Module 4 Assignment 4.2: Write a Annotated Bibliography
2015, 37: 1090–1097
Sequencing learning experiences to engage different level learners in the workplace: An interview study with excellent clinical teachers
H. CARRIE CHEN1, PATRICIA O’SULLIVAN1, ARIANNE TEHERANI1, SHANNON FOGH1, BRENT KOBASHI1
& OLLE TEN CATE2
1University of California, USA, 2University Medical Center Utrecht, The Netherlands
Abstract Purpose: Learning in the clinical workplace can appear to rely on opportunistic teaching. The cognitive apprenticeship model
describes assigning tasks based on learner rather than just workplace needs. This study aimed to determine how excellent clinical
teachers select clinical learning experiences to support the workplace participation and development of different level learners.
Methods: Using a constructivist grounded theory approach, we conducted semi-structured interviews with medical school faculty
identified as excellent clinical teachers teaching multiple levels of learners. We explored their approach to teach different level
learners and their perceived role in promoting learner development. We performed thematic analysis of the interview transcripts
using open and axial coding.
Results: We interviewed 19 clinical teachers and identified three themes related to their teaching approach: sequencing of
learning experiences, selection of learning activities and teacher responsibilities. All teachers used sequencing as a teaching
strategy by varying content, complexity and expectations by learner level. The teachers initially selected learning activities based
on learner level and adjusted for individual competencies over time. They identified teacher responsibilities for learner education
and patient safety, and used sequencing to promote both.
Conclusions: Excellent clinical teachers described strategies for matching available learning opportunities to learners’
developmental levels to safely engage learners and improve learning in the clinical workplace.
Introduction
Of the many models for thinking about learning in the clinical
setting, one of the most pervasive is the apprenticeship model
in which learning occurs through participation. In apprentice-
ships, learning is situated in the context of the workplace and
triggered by engagement in work activities. The assumption is
that apprentices are able to inherently learn all that was
necessary for the job primarily by doing (Billett 2001; Collins
2005). In the past few decades, attention has shifted towards
increased structuring of these learning experiences in the
clinical workplace through strategies such as structured
feedback, regular workplace-based assessments (mini-CEX)
and portfolios. Consistent with this trend is Allan Collins’
introduction of the cognitive apprenticeship, a variation of the
traditional apprenticeship model (Collins 2005). In contrast to
traditional apprenticeship, the cognitive apprenticeship takes a
more deliberate approach to promote the development of
cognitive skills needed for practice. It focuses on the content
required for expertise, social characteristics that impact
learning (e.g. real-world context), teaching strategies to
promote learning and principles for ordering learning activ-
ities. Learners are given tasks based on what the learner should
be learning rather than just what the workplace needs done.
This more deliberate matching of activities to learner needs has
also been described as supported participation, which is a key
to clinical workplace learning (Billett 2002; Dornan et al.
2007). To accomplish this, both Collins and Dornan
argue that curriculum leaders need to developmentally
order or sequence learning activities in the curriculum
Practice points
! Excellent clinical teachers deliberately structure and sequence learning opportunities in the clinical work-
place for different level learners.
! Excellent clinical teachers sequence clinical learning opportunities by adjusting case content, managing
case complexity and tailoring expectations for differ-
ent learners.
! Excellent clinical teachers strategically select learning activities to promote individual learner progression
along a developmental trajectory.
! Both learner growth and patient safety considerations drive the attention of excellent clinical teachers to
learner developmental levels and selection of learning
activities.
Correspondence: H. Carrie Chen, MD, MSEd, Department of Pediatrics, University of California San Francisco, 550 16th Street, 4th Floor, Box 0110, San Francisco, CA 94158-0110, USA. Tel: 1 415 502 2972; Fax: 1 415 476 5354; E-mail: carrie.chen@ucsf.edu
1090 ISSN 0142-159X print/ISSN 1466-187X online/15/121090–8 ! 2015 Informa UK Ltd. DOI: 10.3109/0142159X.2015.1009431
(Collins 2005; Dornan et al. 2014). This includes increasing the
complexity and diversity of activities over time, and introdu-
cing whole tasks before breaking down into part-task activities
(Collins 2005). Dornan and others further argue that individual
teachers also have to identify ways to enable learner partici-
pation in workplace activities appropriate to their level of
development or training (Billett 2002; Dornan et al. 2007, 2014;
Teunissen et al. 2007).
Due to increasing emphasis on competency-based educa-
tion, learner-centered teaching and early clinical experiences,
clinical teachers, more than ever, need to support the clinical
learning and developmental progression of a wider range of
individual learners. Clinical teachers must have the skills to
assign workplace activities that provide the most effective
learning opportunities for each learner. Yet promotion of
learning in the clinical workplace is already demanding and
complex. Challenges include the unpredictable and opportun-
istic nature of clinical learning and the need to engage multiple
level learners (Ramani & Leinster 2008). Indeed, the problems
most commonly identified with teaching and learning in the
clinical setting include teaching pitched at the wrong devel-
opmental level and the lack of learner participation in clinical
workplace activities (Spencer 2003). Ramani and Leinster note
that clinical teachers can help different level learners to learn
from the same patient by choosing different teaching goals and
focusing on specific learning activities for the different level
learners (Ramani & Leinster 2008). Yet little is known about
how clinical teachers accomplish those goals.
