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 the doctors.

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 of Medicine.

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