Abstract
All medical educators have experienced “teachable moments” during their career, and most can likely share examples of these moments from both training and their role as educators. In addition, most if not all have faced a situation in which an educational opportunity fell short or was missed entirely. This View from the Association of Pediatric Program Directors is designed to help pediatric medical educators recognize these teachable moments and feel better prepared to seize them when they arise. First, the authors collate definitions of the “teachable moment” from a variety of sources into 1 coherent definition, using common themes of shared responsibility between educator and learner, spontaneity, consideration of the learning environment, and expanding teaching into other applications. Next the authors provide methods to help educators capitalize on teachable moments when they occur, including discussing goals and expectations, building a culture of error, anticipating common errors made by learners, withholding the answer, managing time effectively, and practicing mindfulness. Numerous examples are described to further understanding. By employing these tactics, both educators and learners can maximize their ability to utilize teachable moments in a variety of clinical settings.
Keywords
The concept of the “teachable moment” is widespread in the realm of education as a technique for parents and early education teachers to enhance the developmental skills of children. Teachable moments occur in the context of everyday behavior and inherently center on practical knowledge and skills. While the term is most commonly used in elementary education,
2
,3
the teachable moment is clearly applicable in graduate medical education as well, where a large proportion of teaching occurs within the context of a clinical learning environment. This manuscript synthesizes definitions from the literature into a workable definition of the teachable moment in medical education, and then proposes methods to maximize learning when teachable moments occur.Recognizing the Teachable Moment
Most medical literature on the “teachable moment” refers to patient education, for example, using a diagnosis of chronic obstructive pulmonary disease to counsel about smoking cessation.
4
Other authors have cited successful frameworks for teaching in brief segments, such as the 5 “microskills” of the One-Minute Preceptor model,5
but these generally occur as part of routine, scheduled teaching interactions as opposed to the more spontaneous teachable moment. After conducting a narrative review of existing lay, educational, and medical literature, we found the following to be unifying features of the teachable moment posited by a variety of sources.Shared Responsibility and Bidirectional Learning
Some authors base their definition of the teachable moment on the readiness of the learner,
6
while others focus on the preparedness of the educator.7
Indeed, some authors have suggested that separate “teachable moments” and “learnable moments” exist.8
,9
However, this seems analogous to thinking about playing tennis as a solitary endeavor: finding a teachable moment without a learner is like serving into an empty court, and considering a learnable moment without a teacher is akin to waiting to return a ball without anyone serving from the other side of the net. The better approach focuses on a shared responsibility between both learner and educator.,11
Furthermore, the learning is often bidirectional, wherein both educator and learner leave the situation having newfound knowledge.11
The majority of authors agree that some level of preparedness on both parts is necessary for successful teachable moments. It is worth noting, while there is a role for practicing teaching skills without learners, and self-directed learning without a specific teacher happens frequently, these events occur outside of the sphere of what we would classically consider a “teachable moment.”Spontaneity
Surely all medical educators can remember an occasion when a trainee asked an unanticipated question. Indeed, spontaneity is common to many definitions of a teachable moment.
6
,,12
The unexpected nature of these encounters reinforces the need for attentiveness and preparedness to recognize these “fleeting opportunities”Baxter S. Early learning ideas/learning about the world: teachable moments. 2007. Available at: http://aplaceofourown.org/question_detail.php?id=101. Accessed January 21, 2020.
13
when they arise. A nonthreatening environment in which learners’ minds can stretch without fear of judgment also fosters spontaneity.Lewis B. How to create teachable moments in the classroom. 2019. Available at:https://www.thoughtco.com/what-is-a-teachable-moment-2081657. Accessed January 21, 2020.
Appropriate Environment
Teachable moments occur ubiquitously, from the outpatient clinic, the inpatient wards, the procedure suite, or somewhere in between. Most early education experts comment on the importance of the right environment for teachable moments,
11
implying that certain situations are more conducive to teachable moments than others. For example, inpatient Family-Centered Rounds serves as an ideal situation for a teachable moment. At the bedside after an intern presents a patient with a red, swollen knee is the perfect environment for a discussion on the differential diagnosis for arthritis. Both learner and educator expect to find learning opportunities in this setting. Conversely, providing constructive feedback in the hallway at the end of a resident's 24-hour shift may prove less successful.Expanding Learning Into Practice
One of the strengths of a teachable moment is that the learning occurs in context, building strong memory associations for future retrieval.