Studies and assessments of excellent teaching in clinical
settings have primarily focused on the characteristics (e.g.
knowledge, enthusiasm, role model) or general skills (e.g.
feedback, communication) of the teacher and have generally
overlooked the teacher’s role in choosing opportunities for
effective learning (Irby 1995; Buchel & Edwards 2005; Sutkin
et al. 2008; Fluit et al. 2010). Studies of teaching practices in
clinical settings that apply Collins’ cognitive apprenticeship
model have focused on the model’s teaching strategies, but not
on the challenge of engaging different level learners in the
clinical workplace (Taylor & Care 1999; Woolley & Jarvis 2007;
Stalmeijer et al. 2009, 2013). The purpose of this study is to
determine how excellent clinical teachers approach the
selection of learning experiences in the clinical context to
support the workplace participation and developmental
growth of different level learners.
Methods
Design
This was a single institution qualitative interview study of
teaching practices among excellent clinical teachers. We
selected a grounded theory approach from a constructivist
perspective in order to develop an understanding and model
for teacher selection of learning experiences for different level
learners in clinical workplaces. By selecting a constructivist
perspective, we acknowledge that teachers may conceptualize
this process in different ways and that our understanding is an
interpretive one (Watling & Lingard 2012; Creswell 2013;
O’Brien et al. 2014).
Context
We conducted this study at the University of California San
Francisco (UCSF) School of Medicine, and with ethical
approval of the UCSF institutional review board. The UCSF
undergraduate and graduate medical education programs are
consistently ranked among the best in the United States (US
News and World Report 2014). UCSF has an Academy of
Medical Educators (AME) where the members are selected via
an external review process based on their excellence in direct
teaching and accomplishments in an additional area of medical
education such as curricular development, advising/mentor-
ing, educational administration/leadership or educational
research. AME members exemplify the best teachers at
UCSF and represent 4–5% of the faculty across all core
teaching sites, departments and clinical and classroom settings
(Cooke et al. 2003).
Participants
We used purposeful sampling methods to select participants
who were most likely to provide the richest information about
the selection of clinical learning activities for multiple levels of
learners (Coyne 1997; Creswell 2013). We defined clinical
teachers as physician faculty members who directly supervised
learners in the clinical environment and who cared for patients
jointly with the learner. These teachers were responsible
simultaneously for both medical students and residents/
fellows who were on clinical rotations for their individual
training programs with primary learning goals relating to
patient care competencies. We considered medical students at
any level of training, but primarily clerkship students, as junior
learners; interns as intermediate or more advanced learners
and senior residents/fellows as senior learners.
We first used criterion sampling to pick participants who
met our pre-specified criteria of: (1) membership in the UCSF
AME, (2) practicing physician and (3) taught learners of
multiple levels of training in the clinical setting (Coyne 1997;
Creswell 2013). Seventy-seven clinical teachers met these
criteria. We then used theoretical sampling to select individ-
uals based on whom we predicted would add new and
varying perspectives on teaching (Coyne 1997; Watling &
Lingard 2012; Creswell 2013). For instance, we anticipated
that clinical teachers from different specialties (e.g. surgery
versus psychiatry) or who work in dissimilar clinical settings
(e.g. intensive care unit versus outpatient clinic) might have
different approaches. Therefore, we specifically sampled
from a variety of specialties as well as a range of inpatient
and outpatient clinical settings. When emerging themes from
early interviews suggested a potential difference in perspec-
tive among teachers from procedural specialties, we explicitly
recruited additional participants from procedural specialties
to further explore their perspectives. We accomplished this
by sending invitations to participate in individual interviews
in multiple waves, selecting who was invited in each
successive wave based on who had agreed to be inter-
viewed. We stopped our recruitment when we reached
theoretical saturation, at which point invitations to 46 of the
77 current physician AME members had been sent.
Sequencing learning experiences
1091
Instrument
Because we wanted to explore teacher selection of clinical
workplace activities for different level learners, which may be
a deliberate approach to structuring clinical learning, we used
the framework of Collins’ cognitive apprenticeship and
curricular sequencing (Collins 2005) to inform the develop-
ment of an interview guide. To allow more open discussion,
we did not include specific terminology from those frame-
works in our interview questions or probes. The guide for our
semi-structured interviews included the following questions:
(1) Please describe your approach to teach learners at different
levels in a clinical setting. (2) How did you develop your
current approach to work with learners at different levels? (3)
What role, if any, do you think faculty play in promoting the
developmental progression of learners in the clinical settings?
How might the faculty do a better job of this? (4) Do you have
other comments about your teaching experiences with
learners at different levels? We piloted the interview guide
with experienced teachers who were not in the AME and made
minor edits to the probes before using the guide with study
participants.
Procedure
Two authors (BK and SF), who were non-AME junior clinician
educators, trained in interview methods, conducted the semi-
structured interviews. As non-AME members, they were not
well known to the study participants and could function as
outsiders (Creswell 2013). However, they were also clinical
teachers with insider knowledge of the teaching roles and
contexts of their interviewees. Each interviewed approximately
half of the study participants either in-person or by telephone
between January 2012 and March 2013. They debriefed their
interviews with a third author (HCC) who, as an AME member
meeting study criteria, was fully positioned as an insider. This
facilitated understanding and appreciation of complexity and
patterns present in the data while avoiding an insider’s
influence on the data collection. Interviews averaged 30 min-
utes in length (range 15–50 minutes). All interviews were
audio-recorded and the audio files were transcribed verbatim
by an external service and de-identified.
