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The interest in nephrology as a career has declined over the last several years. Some of the reasons cited for this decline include the complexity of the specialty, poor mentoring and inadequate teaching of nephrology from medical school through residency. The purpose of this article is to introduce the reader to advances in the science of adult learning, illustrate best teaching practices in medical education that can be extrapolated to nephrology and introduce the basic teaching methods that can be used on the wards, in clinics and in the classroom.
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Applying effective teaching and learning techniques
to nephrology education
Helbert Rondon-Berrios and James R. Johnston
Renal-Electrolyte Division, University of Pittsburgh School of Medicine, Pittsburgh, PA 15261, USA
Correspondence and offprint requests to: Helbert Rondon-Berrios; E-mail:
The interest in nephrologyas a career has declined over the last several years.Some of the reasons cited for this decline include
the complexity of the specialty, poor mentoring and inadequate teaching of nephrology from medical school through residency.
The purpose of this article is to introduce the reader to advances in the science of adult learning, illustrate best teaching
practices in medical education that can be extrapolated to nephrology and introduce the basic teaching methods that can be
used on the wards, in clinics and in the classroom.
Key words: learning, medical education, nephrology, teaching
Anybody who believes that all you have to do to be a good teacher is to
love to teach also has to believe that all you have to do to be a good sur-
geon is to love to cut.
Adam Urbanski, President of the Teachers Association of
Rochester, Rochester, New York
Kidney disease is a major health care problem in the USA. The
prevalence of chronic kidney disease is growing, especially in
the older population. However, changes in the health care system
make it difcult to predict whether this need will cause an in-
creased demand for nephrologists [1]. Despite an apparent de-
mand, interest in nephrology as a career choice has decreased.
For appointment year 2016, 58.9% of nephrology fellowship train-
ing programs did not ll in the nephrology match and there were
only 0.6 applicants per nephrology fellowship position [2]. Sev-
eral reasons have been cited for this decline, including percep-
tions that nephrology is too complex, poor mentoring and
inadequate teaching of the subject [3]. What is more, innovation
and research in nephrology education are lacking [4]. Teaching
nephrology is a demanding, complex and often frustrating task,
a task many nephrologists assume without proper preparation.
To face this problem, nephrologists who assume a teaching role
should not only be familiar with best existing teaching practices
but should also consider novel strategiesto adapt to the changing
need of todayslearner[57]. However, the literature of best
teaching practices pertinent to nephrology education is very
scarce. The purpose of this article is to review the existing litera-
ture regarding best teaching practices in medical education and
consider options applicable to nephrology education.
What makes good teachers and do they make a
The question, what makes a good clinical teacher in medicine?
has been the subject of considerable controversy. To identify
some of the qualities that make a good teacher, Elnicki and Coo-
per [8] surveyed 72 third-year medical students who were rotat-
ing in the general internal medicine inpatient service on
numerous teaching behaviors of attending physicians and
house staff and evaluated their overall teaching effectiveness.
Received: May 18, 2016. Accepted: July 19, 2016
© The Author 2016. Published by Oxford University Press on behalf of ERA-EDTA.
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For commercial re-use, please contact
Clinical Kidney Journal, 2016, 18
doi: 10.1093/ckj/sfw083
CKJ Review
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by guest on September 1, 2016 from
Teaching effectiveness of attending physicians correlated most
strongly with the teachers behaviors: showing enthusiasm and
interest in teaching (R
= 63.6%, P < 0. 01), inspiring con dence in
their knowledge and skills (R
= 9.9%, P < 0.01) and providing use-
ful feedback (R
= 5.0%, P < 0.01) and less strongl y with encour -
aging students to accept increasing responsibility (R
P = 0.03). Sutkin et al.[9] performed a systematic review of the lit-
erature to answer the same question. The authors found 68 arti-
cles, mostly surveys and essays, identifying 480 descriptions of
characteristics of a good clinical teacher that they clustered in
ve common themes:
1. Medical knowledge
2. Clinical competence
3. Positive relationship with students
4. Communication skills
5. Enthusiasm for teaching
There is also evidence that good teachers inuence studentsper-
formance and specialty choice. Stern et al.[10] analyzed a data-
base of 362 third-year medical students who rotated in
inpatient general medicine and cardiology services and their
138 supervising faculty physicians. The investigators organized
the data in pairs of studentfaculty physician and correlated fac-
ulty physician ratings by the student in the pair with the stu-
dents individual score in the National Board of Medical
Examiners (NBME) subject examination in internal medicine, a
validated instrument of postclerkship knowledge. After multi-
variate analysis, ratings of faculty physicians were small but sig-
nicant predictors of students performance on the NBME subject
examination (βcoefcient = 0.15, P = 0.0047). Grifth et al. [11]
went to explore the question of whether excellent clinical tea-
chers can inuence the specialty choice of top students who usu-
ally have other choices available (other than internal medicine).
The investigators analyzed a prospective cohort of 52 students
who rotated in their third-year medicine clerkship and scored
in the top 30% of the US Medical Licensing Examination step 1
within the prior 2 years. These students rated 62 faculty physi-
cians with whom they worked during their clerkship rotation.
Using multiple regression analysis, the investigators found that
exposure to highly rated faculty physicians (rated top 20%) was
an independent predictor of internal medicine residency choice
for excellent medical students (P = 0.02).
Principles of adult learning
There are many different models to explain how adults learn [12];
however, the best known of these efforts is andragogy,de-
scribed by Knowles in 1973 [13]. For Knowles, andragogy was
based on six crucial assumptions (Table 1) about the characteris-
tics of adult learners, different from the assumptions about child
learners on which traditional pedagogyis founded:
1. Learnersexperience: Adults like to be given the opportunity to
use their existing knowledge foundation and apply their life
experiences to their own professional development (e.g. a
nephrology attending asks a medical student if he or she
has ever taken care of a patient with hyponatremia). This
also has some potentially negative effects. As adults accumu-
late experience, they may develop mental habits, biases and
preconceptions that tend to close their minds to new ideas
and alternative ways of thinking (e.g. the student above re-
sponds afrmatively but also remembers that the patient
with hyponatremia was given NaCl tablets to correct the so-
dium decit).
2. Self-directedness: Adults feel responsible for their own lives.
This sense of self-responsibility results in a psychological
need to be seen and treated by others as being capable of
self-direction. Therefore, they resent and resist learning
when they feel others are imposing information on them.
(This can be avoided by the nephrology attending meeting
with the renal fellow on the rst day of the rotation and soli-
citing the fellows learning goals for the month.)
3. Readiness to learn: Adults become ready to learn when they
have to cope effectively with problems that arise in the pre-
sent. The key concept here is timing the learning experience
to coincide with a task, i.e. nding a teachable moment (e.g.
right after a medical student has completed a presentation
on a patient with hypokalemia, the nephrology attending suc-
cinctly reviews the diagnostic approach to hypokalemia).
4. Orientation to learning: Adults are motivated to learn things
when they perceive that learning will help them deal with
problems they confront in real life. They learn new knowledge
most effectively when it is presented in the context of appli-
cation to real-life situations (e.g. a nephrology attending
notes the large number of patients with chronic kidney dis-
ease the fellows see in the clinic and then reviews the fellows
charts and instructs them on current standards of care for pa-
tients with chronic kidney disease).
5. Need to know: Adults do not pursue learning for the sake of
learning. They want to know why they need to learn some-
thing before undertaking learning (e.g. a nephrology attend-
ing lists three clinically relevant learning objectives at the
beginning of his lecture on recognizing and treating kidney
allograft rejection).
Table 1. Principles of adult learning and their application to
nephrology education [14]
Principle Application
1. Learners
Teacher should connect students life
experiences and prior learning to new
information. Teacher should also nd ways
to help students examine their own habits
and biases and open their minds to new
2. Self-directedness Teacher should give up control of the course
and allow trainees to be empowered.
Teacher should allow learners to establish
their own learning goals and activities.
Teacher should encourage independent
study and allow learners to proceed at their
own pace.
3. Readiness to
Teachers should look for a teachable
moment, an unplanned opportunity that
lends itself to discussion of a particular
4. Orientation to
Teachers should teach not only content that is
useful for the learners tasks at hand but in a
way that explicitly states its practical
5. The need to know Teacher should explicitly state the educational
objective at the beginning of the activity.
Teachers must help trainees become aware
of their need to knowand make a case for
the value of learning something by making it
applicable to their practice.
6. Motivation Teacher should create a non-threatening
welcoming classroom environment.
2|H. Rondon-Berrios and J.R. Johnston
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6. Motivation: Adults respond to some external motivators (e.g.
high salaries, academic promotion, meeting performance
standards), but the most potent motivators are internal pres-
sures (e.g. job satisfaction, self-esteem). Adults are motivated
to learn when they are recognized and appreciated for their
individual contributions to the class (e.g. nephrology attend-
ing asks questions to a group of medicine residents in a non-
threatening way, calls each by his/her rst name, reinforces
positive behavior and uses constructive criticism).
In 1984, Kolb developed a way of looking at the adult learning pro-
cess, which he called the Experiential Learning Cycle (Figure 1)
[15]. Learning is the acquisition of new knowledge, skills and at-
titudes. Kolb sees learning as happening in a cycle made up of
four stages:
1. Concrete experience: The learner must havean experience; he or
she must experience something directly.
2. Reective observation: The learner reects on the experience,
comparing it with his/her prior knowledge.
3. Abstract conceptualization: The learner learns from the experi-
ence, he/she thinks about his/her observations and concludes
something from them.
4. Active experimentation: The learner tries out what he/she has
learned. This active experimentation stage becomes the
basis of future learning.
It is important to note that a trainee can enter the learning cycle at
any point. Completion of each stage is essential before progressing
to the next, allowing for complete learning to occur.
McCarthy incorporated Kolbs ideas and developed a tool
called 4MAT that can be used to train people in a way that suits
all learning styles [16]. An effective teaching session should be
planned to facilitate each of these stages. Table 2describes a lec-
ture-based didactic session for a group of rst-year nephrology
fellows that exemplies the use of 4MAT.
The core principles of andragogy in association with Kolbs
learning cycle provide a sound foundation for planning teaching
The teaching encounter
There are three basic settings where teaching encounters can
1. Teaching in the clinical environment: This includes teaching in
various clinical rotations such as renal inpatient consult, in-
patient end-stage renal disease service, outpatient nephrol-
ogy clinic, outpatient dialysis clinic and transplant
nephrology rotation.
2. Teaching in the classroom (for large groups): Lectures are the
oldest and most common method of instruction for large
Fig. 1. Kolbs learning cycle and the 4MAT model [15].
Teaching methods in nephrology |3
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3. Teaching in small groups: Examples of this include workshops,
seminars and tutorials.
