that staff and students have a similar understanding of the communication requirements. Creating communication learning outcomes for each rotation ensures that this important skill does not get forgotten. Providing the student with a small laminated patient communication summary sheet, such as the Calgary–Cambridge Communication Process Skills Guide, provides a framework for them to follow (Kurtz et al., 2003).

Teaching of oral communication has traditionally focused on veterinary student–client interactions, such as history taking, phone communication, and giving discharge instructions. If the exam rooms have one-way glass or video cameras, students can practice their communication skills under observation with direct feedback. If the exam rooms are closed to observation, using two students at a time in a room can enable one student to be the communicator and one to be the recorder for peer feedback. A resident or clinician can serve the same role, but that is often more threatening to the student. Another method for getting immediate and direct feedback is to solicit feedback from the client. Experienced clients can often give very helpful suggestions. If the clinician is comfortable with teaching the component skills for client communication, using role play in the rounds setting provides an opportunity for practice and feedback (Nestel and Tierney, 2007). Phone communications are an opportunity to practice more advanced skills, such as talking about money and empathically listening to an anxious client.

As teamwork becomes the norm in veterinary medicine, being overt and mindful about communications within the hospital is a necessary step. It is helpful to students to have clinicians discuss the communication standards and processes within the hospital, rather than simply modeling them. In busy hospitals these communications can involve a plethora of face-to-face, phone, e-mail, text message, and web-based medical record communications. Without agreed upon standards, communications can be less than professional and occur at all hours, regardless of emergent status, under the stress of handling complex cases in a complex environment. Sample rules include that text messages and e-mails are limited to facts; communication between certain hours is limited to a true need-to-know basis; face-to-face communication is on a first-name basis for all team members within a given area; face-to-face communication uses formal names under specified circumstances; no whining about or belittling of other services or their staff members. It helps to have a ready list of examples of professional exchanges for the clinicians to model and the students to practice. Students are very astute at picking up the “hidden curriculum” in the clinic (Birden et al., 2013; Madigosky et al., 2006), and if poor interprofessional communication behaviors are tolerated, they can become very cynical about whether good communication skills really matter.

Veterinary teaching hospitals are getting bigger and the distractions from mobile technology are increasing. As human hospitals increased in size, many adopted formal communication and body-language rules from the hospitality industry (Wu, Robson, and Hollis, 2013), such as “Smile and make eye contact if you are within 20 feet of another person, speak to the person if within 10 feet.” Showing students that adopting a few basic communication policies can lead to a better work environment and having students practice colleague interaction skills helps to prepare them for work within both small and large organizations.

Medical teams differ by specialty, but those most studied are “action” teams functioning in high-risk settings such as the emergency room, intensive care unit (ICU), surgery, or anesthesia (Fernandez et al., 2008; Manser, 2009; Morey et al., 2002; Morrison, Goldfarb, and Lanken, 2010; Reader et al., 2009; Risser et al., 1999; Salas et al., 2008). Characteristics of highly functional medical teams include dispersed leadership, individual and mutual accountability, defined outcomes that the team needs to accomplish, engaging in open-ended discussion and problem-solving meetings, ability to deliver a collective work product, and ability to discuss, decide, and work together. The role of the senior clinician in the teams with the best performance has been shown to be that of a delegator and flexible process monitor, similar to the Multiplier, who helps every member of the team contribute their best effort to the task at hand (Reader et al., 2009). There are a number of medical staff training protocols that are being adapted for medical student and resident training (Crew Resource Management, MEDTeams, TeamSTEPPS), and the US Accreditation Council for Graduate Medical Education now requires programs to provide this training (Haerkens et al., 2015; Morey et al., 2002; Salas et al., 2008).

Patient safety concerns within human hospitals have resulted in a number of communication protocols designed to prevent errors and improve handoffs between caregiver teams (Haig, Sutton, and Whittington, 2006; Lenert, Sakaguchi, and Weir, 2014; Motley and Dolansky, 2015; Risser et al., 1999; Thompson et al., 2008; Townsend-Gervis, Cornell, and Vardaman, 2014). Teaching these protocols to veterinary students can help develop more precise thinking about the case and can provide opportunities for the practice of basic team communications skills. The most common mnemonic used for case handoffs is SBAR (Situation, Background, Assessment, Recommendation), though more recently the I-PASS (IIPE-PRIS Accelerating Safe Sign-outs) has been developed as another aid for standardizing the handoff (Starmer et al., 2012). These remind the communicator to convey the present situation of the patient, background of the patient, assessment of patient problems, and recommendations for problem resolution. While the mnemonic has not solved all deficiencies in the transfer of case information, it has been shown to improve safety and the quality of the transfer information. Other commonly taught team communication skills (Fernandez et al., 2008; Risser et al., 1999) are the following: