Education

Section one: Historical background

Infants and children have been a part of the practice of anesthesiology since the mid-1800s. Pediatric anesthesia training as a separate and distinct subspecialty of anesthesiology is attributed to Dr. Robert M. Smith at The Children’s Hospital of Boston ( ; ). In 1997 a group led by Dr. Mark Rockoff petitioned the Accreditation Council for Graduate Medical Education (ACGME), which resulted in pediatric anesthesiology becoming an accredited fellowship, with American Board of Anesthesiology (ABA) board certification beginning in 2012 ( ). The Pediatric Anesthesiology Milestones Project was a joint venture of the ACGME and the ABA released in July 2015 ( ). Clearly, the practice of pediatric anesthesiology is constantly evolving, as are the training programs that help develop new practitioners (i.e., general anesthesiology residents or pediatric anesthesiology fellows). To quote , “as the specialty grows, so too must the educational training process,” and so must the practitioner in their role as a clinical instructor.

Section two: Roles of the clinical instructor

The clinical instructor often plays multiple roles when teaching in a clinical setting: role model, supervisor, teacher, and instructional leader ( ). The mind map in Fig. 63.1 outlines each of the four roles of the clinical instructor, and each of the roles is further divided into elements of character and skills. As faculty grow as professionals, they must continually work on both character-related skills and behaviors and the more traditional skills associated with each respective role.

Role model: The process of serving as a role model is ongoing and impactful in an education setting. Sometimes, role models may be contradictory and negative. Embodying the four-character elements noted on the map (consideration, fairness, reflectiveness, accountability) helps ensure positive modeling. Acting as a role model as an intentional teaching strategy is often used in clinical training as part of guiding learners in forming their own professional identities. With this strategy, junior learners listen to and observe an instructor performing the regular duties of the specialty and are introduced to clinical skills and problem-solving, in addition to appropriate values, ethical behaviors, and professional habits.

Tasks that positively enhance the impact of a role model:

• Display enthusiasm toward the practice of your specialty and toward teaching.

• Demonstrate a broad knowledge of medicine with depth in your own specialty.

• Explain your thinking: articulate the mental processes that lead to successful decision making or completion of a procedure.

• Demonstrate clinical competence (lead by example).

• Demonstrate exemplary professional characteristics (e.g., go the extra mile for the team; treat other healthcare professionals and your learners with consideration and fairness).

• Take time each day to critically reflect on your teaching and patient care.

Clinical supervisor: Most clinician educators play the clinical supervisor and clinical teacher roles simultaneously. A clinical supervisor’s primary concerns are the patient and excellence in patient care, whereas a teacher’s primary concern is the learner. This dual role can be challenging for preceptors and confusing for learners. That is a key reason why it is vital to set clear expectations for learners not only in relation to academic performance but also in relation to learners’ roles in each clinical setting and again with each case. Great supervisors incorporate all of the characteristics of the best role models in addition to accessibility to learners, admitting one’s own limits and maintaining emotional control, even in the toughest situations (e.g., error, failure, death of a patient). Supervisors also use their clinical expertise and leadership skills to monitor care and work within or lead the care team. Finally, clinical supervisors build and share case-based examples to continuously build their own knowledge and skills and share that growing expertise with learners ( ).

Tasks that will promote success for clinical supervision:

• Provide structure in the work/learning setting, ensuring that the best possible environment exists for both patient care and learning.

• Articulate expectations, ensuring that the role/job description for each learner/trainee is clearly articulated.

• Provide opportunities for skill and concept development.

• Promote problem-solving and critical appraisal skills through building and sharing case-based examples.

• Monitor patient care, providing oversight for individual trainees and team performance.

• Respond rapidly and rationally to both positive and negative events.

Clinical teacher: Excellence as a clinical teacher within pediatric anesthesiology requires clinical knowledge, pediatric knowledge (the perioperative environment), and educational knowledge. Educational knowledge includes knowledge of learning principles and teaching methods, knowledge about the learners, and knowledge of case-based teaching scripts ( ). The best teachers are learner-centered, focused on meeting the learning needs of each student, resident, and/or fellow. They are also collaborative, engaging learners as team members, guiding their development toward autonomy ( ).

The primary activities that are integrated into the role of teacher in clinical settings include:

• Establishing a positive learning environment (establish rapport and communicate expectations for learner performance).

• Diagnosing learners’ mindset, prior knowledge, structure of knowledge, and motivation.

• Selecting the appropriate teaching mode based on the learner’s developmental level.

  • Instructing novices (medical students) to help build basic skills.

  • Coaching the advanced beginner (residents and beginning fellows) to guide their care planning and skill development.

  • Facilitating the growing autonomy and increasing responsibility for the competent learner (fellows).

  • Listening to and observing learner performance; providing formative (ongoing), specific feedback; and documenting learner performance, making specific notes to help provide better written summative (end of an instructional unit) or periodic feedback.

• Cultivating a psychologically safe environment where trainees can take educational risks (ask questions, say “I don’t know,” admit mistakes, speak up) without fear of judgment, ridicule, or embarrassment ( ).

Instructional leader: For anyone who chooses to become an instructional leader within academic anesthesiology, activities expand beyond one-to-one interactions with learners to overseeing an entire educational process, rotation, or other curricular element, or even an entire training program. Instructional leaders provide guidance for other faculty in addition to learners. Character development at this point might focus on building and modeling a 21st-century mindset—a growth mindset that embraces lifelong learning and sees setbacks (disappointments, delays, failures) in oneself or others as opportunities for growth rather than signs of “failure” ( ; ). Most instructional leaders also need to build the mindset and skills to become an educational change agent and an educational scholar. There is much to learn, requiring the same kind of deliberate practice that was invested into becoming a skilled pediatric anesthesiologist. This is one reason why so many faculty choose to complete a complementary degree in academic medicine, medical education, or education in the health professions.

The tasks of an instructional leader and scholar may include:

• Curriculum development that promotes excellence in clinical education.

• Evaluation and improvement of teaching.

• Mentoring of self and others to enhance well-being.

• Educational research toward creating new knowledge concerning teaching and learning in clinical settings.