Irby and Bowen [17] developed a three-step approach for time-ef-
cient teaching in the clinical environment. Each teaching en-
counter has three stages:
1. Planning: preparing for teaching by planning when and how to
2. Teaching: using a variety of teaching methods to actively in-
volve the learners
3. Reecting: evaluating learners performance, giving feedback
and encouraging self-reection
This review will focus on the planning and teaching stages of the
teaching encounter.
The advantages of advance planning include sharpening expec-
tations, clarifying roles and responsibilities, allocating time for
instruction and feedback and focusing learners on important pri-
orities and tasks. The planning stage includes the following im-
portant elements:
Establishing expectations: At the beginning of the rst teaching
encounter, expectations should be clearly communicated. Ex-
pectations are the ground rules or the code of conduct for the
teaching encounters. Communicating expectations early re-
duces ambiguity, avoids future conicts and provides the
basis for feedback and evaluation.
Establishing goals and objectives: A goal or objective is dened as
an end toward which an effort is directed. A goal is a broad
statement of what the students will be able to do when they
have completed the teaching session. In contrast to goals, ob-
jectives are specic actions that support the attainment of an
associated goal. A key to formulating useful educational ob-
jectives is to make them specic and measurable. Five basic
elements should be included in such objectives [18]:
Who will do how much (how well) of what by when?
12 3 4 5
Goal 1:
Internal medicine residents should be able to manage
hyponatremia appropriately.
Objective #1:
Second-year internal medicine residents will estimate
at least once satisfactorily
the response to uidrestrictionbasedontheurine:plasmaelec-
trolyte ratio
by the end of the nephrology elective.
An objective is specic, measurable, attainable, relevant and
timeframed.Goalsshouldbe clearlystated,appropriate, realistic,
doable, comprehensive andworthwhile.
In 1956, Bloom published aframework for categorizing educa-
tional objectives, also known as Blooms taxonomy [19]. Blooms
taxonomy divides theway people learn into three domains: cog-
nitive, skills and attitudes. The cognitive domain refers to the in-
tellectual capabilities or mental skills. Bloom identied six levels
within the cognitive domain: from the lowest level, simple recall
offacts,i.e. knowledge, throughincreasinglymore complex levels
such as analysis, synthesis and evaluation (Figure 2). When for-
mulating an objective, the verb used in will do(number 2) and
the teaching strategy used to accomplish such objectives should
match the Blooms taxonomy level being assessed (Table 3).
Soliciting learnersgoals: Students should have their own
learning goals that will be particular for their own needs
and experience. Teachers should solicit learnersgoals. Mu-
tual understanding of learnersgoals facilitates feedback
regarding progress toward and attainment of them.
Create a positive learning climate:L earners are more likely to par-
ticipate and contribute to the groups learning if a safe and re-
spectful learning environment is created. Some strategies to
achieve this are calling learners by their rst name, soliciting
learnersgoals, encouraging interactions and discussion,
Fig. 2. Blooms taxonomy pyramid of learning domains [19].
Table 2. The 4MAT cycle and its application to a lecture on the management of lupus nephritis
question Learners main interest Learningteaching task
1 Why? Learner seeks a personal connection, meaning Faculty asks the learner if he/she has ever taken care of a patient
with lupus nephritis and what was it like
2 What? Learner seeks facts and to gather information Faculty proceeds to deliver the core content of the lecture on the
management of lupus nephritis
3 How? Learner seeks to apply ideas Faculty asks questions related to lupus nephritis management
4 What If? Learner seeks to rene what they have learned
and integrate it into their lives
Learner applies his or her knowledge of lupus nephritis
management in a patient
4|H. Rondon-Berrios and J.R. Johnston
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using positive reinforcement, promoting enthusiasm and
humor and being respectful of others (and their time).
Teaching in the clinical environment
The patient care setting is likely the most difcult and complex
educational arena that the clinician educator will encounter.
The learners vary from third-year medical students to senior re-
sidents and fellows. Teaching to the different levels of learners is
quite challenging and the educator constantly runs the risk of
boring some while confusing others. The patients are complex,
the demands for rapid patient care are intense and faculty face
constant time pressure to provide quality care, educate and bill.
The number of learners in the outpatient setting is usually
much smaller (almost always one to one), but the constraints of
time and efciency still apply. In the clinical setting, learners and
teachers prioritize educational opportunities as illustrated in a
survey conducted at the University of Pittsburgh in 2003. Resi-
dents, program directors and medical students considered proce-
dures, case management, 5-min talks and bedside teaching as
the highest-value learning experiences [R. Patel (personal com-
munication. September 18, 2013)].
In the patient care setting, faculty teach most effectively
when they set the stage for teaching. This planning stage was dis-
cussed previously in this article. Please note, in the clinical envir-
onment, not every patient is a teaching case. The educator must
be selective in picking teachable moments[20,21].
A number of techniques have been used successfully for
teaching in the clinical environment [2224].
Role modeling
This method works best with inexperienced learners or when the
learner encounters an unfamiliar problem. The educator sets the
stage, e.g. Watch how I discuss the need for dialysis with this pa-
tient.After the session, the teacher will debriefthe learner and
activate the opportunity for teaching. The learner is asked to de-
scribe what was modeled, followed by questioning ( gently) on
why dialysis was needed, the side effects of the procedure and
so on. The clinician educator can also use this technique to
think out loud in front of the patient and the learner, modeling
the decision-making process.
