Cultivating and recognizing teachable moments
I went with four students to interview a woman with AIDS. A first-year medical
student named J. attempted the interview. Finding the patient confused and
lethargic, J. handled the situation thoughtfully and compassionately. Although
she hoped that the interview would be helpful, she saw that the woman was
tired and was willing to let her rest. As we left, feeling disappointed,
the patient's sister entered the room. I perceived that this woman wanted
something from us and offered to have our team talk with her. Sitting beside
the patient's sister on a couch, J. gently elicited the story of a single
woman with two children who was trying to take care of a sick, confused
sister in an apartment building where neighbors would reproach a person
they knew had AIDS. We allowed this woman to cry. J. gently validated her
intention to discuss some practical decisions about her sister's care with
Teachable moments like this often occur unexpectedly. In the above case,
despite the student's impressive skills in talking to patients, the planned
teaching exercise failed to come off. Some useful lessons were nonetheless
learned, such as when and how to terminate a patient interview, the importance
of respecting a patient's wishes and how setting the right example may outweigh
the need to complete a teaching exercise. These are powerful lessons. One
might even say that it was precisely because of J's example of respect for
the patient that the fruitful encounter with her sister ensued. The teachable
moment crystallized at the very moment the sister conveyed her availability,
even desire, to talk with the students and their teacher.
Not all teachable moments are this dramatic; they can involve making a small
point. Taking advantage of an unplanned opportunity almost always leads
to learning on an expanded level. What starts as a didactic lesson may end
in the uncovering of important attitudes, values or meaning.
Recognizing teachable moments requires both mindfulness and a learner-based
mind-set. The teacher must be aware of what is going on around him or her:
mindful of how students are reacting; mindful of a patient's family member's
body language; and mindful of the multiple levels of learning. Recognizing
teachable moments also will be facilitated by a mindset centered on helping
the student to learn, as opposed to "teaching" the student. The
teacher must see what goals the student has, what he or she knows, feels
and is open to.
Do teachable moments always occur unexpectedly? Yes and no. One cannot prescribe
a teachable moment. On the other hand, cultivating the skills of mindfulness
and learner-centered teaching leads to recognition of more teachable moments.
Earning the trust of the learner facilitates these moments, for the learner-centered
teacher depends on the student to participate actively. The learner must
trust the teacher to give honest feedback and to suggest learning exercises,
as in the next example. N. had difficulty establishing rapport with patients
in an interview. The teacher spontaneously suggested that another student
play the role of the patient and tell N.: "I found out it was malignant."
N. offered several verbal responses to this statement until he found the
most suitable and comfortable response for him. Thus, N. practiced and mastered
a new skill with both a moral and technical dimension.
In medical education, which often involves active, practical learning with
real patients and peers, teachable moments abound. But classroom discussion
still presents opportunities so long as the teacher uses a more student-centered
mode. Instead of simply providing the answer to a student struggling with
a question, for example, the teacher might ask about the usefulness of the
information or the methods available for researching it. Also, in the classic
mode of problem-based learning, the teacher's retort to a student's question
could be some variation of "what do you think the answer is?"
Or perhaps, "tell me what you know about that." The value of the
open-ended question is that the student is not pinned down to a specific
answer, but can say however much he or she knows. The teacher has many choices
in his or her response. He or she may probe further, provide information,
involve another student, challenge or praise the student or validate his
or her efforts. This classic response has many variations, and as simple
as it is, often opens a door to a teachable moment.
William T. Branch, Jr. is the Carter Smith, Sr. Professor of Medicine, director
of the Division of General Medicine and vice chairman of the Department
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