Data analysis
Consistent with our grounded theory approach, we carried out
inductive thematic analysis of our data using an iterative
process during and after data collection. In inductive thematic
analysis, themes are not imposed, but emerge naturally from
the data (Bowen 2006). Though we had a cognitive appren-
ticeship and curricular sequencing framework in mind when
developing our interview guide, we took this open approach
to our data analysis to allow for emergence of potential
additional elements and concepts. To ensure analytical rigor,
we used multiple coders for investigator triangulation
(Creswell 2013). After familiarizing ourselves with the tran-
scripts, the three authors who are clinical teachers (HCC, BK
and SF) performed initial open coding of the same six
randomly selected transcripts to identify codes. We compared
our coding lists and reconciled differences. We developed a
codebook for thematic analysis and two authors (either HCC
and BK or HCC and SF) independently applied it to all
transcripts for open and axial coding (Corbin & Strauss 2008;
Creswell 2013). The authors met and discussed all transcripts
and reconciled any discrepancies.
We then organized the emergent themes using the
sensitizing concepts of cognitive apprenticeship and curricular
sequencing. Sensitizing concepts are concepts brought to data
analysis to allow for a frame of reference in organizing and
reporting the emergent themes (Bowen 2006). Using the
organizing framework of cognitive apprenticeships and cur-
ricular sequencing, one author (HCC) took the lead in further
abstracting, organizing and synthesizing the themes into a
cohesive model grounded in the data. To maintain reflexivity,
these final phases of analyses involved discussions with the
larger study team (Creswell 2013). The three non-clinician
team members (PO’S, AT and OtC), one of whom was from
outside UCSF (OtC), functioned as outsiders to provide diverse
perspectives and challenge assumptions. They were in agree-
ment with the model and themes identified.
We used Dedoose Version 4.12.4 (http://www.dedoose.-
com) for our data organization and analyses. As a part of our
analyses, we looked at frequency of codes, co-occurrence of
codes and stratification of codes by years of teaching experi-
ence. We reached saturation within our sample; we did not
discover new codes or themes despite additional sampling of
clinical teachers from a variety of specialties and clinical
settings. Also, the amount of data we gathered was sufficient to
inform our understanding of teacher selection of learning
experiences for different level learners (Morse 1995; Watling &
Lingard 2012).
Results
Of the 46 clinical teachers invited, 20 responded; one declined
and we interviewed all 19 who agreed to participate. They
averaged 18 years (range 6–33 years) of teaching experience
among them. All taught both medical students and residents,
and more than a third of them also taught fellows. They were
58% (11) men, represented 10 specialties and taught in diverse
clinical settings. See Table 1 for details.
While not a theme of focus in this study, the clinical
teachers provided a rich description of the clinical context in
which they taught. They described the relative lack of
flexibility in the clinical teaching environment. For the most
part, they felt they had no control over which patients were
available or the difficulty of the patient case and therefore had
no ability to design the content of the learning experience.
‘‘Mostly [learners] just get who they get and then they’re sort of
just forced – and we’re forced – to make it work from there’’
( participant-11).
The teachers then described how they worked with
different level learners within this context. We were able to
identify three themes related to their teaching approach:
(1) sequencing of learning experiences, (2) selection of
learning activities and (3) teacher responsibilities. These
themes appeared across specialties; our initial perception of
potential differences between teachers from procedural and
H. C. Chen et al.
1092
non-procedural specialties was not borne out. Table 2 lists the
themes, subthemes and additional participant quotes.
Sequencing of learning experiences
To manage the relatively fixed clinical contexts, all clinical
teachers interviewed described deliberate ordering or sequen-
cing of clinical learning experiences in order to adapt these
experiences for learners of different levels. None of the
teachers relied on sequencing as specified by the curriculum
alone. Increasing years of teaching experience was associated
with more descriptions of sequencing practice. The teachers
sequenced learning experiences using three keys factors:
content, complexity and expectations.
Content
The clinical teachers varied the type of teaching content by the
level of learner. For junior learners, they focused on teaching
about common problems or skills. ‘‘I’m generally looking
for . . . patients with bread-and-butter problems . . . and then
more acute but common problems’’ ( participant-11). ‘‘I’m
trying to contextualize what they’re learning so that it can be
useful to any field they go into’’ ( participant-6). They
emphasized knowledge of pathophysiology and clinical pres-
entations (e.g. expected physical exam findings), and skills in
basic communication (e.g. rapport building) and clinical
reasoning. They also initially focused more on the mechanics
of a skill – for instance whether all sections of a note are
present and whether contents are appropriately categorized
rather than the ability of the note to convey relevant
information. For the more advanced learners, the teachers
focused on knowledge of treatment and patient management
plans, more advanced communication skills and clinical
decision-making skills. For senior learners, the focus
shifted to learner application of evidence for management
decisions, ability to anticipate outcomes and leadership and
teaching skills.
Complexity
Clinical teachers preferentially chose less complex patients for
junior learners. This included cases which were less compli-
cated procedurally or medically, and situations with less
complicated communication (welcoming, cooperative, cogni-
tively intact patients) or psychosocial issues for early learners.