Pattern recognition or Aunt Minnie
If your Aunt Minnie is walking down the street in her favorite hat,
shoes and dress, you will easily recognize her without seeing her
face. This is a variation on the theme of if it walks like a duck and
quacks like a duck, it is probably a duck.Experienced clinicians
use this technique of pattern recognition frequently to rapidly
reach a diagnosis. When using this method in the patient care
setting, the learner takes the history and examines a patient
and then presents the case to the teacher as a one-linerwith a
presumptive diagnosis. For example, Mr. McHepsee is a 40-year-
old gentleman who has a history of hepatitis C, frothy urine, and
palpable purpura on his hands, feet and ears. I think he has hepa-
titis Cassociated cryoglobulinemia. While the learner is writing
the note, the teacher sees the patient and constructs a diagnosis
and management plan. This is followed by a case discussion with
the learner, review of the note and sign-off. Both the teacher and
the learner must understand the process. The teacher needs to
see the patient or know the diagnosis. If the teacher is unsure
of the diagnosis, then this must also be communicated to the
learner. It teaches the valuable lesson of being able to say, I
dont know,a widely recognized sign of clinical maturity [25].
One-minute observation
One-minute observation benets the educator and learner in
several ways. It is a quick way to observe the learner performing
aspecic skill such as discussing dialysis modalities, obtaining
consent for a renal biopsy and so on. It is also a required part of
medical training, the mini-clinical evaluation exercise (mini-
CEX) [26]. The key to this method is immediate feedback to the
learner. Documentation of the mini-CEX in the learners portfolio
allows tracking of improvement during residency or fellowship
and is useful in the current evaluation using milestones.
The Five Microskills or the one-minute preceptor
The Five Microskills are valuable in a number of ways. This meth-
od takes advantage of the teachable moment. It allows teaching
on the y, i.e. there is no preparation required for the learner or
the teacher. It is best applied when the learner needs guidance
in progressing to the next step. Examples include the learner
who reports but stops before interpreting or the trainee who pre-
sents a general management plan but no specics [27,28]. The
Five Microskills are as follows:
1. Get a commitment—‘What do you think is going on?
2. Ask about supporting evidence
3. Teach a general principle
4. Reinforce what they did correctly
5. Identify areas that need improvement
An example of this method in action is presented in Table 4.
Teaching in the classroom
The lecture is the most commonly used teaching method to pre-
sent information to large groups of learners. When done well, it
can introduce new material and can be recorded for online review.
Since it is a controlled setting, the material can be presented in an
organized fashion supported by evidence from other sources. Lec-
tures have come under increasing criticism for being teacher cen-
tered, i.e. lacking the capacity to adjust to the learning styles of
members of the audience. Lecture participation is passive, de-
creasing the retention of salient points from the presentation.
Table 3. Educational objectives and teaching strategies based on Blooms taxonomy
Cognitive domain level Verb used when formulating educational objective Teachingstrategy used to achieve educational objective
Knowledge Dene, list Lecture, video
Comprehension Describe, explain, identify Questions, test, presentations
Application Apply, demonstrate, perform Practice exercises, simulations, role play
Analysis Analyze, calculate, compare, contrast, differentiate,distinguish Case studies, discussions
Synthesis Arrange, compose, create, design, formulate, organize, prepare Project, plan
Evaluation Assess, evaluate, estimate, judge Critiques
Teaching methods in nephrology |5
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Other criticisms include an unenthusiastic speaker who reads
his/her slides and turns his/her back on the audience as well as
sensory overload (death by PowerPoint) caused by too much infor-
mation per slide, too manyslides, small font size and unnecessary
animations. However, lectures remain one of the primary meth-
ods of teaching. There are many guides on proper and improper
presentations [2933]. The following hints are taken from these
sources as well as the authorsown experience in critiquing and
giving lectures.
1. Preparation: The speaker must understand what the audience
wants and the level of the learner in the audience. The needs
of a medical school class are far different than those of collea-
gues at a specialty society meeting. A lecture should stick to a
single topic, delineate a few specic learning objectives and
deliver the material as a owing coherent process. Before
the PowerPoint program is opened, an outline of the presenta-
tion is very helpful in organizing the material needed.
2. Keep it simple: Speakers are invited because they are experts on
a topic. As experts, we are passionate about our areas of inter-
est. Presenters frequently make the error of ooding the audi-
ence with too many details. There is no quicker way of losing
your listeners than by referring to obscure factoids that have
little to do with your major themes. Pick three or four main
points that you want the audience to take home, emphasize
them in the beginning, discuss them in the body of the talk
and state them clearly when nishing.
Slide mechanics: Please remember, you are the focus of the
presentation, not the slides. The PowerPoint presentation is a
tool to help you develop the three or four objectives of your
talk. Therefore, slides should be easy to read. Your text should
be clearly visible on the background: white or pale text on a
dark background or black or dark blue on lighter backgrounds.
Next, use a font that is readable from the back of the room.
The larger the venue, the larger the font should be. Anything
less than a 28-point font will frustrate the audience due to the
difculty in reading it. Fonts that are sans serif such as Calibri
or Arial work better in presentations than fonts such as Times
New Roman that function better on the printed page. These
guidelines also apply to tables and gures. A table with 30
rows showing a studys population demographics is distract-
ing and irritating. Pick those rows that deserve to be high-
lighted and present that material on a slide or highlight and
expand the rows of interest. The speaker should not be say-
ing, I apologize for this busy slide.
Limit the material on the slide. A useful rule is six lines per
slide and six words per line. When possible, the presentation
should use pictures with color [33,34]. These have the highest
retention rate after the lecture. A slide should have one mes-
sage and be parsimonious in the number of pictures, gures
and graphs. A slide that contains a western blot, two compli-
cated bar graphs and the proposed structure of an epithelial
transporter is confusing and dilutes your message.