14
Furthermore, an ideal teachable moment is transferrable and generalizable to other contexts, which some authors describe as turning “learning into practice.”Center for Occupational Research and Development. What is contextual learning? 2019. Available at: https://www.cord.org/cord_ctl_overview.php. Accessed January 21, 2020.
7
William Branch defined a teachable moment in medical education as “Taking advantage of an unplanned opportunity [that] leads to learning on an expanded level.” While expanding learning beyond a specific context is essential in all human learning,15
skills-based learning offers a common application of this in medical education. For example, when an educator supervising a lumbar puncture provides a lesson in appropriate sterile techniques, the learner may take away lessons that can be used in myriad other procedures. Modeling professionalism, displaying empathy, navigating a challenging patient interaction, and demonstrating clinical reasoning skills can all serve as teachable moments that have a lasting impact on learners’ behavior.16
Educators can further enhance these learning encounters by deliberately debriefing with learners afterward, making sure to name specific skills they utilized and reflecting on what could have gone better. This can help learners see how practicing physicians engage in deliberate practice utilizing mindfulness and metacognition, 2 key skills.17
,18
We will expound on the concept of mindfulness and how to use it to seize the teachable moment below.A Comprehensive Definition
In trying to combine these major themes, we propose the following definition:
A teachable moment occurs when a mindful teacher and a ready learner spontaneously share an educational experience within the context of a specific learning environment, ideally facilitating generalization and expansion to future encounters and scenarios.
Seizing the Teachable Moment
Now that a unifying definition has been proposed to assist in better recognizing teachable moments, the focus can shift toward capitalizing on them. The following strategies will prepare learners and educators to achieve this goal. The strategies are summarized with examples in Table.
TableStrategies for Teachers to Maximize Teachable Moments, With Corresponding Sample Prompts and Behaviors
| Preparation | Sample Prompts or Behaviors |
|---|---|
| Discuss goals and expectations |
|
| Build a culture accepting of error |
|
| Anticipate errors |
|
| Develop teaching scripts |
|
| Withhold the answer |
|
| Manage time effectively |
|
| Practice mindfulness |
|
Discuss Goals and Expectations Ahead of Time
While the learning in a teachable moment may be bidirectional, the primary focus should be on the needs of the learner.
6
,11
A simple yet effective method to understand those needs is to make time at the beginning of a clinical experience to discuss the learner's goals. This can occur on the first day of a clinical rotation, the first 10 minutes of a shift in the emergency department, or before seeing a patient in the outpatient clinic. If an Adolescent Medicine attending knows that her resident has a primary goal of improving his communication around the bimanual exam, she can focus her teaching on this procedural ability rather than the differential diagnosis of cervical motion tenderness, which may be rote for the learner by now.In addition, reviewing both the educator's and the learner's expectations during this initial check-in can facilitate more readily and rapidly arriving at teachable moments. For example, if the learning environment encourages learners to ask questions as they arise, as opposed to saving them for a separate, prescribed time, this allows the learner freedom to follow spontaneous lines of inquiry. Similarly, educators can set expectations that learners will receive formative feedback in real time. Setting expectations early opens the door for clearer, more productive teaching.
Build a Culture Accepting of Error
Traditional education puts value on students knowing the right answer to questions. Learners spend the majority of their time in school trying to showcase their knowledge. Admission to medical school and residency training is highly competitive and based on trainees’ scores in class and on standardized tests. Thus, it is not surprising that many learners in medicine make every effort to showcase the information they know to their instructors while avoiding exposing gaps in their knowledge. This attitude can hinder learners’ growth and development, making it difficult for teachers to identify teachable moments. Making errors has been shown to be a valuable and unique learning experience, and normalizing mistakes helps learners feel comfortable exposing gaps in their knowledge.