They reserved more complicated cases with ‘‘gray zones’’ and
nuances requiring advanced clinical judgment for more senior
learners. In situations where the problem was inherently
complex, the teachers provided scaffolding to help learners to
prepare for or manage the complexity. They broke things
down into manageable parts and limited the tasks given to the
learner. ‘‘It’s actually quite remarkable the . . . steps that you
can take a very junior trainee through in the operating room’’
( participant-10). This included breaking procedures down into
a series of smaller steps. As learners progressed, they took on
several steps chunked together and finally brought all the steps
together into a whole. The teachers also supported learners by
offering tips for completion of complex tasks or by providing
on-the-spot support. ‘‘Just because a patient is complex doesn’t
mean that they won’t be working with a student . . . because
the resident may also be in the room with them, or I may be in
the room with them’’ ( participant-4).
Expectations
The vast majority of clinical teachers used differing expect-
ations of the learners to shape their teaching and the learners’
experiences. For instance, they only expected junior learners
to demonstrate basic knowledge, clinical reasoning and patient
care skills; be able to attend to 1–2 patients or issues; and to
require close supervision and support. They then raised their
expectations for more experienced learners. This included an
expectation of graduated responsibilities and increased auton-
omy of the learners over time. More senior learners were
expected to demonstrate increasing ability to handle higher
patient volumes, prioritize tasks and work efficiently, function
effectively within clinical teams/systems, inform practice with
evidence from the literature and supervise and teach junior
learners.
In terms of the R3, I give them space . . . I sit quietly
and let the R3 [lead multidisciplinary rounds] . . .
I delegate [assignment of intern tasks] to the
R3 . . . .Interns who seem to be not performing, . . .
if there are [medical student] progression
issues, I usually let the R3 try to tackle it first.
( participant-16)
Selection of learning activities
In addition to having a specific sense of the order in which
learning should occur, the clinical teachers also described how
they decided what activities to select for an individual learner.
Teachers used a combination of the learner’s level of training
and associated expected competencies, and information about
the learner’s actual developmental level to choose learning
activities for learners.
Table 1. Demographics of study participants.
Participants n¼19
Gender Female 8 (42%) Male 11 (58%)
Specialty Procedural (anesthesia, obstetrics/gynecology,
otolaryngology, surgery) 5 (26%)
Non-procedural (dermatology, family medicine, geriatrics, medicine, pediatrics, psychiatry)
14 (74%)
Clinical settinga
Outpatient clinic or emergency room 13 (68%) Inpatient ward, nursery, or nursing home 13 (68%) Intensive care unit or operating room 5 (26%)
Location County hospital 4 (21%) Tertiary care hospital 9 (47%) Veteran’s hospital 6 (32%)
Teaching Experience #10 years 5 (26%) 11–20 years 7 (37%) $21 years 7 (37%)
aMost participants taught in more than one clinical setting.
Sequencing learning experiences
1093
T a b
le 2
. S
tr a te
g ie
s fo
r su
p p
o rt
in g
th e
w o rk
p la
c e
p a rt
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a tio
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m e n ta
l g ro
w th
o f
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e rs
a t
d iff
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le ve
ls .
S tr
a te
g y
S u g g e st
io n s
fo r
p ra
c tic
e P
a rt
ic ip
a n t
d e sc
ri p
tio n s
S e q
u e n c in
g o f
le a rn
in g
e xp
e ri e n c e s
A d
ju st
te a c h in
g c o n te
n t
! C
h o o se
d iff
e re
n t
g o a ls
a n d
fo c u s
c o n te
n t
o f
te a c h in
g b
a se
d o n
le a rn
e r
le ve
l –
J u n io
r le
a rn
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: c lin
ic a l p
re se
n ta
tio n s
o f
c o m
m o n
p ro
b le
m s,
p a th
o p
h ys
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c lin
ic a l
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e r
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(e .g
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p ro
a c h
to a n e m
ia , c o n c e p
tu a lf
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o rk
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e ss
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m e c h a n ic
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id -l
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a rn
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: p
a tie
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a d
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g si
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te a m
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h ip
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m a n a g e m
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sk ill s,
te a c h in
g sk
ill s
‘‘ W
ith th
e m
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I tr
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fo c u s
.. .m
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g ..
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m a n a g e m
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.’ ’
(p a rt
ic ip
a n t-
1 6 )
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h e n
I’ m
ro u n d
in g
w ith
a fe
llo w
.. .I
m ig
h t
a sk
: S
o yo
u w
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g ,
w h a t’
s th
e e vi
d e n c e
fo r
it? H
o w
d id
yo u
m a k e
th a t
d e c is
io n
to c h o o se
to g e t
th a t
d ia
g n o st
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y? ..
.O r,
if w
e w
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to d
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w h a t
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? ’’
(p a rt
ic ip
a n t-
7 )
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d e r
c a se
c o m
p le
xi ty
! C
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c a se
s w
ith d
iff e re
n t
le ve
ls o f
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p le
xi ty
fo r
d iff
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n t
le ve
l le
a rn
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– J u n io
r le
a rn
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: st
ra ig
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a rd
m e d
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ro b
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s (e
.g .
ty p
ic a l a st
h m
a ,
g a st
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ri tis
/ d
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ra tio
n ),
lo w
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s, si
tu a tio
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w ith
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ith n u a n c e s
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r le
a rn
e rs
: b
re a k
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n ta
sk s
in to
sm a lle
r p
a rt
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.g . fo
c u s
o n
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to ry
o r
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h ys
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p e rf
o rm
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), o ff e r
su p
p o rt
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. tip
s fo
r d
o c u m
e n ta
tio n ,
d o in
g th
e e xa
m to
g e th
e r)
‘‘ ..