Finally, as demonstrated in the McMillan [32] and Phillip
[33] web links, be cautious with animation. The use of this
tool can be helpful in providing emphasis. When overused,
animation distracts from the presenter and from the
3. The presenter: Giving a lecture is, in many ways, a perform-
ance. Interacting with the audience through body language,
enthusiastic delivery and smiling enables the speaker to
more readily engage those in attendance. Position the com-
puter monitor on the podium so that you can maintain eye
contact with the audience. Do not turn your back on the audi-
ence to highlight areas with a laser pointer. Slide emphasis
can be much more effectively done by using simple anima-
tion to have a line of text or gure appear in the slide or by
using the computers pointer function. Above all, do not read
the slides. The audience knows how to read and nothing is
more boring than a speaker reading his presentation in a
Illustrate concepts with stories from your experience. Pa-
tient cases are particularly useful when giving clinically
based talks, but stories can also be used in basic science lec-
tures to note how a particular collaboration came to be or the
background behind an experiment that led toa new discovery.
Lastly, speakers should actively try to rebootthe audi-
ence every 1015 min. Bligh [35] has shown that the audi-
ences attention will start to diminish 10 min into a talk.
Knowing this, the presenter should use these intervals to re-
gain the audience by asking questions, telling a story or pre-
senting a case.
4. Rehearse: Practicing the lecture can reveal much that is right or
wrong with a lecture. The presentation should be given out
loud to a colleague. This allows the presenter to assess the
amount of time needed to give the lecture, to evaluate
Table 4. Use of the Five Microskills teaching technique in nephrology education: a renal fellow presenting a case of multifactorial acute kidney
injury in a patient with oliguria
Step Example
1. Get a commitment Preceptor: What do you think is going on?
Learner: I think he has ATN.
2. Ask for supporting evidence Preceptor: What supports your diagnosis?
Learner: The patient has exposure to IV contrast, aminoglycosides and his systolic BP has been less than 90
mmHg for several hours.
Preceptor: What did the urine sediment show?
Learner: I didnt do that. It is obvious from the history that he has ATN.
3. Teach a general principle Preceptor: The situation you describe is certainly consistent with ischemic or toxic ATN. A urine sediment
exam showing dirty brown granularcasts would help conrm your diagnosis and eliminate other
4. Reinforcement Preceptor: You did a nice job identifying the possible causes of the patients acute kidney injury.
5. Identify areas that need
Preceptor: Always make sureyou check the urine sediment by microscopy. Come on, lets get some urine and
Ill show you how to do a poor mans renal biopsy.
This scenari o was a case with a novice rst-year renal fel low. Subsequent eva luation showed a bland uri ne sediment and hydronephrosis on ultrasound due to an
occluded Foley catheter. The fellow noted that it was a valuable lesson.
6|H. Rondon-Berrios and J.R. Johnston
by guest on September 1, 2016 from
transitions and to obtain feedback on the effectiveness of a
lecture. The use of a coach is invaluable in improving presen-
tation skills.
Teaching in small groups
Small group interactions are frequent in the clinical and preclinical
yearsof medical education. Before entering thewards, medicalstu-
dents traditionally participate in workshops and problem-based
learning sessions. Increasingly, ipped classroomsand team-
based learning sessions are beingintroduced.In the clinicalsetting,
work rounds, morning report and teaching rounds have been a
mainstay of instruction [21,36]. Small groups encourage active
learning, provide greater interactions among students and with
the teacher and enhance communication skills and team work.
As with any educational exercise, the teacher must be pre-
pared. Knowing how many learners will be in the group and the
level of training is vital. The teacher must include all participants
in the discussions, establish goals for the sessions (patient care,
interpretation of labs, images, etc) and encourage interaction
within the group as well as peer teaching. Resources such as elec-
tronic medical records and computerized knowledge bases or ref-
erence texts should be available for further discussion,
answering questions and clarifying decision making.
As discussed previously, the facilitator should have group
members introduce themselves and determine what the individ-
ual goals are for each learner at the beginning of the session. The
teacher must also clearly state the goals expected for the small
group sessions. After the session starts, the facilitator guides
the small group conference. Telling the group that participation
is expected may require gentle questioning of less involved lear-
ners and steering discussion away from more vocal learners, giv-
ing all an opportunity to participate. Dene tasks, e.g. Iwould
like you to present this patientor Can you nd out what infor-
mation is available on treatment of this illness?Resist the urge
to lecture and talk too much. The facilitators job is to lead and
encourage discussion and not be the focus of the activity. The
microskills approach discussed previously is a good approach.
During training, doctors receive little or no preparation in how
adults learnor on how to teach the skills of clinical practice, patient
care and research. As interest in nephrology fades and the need for
nephrology care and insights into the functioning of the kidney
grows, we as a community must reignite the spark in our learners
that captured our own excitement. We must also prepare our fel-
lows to practice high-quality clinical care and undertake research
to understand renal physiology and pathophysiology. Effective
and enthusiastic teaching in medical school and residency is a
rst step in this direction. Teaching skills are not some mysterious
or arcane talent limited to a few. Excellence in education can be
taught and matured with faculty development and teaching coa-
ches. Building time for education into our schedules in the lab,
on the wards, in the clinic and in the classroom will pay benets
later by increasing interest in our eld and producing inquisitive
and competent nephrologists. Rewarding good teaching through
academic advancement of clinician educators will also forward
this goal. Our hope is that reviews such asthis will increase efforts
in the eld to mentor and develop the nephrologists of the future.