19
Developing a culture of error where trainees feel comfortable making and discussing mistakes is essential, to “spend less time hunting for errors and more time fixing them.”
20
Techniques for achieving this culture include reframing mistakes as “learning opportunities,” praising risk-taking by learners, and rewarding right answers with harder questions to “stretch” learners to their limits.20
Anticipate Errors
Master teachers use their expertise and experience to anticipate teachable moments based on common learner errors,
8
a method that becomes easier once an educator has established a culture of error. These opportunities can be in the realms of medical knowledge, clinical reasoning, communication, or procedures. For instance, when a pediatric intern presents an infant with spitting after feeds, the expert educator can predict that the resident may suggest prescribing a histamine-2-receptor antagonist and can mentally prepare her brief teaching point about the difference between physiologic reflux and pathologic gastroesophageal reflux disease. By anticipating errors, the educator is prepared to interject a teaching point at the appropriate moment.Develop Teaching Scripts
Similarly, expert clinician-educators develop “teaching scripts” for frequently encountered teachable moments.
21
Experts suggest these teaching scripts consist of the triad of a trigger, key teaching point(s), and teaching strategies.21
Once the trigger, or teachable moment, is recognized, the educator can launch into the script by focusing on 1 to 2 salient teaching points and utilizing a teaching technique that best drives home the lesson. The optimal teaching strategy varies based on the situation; for example, providing a mnemonic may be suitable for an intern to remember the differential diagnosis of an anion-gap metabolic acidosis, while modeling shared decision-making may be more appropriate when coaching residents through an end-of-life care discussion. Importantly, the development of these scripts is an iterative process, as expert teachers constantly refine and improve their teaching scripts over time.21
Many educators prepare teaching scripts ahead of time and keep them in a physical or virtual notebook (eg, on a smart phone or tablet) to be used when appropriate. Sharing these with others in some sort of repository can also prove useful. The Society of Hospital Medicine's Teaching Scripts webpage22
offers practical examples of reusable, effective teaching scripts.Weiss L, Thakkar N, Henson C, et al. Teaching scripts. 2020. Available at: https://www.sohmlibrary.org/teaching-scripts.html. Accessed August 14, 2020.
Withhold the Answer
By encouraging learners to discuss all potential answers to a question, not just the one they think is right, teachers can keep learners more productively engaged and build suspense.
20
For example, when discussing the differential diagnosis for fever in a newborn admitted to an inpatient service, the teacher should refrain from revealing to the group what she thinks is the correct answer, and instead push the learners to approach each potential cause, such as pneumonia, urinary tract infection, or meningitis, with equal consideration and thought. This increases the teacher's understanding of the learners’ thought processes, gaps in their reasoning, and the odds of unearthing a teachable moment.A similar technique involves asking a question and then asking all team members to write down their answer on a piece of paper. The learners then all share what they wrote and defend their reasoning. By making “everybody play,” learners stay engaged and learn that all group members will be expected to think about an answer and engage in discussion, not just the first person who volunteers. This builds a culture of error, and forces learners to commit to and defend an answer to the group.
Manage Time Effectively
Paying attention to the timing of teaching is a component of finding the right educational environment. It is important to remember that it is called a “teachable moment” and not a “teachable hour” for a reason. The structure of the clinical work must be such that it allows for brief forays into teaching, and those diversions must remain brief so that clinical work can be accomplished. Often, the most effective teachable moments occur in less than 5 minutes by delivering a brief, easily digestible, clinically relevant teaching point that learners can quickly retrieve when facing a similar situation.
Practice Mindfulness
Over the last decade, mindfulness has become an important topic for physicians, often focused toward improving physician wellness. In addition, it has been suggested that mindfulness is required to recognize teachable moments. Mindfulness has been defined as “paying attention in a particular way: on purpose, in the present moment, and nonjudgmentally.”