.I ’ll
tr y
to se
le c t th
e c a se
s th
a t a re
th e
m o st
p a ra
d ig
m a tic
.. .s
o th
a t it
re in
fo rc
e s
in re
a lt
im e , in
th e
st u d
e n t’
s m
in d
, w
h a t a
p a tie
n t w
ith a
[c o n g e st
iv e
h e a rt
fa ilu
re ] e xa
c e rb
a tio
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.o r.
.. e n d
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a g e
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d is
e a se
lo o k s
lik e .
S o ,
I’ ll
tr y
to b
e ve
ry in
te n tio
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c re
a tin
g o p
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fo r
e a rl y
le a rn
e rs
to im
p ri n t
th e ir
le a rn
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a c la
ss ic
c a se
’’ .
(p a rt
ic ip
a n t-
2 )
‘‘ I th
in k
a b
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w h a t
I w
a n t
th e m
to le
a rn
, I th
in k
a b
o u t
w h a t
p a tie
n ts
m ig
h t
b e st
e xe
m p
lif y
th a t,
w ith
o u t
a n y
c o n fo
u n d
in g
c o m
p le
xi tie
s to
it, a n d
th e n
I th
in k
a b
o u t
w h a t
th e
in te
ra c tio
n w
o u ld
b e
lik e
fo r
th e
st u d
e n t,
a n d
w h e th
e r
th a t
p a tie
n t
a n d
p a re
n t
c o m
b in
a tio
n w
ill e n h a n c e
th e
st u d
e n t’
s a b
ili ty
to le
a rn
w h a t
I w
a n t
th e m
to le
a rn
, o r
g e t
in th
e w
a y’
’. (p
a rt
ic ip
a n t-
1 9 )
‘‘ W
h a t It
e n d
to d
o w
h e n
so m
e o n e ’s
fir st
le a rn
in g
.. .i
s to
b re
a k
th e
p ro
c e d
u re
in to
st e p
s ..
.e ve
n a
re la
tiv e ly
si m
p le
p ro
c e d
u re
, I st
ill d
o n ’t
h a ve
th e m
d o
th e
w h o le
th in
g a t
o n c e ’’
. (p
a rt
ic ip
a n t-
6 )
T a ilo
r e xp
e c ta
tio n s
! H
a ve
g ra
d u a te
d e xp
e c ta
tio n s
fo r
le a rn
e rs
– S
e n io
r le
a rn
e rs
: g re
a te
r re
sp o n si
b ili ty
a n d
a u to
n o m
y, in
c re
a se
d e ff ic
ie n c y,
m a n a g e m
e n t
o f
h ig
h p
a tie
n t
vo lu
m e s,
e ff e c tiv
e fu
n c tio
n in
g w
ith in
sy st
e m
s, e vi
d e n c e -b
a se
d p
ra c tic
e ,
su p
e rv
is io
n a n d
te a c h in
g o f
o th
e rs
‘‘ I’ m
n o t in
a p
o si
tio n
to c h a n g e
w h a t a
su b
-i n te
rn ..
.o r w
h a t a n
R 2
is a sk
e d
to d
o b
y th
e sy
st e m
. I a m
in a
p o si
tio n
to ..
.e xp
a n d
.. .o
r n a rr
o w
th e
sp e c tr
u m
o f
m y
e xp
e c ta
tio n s
fo r
th e m
’’ .
(p a rt
ic ip
a n t-
3 )
‘‘ T h e
fe llo
w s
.. .i
t’ s
m o re
o f
a le
ve l o f
ju d
g m
e n t
a b
o u t
w h e n
a n d
w h a t
p ro
c e d
u re
s to
d o ,
a n d
p u sh
in g
th e m
m o re
a b
o u t h o w
th e y’
re d
e c id
in g
o n
th e
p la
n o f c a re
fo r
th a t p
a tie
n t,
a s
w e ll
a s
w a tc
h in
g th
e m
su p
e rv
is e
th e
re si
d e n ts
’’ .
(p a rt
ic ip
a n t-
1 5 )
S e le
c tio
n o f
le a rn
in g
a c tiv
iti e s
A ss
e ss
d e ve
lo p
m e n ta
l le
ve l
! A
ss e ss
d e ve
lo p
m e n ta
l le
ve l o f
le a rn
e rs
– A
sk a b
o u t
le a rn
e r’
s le
ve l o f
tr a in
in g ,
p ri o r
e xp
e ri e n c e s/
b a c k g ro
u n d
– O
b se
rv e
le a rn
e rs
’ p
re se
n ta
tio n s
a n d
in te
ra c tio
n s
w ith
p a tie
n t
– U
se p
ro b
in g
q u e st
io n s
a n d
h a ve
le a rn
e rs
a rt
ic u la
te th
e ir
th in
k in
g
‘‘ I c a n
d o
so rt
o f
a m
in i-
a ss
e ss
m e n t
o f
w h e re
I th
in k
e a c h
le a rn
e r
is in
re la
tio n sh
ip to
th a t
b e n c h m
a rk
[f o r
le ve
l o f tr
a in
in g ],
a n d
th e n
tr y
to b
ri n g
th e m
u p
to sp
e e d
o r
p u sh
th e m
to th
e n e xt
le ve
l’’ .