Conict of interest statement
H.R.-B. is a member of the advisory board of Astute Medical Inc.
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... The recent advancements in nephrology but the relative lag of nephrology teaching mode further raised a challenge to nephrology educators. To fulfill the requirements to the current medical education system, nephrology education should focus on fostering students' ability to solve complicated clinical problems [3][4][5]. ...
... With the increase in the need for nephrology care and deeper insights into the functioning of the kidney, traditional lectures do not align well with the current requirement for nephrology education to prepare our medical students to practice quality clinical care and undertake research to understand renal physiology and pathophysiology in future [1,[3][4][5]. Recently, there are emerging alternative approaches to the traditional didactic lecture, including the FC and CBL, which focus on improving the medical students' critical thinking and solving clinical practical problems [7,8,10,11]. ...
Full-text available
Background The flipped classroom (FC) is recognized as an effective teaching approaches by emphasizing on the development of high-order abilities; however, the implementation of FC has not been well explored in nephrology education. The present study aims to investigate the efficacy of FC in teaching nephrology via comparing with the traditional lecture-based teaching (LBT). Methods Sixty-two medical clerkship students at Zhejiang University School of Medicine were equally allocated into either LBT or FC group demographically matched. The glomerular diseases module was chosen for the teaching content. Students from the FC group were required to study the pre-class materials in annotated PPT format in advance. In the class, case-based learning (CBL) was employed, students encountered the related clinical cases and participated in the face-to -face discussion. Students from the LBT group attended a didactic lecture during the class. Quiz and questionnaires were performed to assess the efficacy of FC versus LBT. Results Participants from the FC group performed better in the quiz than those from the LBT group with higher total scores (78.06 ± 2.515 vs. 65.16 ± 3.209, mean ± SEM), particularly the scores of the case analysis-related questions (35.81 ± 1.657 vs. 27.42 ± 1.910, mean ± SEM). In the survey, more students considered FC beneficial to comprehension, critical thinking, patient management and team work as compared with LBT. Meanwhile, more participants agreed increased in-class pressure in FC than in LBT. Conclusions This study shows the positive impact of FC combined with CBL approach on nephrology education and provides an alternative pre-class and in-class format for the FC implementation.
... A related but more global issue is the declining interest in the field of nephrology as a future career amongst medical trainees partly due to the perceived difficulty of the subject [7]. In order to revive nephrology as a field, educators must find innovative and learner-centric approaches to teach the specialty at all levels of medical education [8][9][10]. ...
... To overcome some of the above-mentioned limitations of traditional instructive methods, educators in nephrology are exploring newer, innovative and learner-centered pedagogical approaches [8][9][10][11][12]. Digital technology has greatly influenced the learning culture in medicine and nephrology in recent years [13]. ...
A comprehensive, hands-on hemodialysis curriculum during nephrology training is necessary for effective learning and optimal patient care. Traditional instructive approaches are unable to fully meet the needs of the digitally inclined learner and are limited by time constraints and increasing clinical workload. Internet based learning (E-learning) is becoming increasingly popular in medical education and nephrology and gaining even greater relevance in the COVID era. However, it presents technical challenges and may create an environment of social isolation. A ‘blended learning approach’ combines E-learning with traditional methods of teaching and offers advantages over either approach alone. We have designed and implemented a formalized hemodialysis curriculum at our institution that is based on blended learning, utilizing faculty-created E-learning tools combined with traditional pedagogical methods (bed-side and classroom). The web-based tools discuss hemodialysis adequacy, principles of urea transport, hemodialysis access examination and access complications. These tools are open access and structured around the science of cognitive learning using animation, interactivity, self-assessment and immediate feedback features. They have been viewed by a wide audience of nephrologists, dialysis nurses as well as medicine house-staff and have received strong validation in a post-test survey. The online tools have supported a ‘flipped classroom’ instructive model and our blended curriculum has been successfully used for nephrology fellow training at our institution. Incorporating faculty designed/approved E-learning tools to create a ‘blended’ nephrology curriculum for trainees at various levels of medical education, can help streamline active and time-efficient learning, with the goal of improving learner engagement, knowledge acquisition and academic curiosity in the field.
... Nephrology is widely viewed as a more highly specialized eld focusing on rare and severe diseases as compared to other medical branches and not treated as a preferable choice [3,4] Teaching nephrology is also a demanding, complex and often frustrating task. Evidence have shown endeavors in teaching could enhance learning and interest in nephrology [5,6]. However, innovation and research in nephrology education are lacking and the literature of best teaching practices pertinent to nephrology education is very scarce [7]. ...
... The interest in nephrology fades and the need for nephrology care and insights into the functioning of the kidney grows make us a must to prepare our medical students to practice quality clinical care and undertake research to understand renal physiology and pathophysiology in future [1][2][3][4]. Effective and enthusiastic teaching in medical school and residency is a rst step in this direction [5][6][7].In the present study, we implemented FC in clerkship students and compared the students' perspectives and performance with those experienced LBT teaching modality, which was a novel attempt and provided insights for teaching of other modules in nephrology. ...