23
This means that an educator needs to maintain constant, conscious focus on the learning environment in order to take full advantage of teachable moments. This proves challenging with the multiple demands on a medical educator's time and concentration: it may be easy to slip into thoughts of the next clinic patient on the schedule; or the previous perplexing diagnostic dilemma; or what the cafeteria will be serving for lunch today. Being deliberate helps teachers be mindful and remain focused on the task at hand. Many educators take notes, writing down exact phrases that learners use, to facilitate mindfulness and enhance teachable moments.Additionally, approaching learners in the absence of judgment enhances teaching opportunities. It is easy to feel disappointment as a teacher when a learner misfires with a proposed treatment plan, but this sentiment does not benefit the learner and hinders the teacher's ability to focus on seizing a teaching opportunity. Educators can reframe learner “mistakes” as “teaching opportunities,” similar to reframing errors to trainees as “learning opportunities.”
Summary
Recognizing and seizing a teachable moment in medical education requires a firm understanding of its meaning by both the educator and the learner. We can greatly increase these spontaneous teaching and learning opportunities by setting learner-focused goals, building a culture of error and anticipating common errors in knowledge or skills, withholding the answer, managing time effectively, and practicing mindfulness. Together in this construct, prepared educators and ready learners can achieve more frequent and more productive teachable moments.
Acknowledgments
The authors wish to thank Dr Michael T. Byrne, Dr Michael Elnicki, and Dr Dena Hofkosh for their input on earlier drafts of this manuscript.
References
- Human Development and Education.1st ed. Longmans, Green, New York1953
- Teachable Moments: The Art of Teaching in Primary Schools.Open University Press, Buckingham, UK1996
- The anatomy of a teachable moment: implications for teacher educators.J Inquiry Action Educ. 2008; 1: 19-34
- Understanding the potential of teachable moments: the case of smoking cessation.Health Educ Res. 2003; 18: 156-170
- A five-step “microskills” model of clinical teaching.J Am Board Fam Pract. 1992; 5: 419-424
- The changing paradigm for continuing medical education: impact of information on the teachable moment.Bull Med Libr Assoc. 1990; 78: 173-179
- Creating the teachable moment.J Nurs Educ. 1998; 37: 278-280
- Inquiry-based science: turning teachable moments into learnable moments.J Sci Teacher Educ. 2014; 25: 79-96
- Teachable moments, learnable moments: medical rounds as a paradigm for education.Mind Brain Educ. 2014; 8: 3-5
- Cultivating and recognizing teachable moments.Emory Rep. 1996; 49
- Teachable-moment-oriented curriculum practice in early childhood education.J Curric Stud. 2003; 35: 111-127
Baxter S. Early learning ideas/learning about the world: teachable moments. 2007. Available at: http://aplaceofourown.org/question_detail.php?id=101. Accessed January 21, 2020.
Lewis B. How to create teachable moments in the classroom. 2019. Available at:https://www.thoughtco.com/what-is-a-teachable-moment-2081657. Accessed January 21, 2020.
Center for Occupational Research and Development. What is contextual learning? 2019. Available at: https://www.cord.org/cord_ctl_overview.php. Accessed January 21, 2020.
- Introductory psychology.Lancaster Lancashire. viii. MTP Press, Boston1984: 724
- The teachable moment.Acad Med. 2010; 85: 630
- Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains.Acad Med. 2004; 79: S70-S81
- Intuition and Metacognition in Medical Education.Spring Publishing Company, New York, NY2006
- Failure is an option: using errors as teaching opportunities.Pediatrics. 2018; 141: 11-13
- Teach Like a Champion 2.0: 62 Techniques That Put Students on the Path to College.2nd ed. Jossey-Bass, San Francisco2015
- How attending physicians make instructional decisions when conducting teaching rounds.Acad Med. 1992; 67: 630-638
Weiss L, Thakkar N, Henson C, et al. Teaching scripts. 2020. Available at: https://www.sohmlibrary.org/teaching-scripts.html. Accessed August 14, 2020.
- Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life.Hyperion, New York2005
Article info
Publication history
Published online: August 19, 2020
Accepted:
August 17,
2020
Received:
June 1,
2020
Footnotes
The authors have no conflicts of interest to disclose.
Identification
Copyright
Copyright © 2020 by Academic Pediatric Association