(p a rt
ic ip
a n t-
2 )
E n c o u ra
g e
c o n tin
u ity
! B
u ild
o r
p ro
m o te
c o n tin
u ity
w ith
le a rn
e rs
w h e n e ve
r p
o ss
ib le
– H
a ve
ju n io
r le
a rn
e rs
w o rk
w ith
th e
sa m
e se
n io
r le
a rn
e rs
o n
th e ir
te a m
s (e
.g .
sc h e d
u le
sh ift
s o r
ta k e
c a ll
w ith
th e
sa m
e se
n io
r) –
F e e d
fo rw
a rd
in fo
rm a tio
n o n
le a rn
e rs
’ le
a rn
in g
n e e d
s a n d
d e ve
lo p
m e n t
to th
e n e xt
te a c h e r
‘‘ O
u r
b ig
g e st
im p
a c t is
w h e n
w e ’r
e n o t st
a rt
in g
n e w
w ith
e a c h
p e rs
o n , b
u t w
h e n
w e
k n o w
w h e re
th e y
a re
, w
h e re
th e y’
ve b
e e n ,
b e c a u se
th e n
w e
k in
d o f g e n tly
p u sh
th e m
o r
g u id
e th
e m
in to
th e
n e xt
st e p
a n d
h a ve
a p
p ro
p ri a te
e xp
e c ta
tio n s’
’. (p
a rt
ic ip
a n t-
1 1 )
‘‘ W
e a s
a tt
e n d
in g s
si g n
o u t
to e a c h
o th
e r ..
.n o t
ju st
th e
p a tie
n ts
b u t
th e
[le a rn
e rs
] o n
th e
te a m
a n d
w h a t
a re
a s
va ri o u s
p e o p
le a re
w o rk
in g
o n ’’
. (p
a rt
ic ip
a n t-
1 6 )
B u ild
c h a lle
n g e
! C
o n si
d e r
h o w
fa r
o r
in w
h ic
h d
ir e c tio
n s
to p
u sh
le a rn
e rs
– C
h o o se
le a rn
in g
a c tiv
iti e s
a t
le a rn
e rs
’ g ro
w th
e d
g e s
to p
ro m
o te
g ro
w th
– P
ro vi
d e
fe e d
b a c k
w ith
sp e c ifi
c su
g g e st
io n s
fo r
re a c h in
g th
e n e xt
le ve
l o f
d e ve
lo p
m e n t
‘‘ S
o o n e
a p
p ro
a c h
is e st
a b
lis h in
g in
m y
m in
d w
h a t th
e g o a ls
a n d
e xp
e c ta
tio n s
a re
fo r
th e
le a rn
e r
a t
th e ir
le ve
l o f
tr a in
in g
.. .T
h e
o th
e r
si d
e is
m o re
in -t
h e -m
o m
e n t
tr yi
n g ,
b a se
d o n
m y
k n o w
le d
g e
o f.
.. th
a t
in d
iv id
u a l le
a rn
e r,
to ta
rg e t
e d
u c a tio
n a l a c tiv
iti e s
to m
a xi
m iz
e th
e ir
le a rn
in g
o n
a p
a rt
ic u la
r d
a y
o r
w ith
a p
a rt
ic u la
r p
a tie
n t.
S o
it is
b o th
a b
ig p
ic tu
re o ve
r th
e tr
a je
c to
ry o f tim
e I w
o rk
w ith
le a rn
e rs
, a s
w e ll
a s
a d
a y-
to -d
a y,
h o u r-
to -h
o u r
a lm
o st
m o m
e n t-
to -m
o m
e n t
c a lib
ra tin
g o f
a c tiv
iti e s
th a t
id e a lly
ta rg
e t
le a rn
e rs
’ n e e d
s a n d
g o a ls
’’ .
(p a rt
ic ip
a n t-
9 )
T e a c h e r
re sp
o n si
b ili tie
s B
a la
n c e
te a c h in
g a n d
c lin
ic a l re
sp o n si
b ili tie
s !
B a la
n c e
le a rn
e r
p a rt
ic ip
a tio
n w
ith p
a tie
n t
sa fe
ty b
y a p
p ro
p ri a te
ly m
a tc
h in
g th
e le
a rn
in g
a c tiv
ity to
le a rn
e r
le ve
l –
A ss
e ss
th e
le a rn
e r’
s d
e ve
lo p
m e n ta
l le
ve l
– C
o n si
d e r
a sa
fe a m
o u n t
o f
c h a lle
n g e
to b
u ild
in to
a c tiv
ity –
S tr
u c tu
re th
e a va
ila b
le p
a tie
n t
c a se
o r
le a rn
in g
o p
p o rt
u n ity
to m
a tc
h th
e le
a rn
e r
le ve
l b
y va
ry in
g fo
c u s
o n
c o n te
n t,
m a n a g in
g c o m
p le
xi ty
, a n d
a d
ju st
in g
e xp
e c ta
tio n s
‘‘ S
o I’ m
ve ry
a c tiv
e ly
e n g a g e d
in ..