Full-text available
Background Both flipped classroom (FC) and case-based learning (CBL) are recognized as new effective teaching approaches by emphasizing on different aspects of teaching activities; however, the implementation of FC combined with CBL has not been well explored in nephrology education. The present study aims to investigate the efficacy of FC combined with CBL in teaching nephrology via comparing with the traditional lecture-based teaching (LBT). Methods Sixty-two medical clerkship students at Zhejiang University School of Medicine were equally allocated into either LBT or FC group demographically matched. The glomerular diseases module was chosen for the teaching content. Students from the FC group were required to study the pre-class materials in annotated PPT format before the face-to face discussion on the relevant cases during the class. Students from the LBT group attended a didactic lecture during the class. Quiz and questionnaires were performed to assess the efficacy of FC. ResultsParticipants from the FC group performed better than those from the LBT group in the quiz with higher scores in the case analysis-related questions. FC was also considered more helpful than LBT in improving high order cognitive abilities in the survey. Meanwhile, more participants agreed increased in-class pressure in FC than in LBT. Conclusions This study shows the positive impact of FC combined with CBL approach on nephrology education and provides an alternative pre-class and in-class format for the FC implementation.
... The learning is not complete till the individuals practice the skill themselves. 2 In our case, we usually do not allow our undergraduate students to formulate the management plan and discuss it with patients during the OPD postings. This lack of opportunity deprives the students of the experience required for learning. ...
... In this issue of Kidney Medicine, Renaud et al, 11 applying the theory of planned behavior as their frame of reference, performed a sequential explanatory mixed-methods study (ie, analyzing both quantitative and qualitative data) surveying and interviewing nephrology faculty at 6 government teaching hospitals in Singapore with the purposes of exploring: (1) perceptions about active learning, (2) perceptions of difficult teaching topics in nephrology, (3) relationship between the basic notions of the theory of planned behavior and the extent of active learning use to teach difficult topics in nephrology, and (4) factors affecting active learning adoption. ...
Full-text available
Introduction: Social Media (SoMe) is used for the rapid dissemination of information and learning but has its limiting factors. An integrated learning model labeled “Neph E Club” was initiated in 2015. Various social media platforms were used to achieve the goal of SoMe education and lifelong learning. A retrospective study was done to analyze this education model. Methods: Six years of experience with Neph E Club’s social media education model allowed us to look back on the essential components of the SoMe model from 2015 to 2021. Objectives, member recruitment, social media platform, content development, and sustainability were among the aspects investigated and analyzed. Its benefits and downsides were also investigated. Results: For the past 6 years, WhatsApp has been used as a SoMe platform. Other approaches such as Twitter, YouTube, dedicated server, and email methods failed to meet the target during the 6 years. There are now 1018 active members in the WhatsApp group. Downloading nephrology education resources from numerous social media learning websites and conference content to construct a 3 TB digital library and 800 GB of developed and shared content. Members were kept informed daily by sharing information gleaned from the digital library. Topics are chosen based on data analysis and group requests. Students and practitioners shared their contents which included case discussion and initiating data collections. The success of this model is reflected by having shared 2550 Audiovisual (AV) Lectures, 26700 journal articles, and 182 case discussions. Viewership numbers on average reach from 1200 to 2500 per month which indicated multiple sharing. ISN India in his presidential speech in 2017 recommended this model. Conclusion: Neph E Club - Integrated model of learning using SoMe and offline digital Nephrology Library is a cost-effective, widely accepted model of learning in India.
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The vast majority of clinical skills teaching at our medical school in London is delivered through a peer teaching programme, with research demonstrating that medical students unequivocally prefer being taught clinical skills by peer teachers (students) over-qualified physicians. Peer teaching holds a plethora of benefits for both the learner and the teacher; encouraging academic and professional growth for teachers while instilling confidence in tutees through an improved learning atmosphere. Teaching is an essential skill for all physicians, and peer teaching is an invaluable method to cultivate these teaching skills throughout medical education. This article outlines 12 tips on how medical students can be effective and successful clinical skills peer teachers when faced with medical teaching opportunities, whether physically or remotely conducted. We reflect upon our roles as Peer Teacher Leads, overseeing a team of 200 medical student clinical skills peer teachers on behalf of the faculty at our university in London. We are responsible for leadership and quality assurance, holding key input into the organisation, development and delivery of clinical skills teaching. Therefore, we are able to impart unique insight and experience. This practical guidance is gathered from feedback, experience and the wider literature on the topic of peer teaching in clinical skills. We hope that these tips will enable medical student teachers to become more confident and competent in providing worthwhile training to their peers.
New treatments, new understanding, and new approaches to translational research are transforming the outlook for patients with kidney diseases. A number of new initiatives dedicated to advancing the field of nephrology-from value-based care to prize competitions-will further improve outcomes of patients with kidney disease. Because of individual nephrologists and kidney organizations in the United States, such as the American Society of Nephrology, the National Kidney Foundation, and the Renal Physicians Association, and international nephrologists and organizations, such as the International Society of Nephrology and the European Renal Association-European Dialysis and Transplant Association, we are beginning to gain traction to invigorate nephrology to meet the pandemic of global kidney diseases. Recognizing the timeliness of this opportunity, the American Society of Nephrology convened a Division Chief Retreat in Dallas, Texas, in June 2019 to address five key issues: (1) asserting the value of nephrology to the health system; (2) productivity and compensation; (3) financial support of faculty's and divisions' educational efforts; (4) faculty recruitment, retention, diversity, and inclusion; and (5) ensuring that fellowship programs prepare trainees to provide high-value nephrology care and enhance attraction of trainees to nephrology. Herein, we highlight the outcomes of these discussions and recommendations to the American Society of Nephrology.