.m o vi
n g
p e o p
le u p
to sp
e e d
b e c a u se
I a ss
u m
e o n c e
w e ’v
e [a
c c e p
te d
th e
le a rn
e r] ,
w e ’v
e m
a d
e a
c o n tr
a c t
w ith
th e m
th a t
a t
th e
e n d
o f
th is
tim e ,
th e y
h a ve
to b
e a
fu n c tio
n a l[
p h ys
ic ia
n ].
A n d
m y
jo b
is to
m a k e
th e m
a fu
n c tio
n a l[
p h ys
ic ia
n ],
a n d
if I c a n ’t
d o
th a t,
th e n
I’ m
n o t
d o in
g m
y jo
b ’’
. (p
a rt
ic ip
a n t-
1 4 )
‘‘ M
y ro
le is
to e n su
re th
a t th
e o u tc
o m
e is
o p
tim a l,
th a t c a re
is sa
fe ly
d e liv
e re
d , w
ith w
h a te
ve r le
ve l
o f
[le a rn
e r]
.. .w
h o ’s
a ss
ig n e d
to a ss
is t
m e ’’
. (p
a rt
ic ip
a n t-
1 0 )
‘‘ W
e ll,
fir st
o f
a ll,
it’ s
a p
a tie
n t
sa fe
ty is
su e ,
so I’ m
n e ve
r g o in
g to
p u sh
[t h e
le a rn
e rs
to ]
w h e re
th e y’
re n o t
sa fe
w ith
a p
a tie
n t’
’. (p
a rt
ic ip
a n t-
1 7 )
H. C. Chen et al.
1094
In teacher–learner interactions lacking continuity, where
the relationship is new or brief, teachers depended almost
entirely on the learner’s level of training to select learning
activities. ‘‘I will take into consideration . . . what their level
is . . . that’s a pretty good starting point’’ ( participant-18). They
then gathered data from interactions with the learner to
determine the learner’s individual developmental level and
adjust learning activities accordingly. Selection of learning
activities became increasingly individualized as the teacher–
learner relationships became longitudinal. One clinical teacher
described the investment by both the learner and the teacher
in longitudinal relationships and how the two form a partner-
ship to push forward on the learner’s developmental trajectory
together. In order to promote continuity and provide
more individualized teaching, some teachers practiced and
advocated for forward feeding or handing off learners to the
next teacher.
The clinical teacher’s choices of learning activities were
additionally influenced by the curricular goals/objectives,
learner’s goals, their own goals for the learner and develop-
mental considerations. Most teachers solicited learning goals
from learners. However, they felt the learners’ goals needed to
be adjusted based on teacher and curricular goals since
learners do not necessarily have a vision of training outcomes
nor accurate self-assessment and insight. ‘‘We play a role in
guiding them . . . sort of corrections along the path, so that they
can get to this goal that I see more clearly than they do’’
( participant 1). The teachers opted for high yield topics that
met the learner’s learning gaps and deliberately pushed
learners along the developmental trajectory with specific
coaching or challenging assignments.
You want to be able to structure learning such that
the student can feel that they bring something that
they already know, and they can use it . . . but at the
same time, be motivated to build on that skill and to
continue to move forward. ( participant-19)
Teacher responsibilities
For almost all clinical teachers, they viewed the promotion of
learner development as part of their teaching responsibility
and commitment to learners. Some described it as their most
important role as a teacher.
I think we’re fundamental to [promoting develop-
mental progression of learners] . . . if we’re working
with trainees and we’re not watching the store when
we’re with them, then no one’s watching the store . . .
( participant-9)
A small minority (those without longitudinal relationships
with learners) felt that responsibility for promoting learner
development was a separate responsibility from that of
teaching. They took responsibility for teaching specific content
but not necessarily for monitoring or furthering the develop-
ment of a learner’s knowledge or skill from one teaching
encounter to the next. These clinical teachers depended on the
curricular program to ensure developmental progression of
learners.
I don’t per se think that curricular development,
promoting the learning of the student, is the respon-
sibility of the standard faculty member. I think
that’s the responsibility of the educational
leaders . . . They’re the ones who should be in some
way assessing the development of the students
through [standardized] assessments . . . [I] don’t really
expect the faculty members . . . necessarily to have
a goal to move the student forward except in . . . lon-
gitudinal experience[s]. ( participant-10)
Significantly, the clinical teachers discussed the need to
balance their responsibility to learners with their responsibility
to patients. They viewed their job as one of ensuring that
optimal patient care is delivered while simultaneously teach-
ing. For some it was this responsibility to patients or the public
that informed their sense of responsibility to the learner.
In these cases, ensuring patient safety was the primary reason
to attend to learner development.
Discussion
Our study of excellent clinical teachers revealed a deliberate
structuring and sequencing of learning opportunities in the
clinical workplace for different level learners. Despite the
perceived lack of control over patient cases, these excellent
clinical teachers were able to match clinical learning oppor-
tunities to individual learner levels and encourage develop-
mental progression. One, they sequenced clinical learning
opportunities by varying or managing content, complexity and
expectations. Two, they decided which learning opportunities
to select for individual learners based both on expected
curricular competencies and their assessment of learners’
developmental needs. In essence, they adjusted the difficulty/
challenge of a learning opportunity to the learner’s appropriate
learning level, and defined the appropriate learning level to be
the growth edge or next step in the learner’s developmental
trajectory that aligns with curricular aspirations. Both learner
growth as well as patient safety considerations drove clinical
teachers’ attention to learner developmental levels and selec-
tion of learning activities.
Prior studies on selection of patients for student teaching
demonstrated that clinical teachers took into account potential
educational value of the interaction (e.g. how well the patient
case fit their educational/teaching objectives) and used the
potential of psychosocial and communication challenges as
exclusion factors (Simon et al. 2003; Gierk & Harendza 2012).
We looked at clinical situations where the teacher is required
to care for a panel of patients with a range of different level
learners and must balance patient care with their teaching
responsibility. Here we found that they similarly considered
the educational value of learning activities and were influ-
enced by the presence of psychosocial and communication
challenges. However, instead of merely choosing from among
available patient cases, the excellent clinical teachers we
Sequencing learning experiences
1095
studied actively structured the available cases and learning
opportunities to suit the developmental level of their learners.
The teachers supported individualized learning by applying
sequencing principles at the level of individual learner
interactions. Previously, the concept of sequencing had only
been described at the curricular level (Collins 2005; Dornan
et al. 2014). The teachers’ strategies of varying content and
managing complexity incorporate Collins’ three principles for
curricular sequencing: increasing complexity, increasing diver-
sity and conceptualizing whole tasks before breaking the tasks
down into smaller steps (Collins 2005). The management of
complexity by presenting earlier learners with classic cases
and focusing initial content on more generalizable knowledge
and skills exemplifies Collins’ principle of increasing diversity.
It is consistent with clinical teaching models such as the One
Minute Preceptor, where one of the steps is to teach a general
principle (Neher et al. 1992). Bordage also recommended that
initial teaching should focus on prototypes with limited
presentations to provide anchors for future examples that are
more complex and diverse in presentation (Bordage 2007).
In his work with medical students, Dornan has argued that
one of the most important behaviors for clinical teachers to
exhibit is the ability to include learners and support their
participation in authentic patient care activities (Dornan et al.
2014). Our study of excellent clinical teachers corroborates the
findings from Dornan’s studies on medical student learning
(Dornan et al. 2007, 2014) and extends them to include
resident and fellow learning. The teaching practices described
by the excellent clinical teachers in our study can offer
potential guidelines for how others may sequence access to
workplace activities for their learners. Table 2 is a summary of
strategies for sequencing and selecting clinical learning
activities to match learning opportunities with learners at
different levels and ensure patient safety as well as learner
development. These strategies originate from our study results
and include the authors’ interpretation of the data which was
informed by the framework of cognitive apprenticeship. Each
strategy includes specific suggestions for practical application,
derived from examples provided by clinical teachers in our
study.
There are limitations to this study. First, this was a single
institution study. While we did only interview clinical teachers
from one institution, they exemplified faculty with known
excellence in teaching, worked at three very different medical
centers (academic, county, veteran’s administration) and
reflected a variety of specialties. Second, this was an interview
study where clinical teachers provided self-reports of their
teaching practices. Their self-reports may not be an accurate
reflection of their actual teaching behavior in the clinical
environment. This was therefore an initial study to explore
approaches to teaching different level learners, and having the
clinical teachers articulate their practices and the rationale
behind them allowed for better understanding of their
approaches. A follow-up observational study is needed to
confirm our findings for teacher selection of learning experi-
ences for different level learners. Additionally, we focused
only on excellent teachers and future work is needed to
address comparisons to other teachers.
As has been noted by Yardley and colleagues, the
importance of offering cognitive and practical support to
learners is becoming more crucial as early learners spend
increasing time in the clinical workplace (Yardley et al. 2012).
Excellent clinical teachers described on-the-ground sequen-
cing and activity selection teaching strategies, which they used
as an adjunct to curricular sequencing, to choose develop-
mentally appropriate clinical learning experiences for learners
at different levels. These strategies may help all clinical
teachers to safely ensure engagement of every learner in the
clinical workplace and promote learner progression along a
developmental trajectory.
Notes on contributors
H. CARRIE CHEN, MD, MSEd, is Professor of Pediatrics at the University of
California, San Francisco School of Medicine.
PATRICIA O’SULLIVAN, EdD, is Professor of Medicine at the University of
California, San Francisco School of Medicine.
ARIANNE TEHERANI, PhD, is Associate Professor of Medicine at the
University of California, San Francisco School of Medicine.
SHANNON FOGH, MD, is Assistant Professor of Radiation Oncology at the
University of California, San Francisco School of Medicine.
BRENT KOBASHI, MD, is Assistant Professor of Medicine at the University
of California, San Francisco School of Medicine.
OLLE TEN CATE, PhD, is Professor of Medical Education and Director of
the Center for Research and Development of Education at the University
Medical Center Utrecht, the Netherlands.
Acknowledgments
The authors would like to thank the members of the UCSF
Academy of Medical Educators who participated in the study.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of this article.
This project was funded by an education grant from the
Association of American Medical Colleges Western Group on
Educational Affairs. In addition, Dr. Chen’s work in medical
education is supported in part by the Abraham Rudolph
Endowed Chair in Pediatric Education from the UCSF
Academy of Medical Educators. The funding sources had no
involvement in study design, data collection and analysis,
interpretation of results or preparation or approval of the
manuscript.
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