Mother-infant attachment is an intimate, lasting and satisfying relationship that leads to better cognitive, emotional and social growth of the infant. The aim of this study was to determine the effects of breastfeeding training by role-play on mother-infant attachment behaviours. This research was a randomised clinical trial (parallel design). Inclusion criteria were: no history of mental disorders; ability to read and write the Persian language to complete the questionnaire; no history of drug and tobacco intake in primigravida women. The sample comprised 100 pregnant women (in 2 groups), selected through simple random sampling at healthcare centres. The researcher reviewed prenatal care registries of selected healthcare centres and extracted the names of pregnant women in their early third trimester. The data were imported into randomisation software. The control group received routine breastfeeding training, while the intervention group received routine training together with training through role-play. The data collection tool was the Maternal Behaviour Inventory Questionnaire. Consequently 75 samples were analysed in SPSS16. Independent t-tests and chi-square tests were used to examine the difference between the two groups. Results showed that the mean score of mother-infant attachment one week after delivery was significantly higher in the intervention group in comparison to that in the control group (p<0.001). No significant difference was observed between the two groups in maternal age, age of marriage, neonatal gender, maternal employment and education, number of parity, and number of abortions (P>0.05). Since breastfeeding training through role-play could affect mother-infant attachment, it is suggested that this type of training should be provided for pregnant women to promote mother-infant attachment and exclusive breastfeeding.
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This is the first nephrology Match since implementation of the "All-In" policy, where all accredited training programs and all positions must be filled through the NRMP Match. Key Points • There was a substantial increase in programs (18%) and positions (25%) certified in the Match in first year of "All-In" over AY 2015. • The number of matched nephrology fellows increased 8.7%, from 254 to 276. • The number of applicants preferring nephrology rose 11% in AY 2016. • There was a slight uptick in applications from US medical graduates (USMGs), but international medical graduate (IMG) applications continued a 6-year decline. • Unfilled programs and positions continued to rise (36.8% and 58.3%, respectively, compared with AY 2015). The "All-In" Match policy, which led to an upturn in certified programs and positions, may have contributed to the larger proportional increase.
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Nephrologists play an important role in providing medical education in a variety of settings, including the medical school classroom, nephrology consult service, outpatient clinic, and dialysis unit. Therefore, nephrologists interact with a variety of learners. In this article the current state of published literature in medical education in nephrology is reviewed. Eight attending roles are identified of the nephrologist as a medical educator in the academic settings: inpatient internal medicine service, nephrology inpatient consult service, inpatient ESRD service, outpatient nephrology clinic, kidney transplantation, dialysis unit, classroom teacher, and research mentor. Defining each of these distinct settings could help to promote positive faculty development and encourage more rigorous education scholarship in nephrology. Copyright © 2015 by the American Society of Nephrology.
Based on a proven six-step model and including examples and questions to guide application of those timeless principles, Curriculum Development for Medical Education is a practical guidebook for all faculty members and administrators responsible for the educational experiences of medical students, residents, fellows, and clinical practitioners. Incorporating revisions driven by calls for reform and innovations in medical education that challenge established teaching models, the third edition includes an awareness of new accreditation standards and regulatory guidelines. The authors have expanded their discussion of survey methodology for needs assessment and stress the importance of writing competency-based goals and objectives that incorporate milestones, entrustable professional activities, and observable practice activities. With updated examples focusing on interprofessional education, collaborative practice, and educational technology, they describe educational strategies that incorporate the new science of learning. A completely new chapter presents the unique challenges of curriculum development for large, long, and integrated curricula. © 1998, 2009, 2016 Johns Hopkins University Press. All rights reserved.
Although there have been mounting concerns over the decline in applicants to nephrology training programs, strategies to entice students and trainees to pursue a career in nephrology are lacking. Furthermore, the complex factors that contribute to career decisions and the lag between a positive interaction and a decision to pursue nephrology make such strategies difficult to assess. Nevertheless, it is still important to continue efforts to mentor and inspire. This article offers 10 strategies to help nephrologists share passion for nephrology in the clinical arena. These include the excitement of the dialysis unit, ethical dilemmas, pearls for the bedside, and questions "on the fly." Copyright © 2015 National Kidney Foundation, Inc. Published by Elsevier Inc. All rights reserved.
Teaching in the hospital may never have been more challenging than it is today. Severity of illness on inpatient teaching services has never been higher while new and time-consuming tasks, like the use of complex electronic health records, pull residents and medical students to computer terminals and away from their patients and learning opportunities at the bedside. Many teaching hospitals now rely heavily if not exclusively on hospitalists to be the primary teachers on general medicine inpatient services. This article asks and answers a series of questions faced by all physicians who teach in the hospital and especially by our younger colleagues who are so anxious to do their job well.
The number of U.S. medical graduates pursuing careers in nephrology has declined over the last several years. Some of the proposed reasons for this declining interest include difficult-to-understand or unstimulating kidney pathophysiology courses in medical school; disheartening inpatient elective experiences; and few opportunities to experience the other aspects of nephrology careers such as outpatient nephrology clinics, outpatient dialysis, and kidney transplantation. Novel and alternative educational approaches should be considered by the nephrology training community to enhance the understanding of nephrology from medical school to fellowship training. Newer teaching methods and styles should also be incorporated to adapt to today's learner. These innovative educational approaches may not only increase interest in nephrology careers, but they may also enhance and maintain interest during nephrology fellowship. In this article, we will review several educational approaches that may enhance teaching and learning in nephrology.