Short Take



	Kelley Skeff, MD, PhD, and Georgette Stratos, PhD

Demystifying Teaching

Training faculty members to improve their teaching skills shouldn't be a revolutionary idea. But it is.

By Sara Selis
Photographs Trujillo/Paumier

In the late 1970s, a Stanford internist named Kelley Skeff saw a void in academic medicine: neglect of the craft of teaching. Teaching was a significant part of all medical faculty members' work but in most cases no one bothered teaching them how to teach. Having worked with dozens of clinical teachers during a general medicine fellowship at Stanford, Skeff observed that many physicians in academic medicine struggled with teaching and did so alone.

So Skeff had an idea: Why not design a program to teach medical faculty how to be better teachers, using a systematic, logical approach?

For some in academic medicine, this was an unusual – even radical – idea. Many viewed teaching as a natural gift: either you had it or you didn't. Others simply assumed that MDs, being intelligent people, knew how to teach.

But Skeff felt that excellence in teaching was too important to be left to chance.

Appreciation of Skeff's idea has grown among medical school faculty and administrators nationwide. In the late 1970s, there were just three or four faculty development programs targeting medical faculty. Today there are more than a dozen. And the Stanford program Skeff developed is thriving and expanding its role in training Stanford faculty and their counterparts throughout the world.

Not such a crazy idea after all

Even back in the 1970s, several people found Skeff's idea reasonable. Among them were two of his Stanford mentors, Daniel Federman, MD, and Harold Sox Jr., MD, who encouraged him to pursue his interests through a PhD in education. In 1978 Skeff followed their advice, enrolling in Stanford's School of Education. Working toward his thesis with professor Nathan Gage, Skeff videotaped hundreds of hours of teaching by Stanford medical faculty. He also noted which teaching behaviors students rated highly and which ones students found less effective. Skeff meanwhile met Georgette Stratos, a UC-Berkeley doctoral student in educational psychology who was doing a project on doctor-patient communication at the Palo Alto Veterans Affairs Hospital.

The two began collaborating on Skeff's project, and their efforts evolved into a comprehensive framework that faculty could use to analyze their teaching. The framework highlights seven facets of the student-teacher interaction – including "learning climate," "communication of goals" and "understanding and retention" – and provides a teaching strategies checklist for each. For instance, the checklist for "feedback" includes these strategies: Tell learners whether their performance is correct, explain why their performance is or isn't correct, and let learners react to feedback.

While these concepts weren't new, Skeff and Stratos brought them together and applied them to medical education – something no one had done before. "We wanted to give teachers a comprehensive, systematic way of examining all aspects of their teaching," Skeff explains.

The framework became the centerpiece of Skeff's thesis, in which he worked with dozens of Stanford medical faculty one-on-one to improve their teaching. In the early 1980s, Skeff and Stratos tested the method with small groups of faculty members in a program called the Clinical Teaching Seminars. In 1985, they secured a grant from the U.S. Department of Health and Human Services, which enabled them to set up shop, and in July 1985 the Stanford Faculty Development Center for Medical Teachers was born.

Today, Skeff is hailed as a pioneer in medical education, and the clinical teaching program he and Stratos created (and still co-teach) is considered the gold standard for faculty development in medical education. The program is cited in the medical education literature, is presented at national society meetings and has been adopted by dozens of medical schools. It has also secured grants from the Macy, Hartford and Robert Wood Johnson foundations.

Furthermore, research showing that graduates of the program are subsequently more versatile in their teaching and receive higher student ratings confirms the effectiveness of Skeff's approach.

The Stanford Faculty Development Center is "the pre-eminent faculty development program in the country," says Wendy Levinson, MD, vice chair of the Department of Medicine at the University of Toronto and past-president of the Society of General Internal Medicine.

Nowadays, Skeff and Stratos continue to co-direct the program, offering the Clinical Teaching Course to small groups of faculty, who come from around the world to attend the intensive monthlong session. The center also offers courses that teach faculty to teach specific subject matter based on the principles in the clinical teaching program. Current courses – taught in collaboration with other Stanford faculty – focus on geriatrics, end-of-life care and contemporary medical practice. More than 225 faculty members at 112 medical schools, including several at Stanford, have completed courses at the center, and all of them have presented the material to faculty and residents at their home institutions – a "train-the-trainer" model that has enabled Skeff's ideas to have an exponential impact on medical education.

Skeff is gratified by the attention the program has received. But what he finds most rewarding is the way the program transforms the careers, and lives, of those who complete it.

"The utility of this work becomes clear every time we work with a new group," explains Skeff, who also directs Stanford's internal medicine residency program. "When you help a teacher discover a powerful new idea about teaching, and you see their potential for teaching others – that gets you pumped up."



	Noreen Henig, MD, director of Stanford's cystic fibrosis center, completed the teaching program this summer. Here she leads morning report.

A life-altering interlude

Consider Robert Centor, MD, who describes his month at the Stanford Faculty Development Center as "a breakthrough" that "helped me understand who I wanted to be and how I would get there." Now director of the division of general internal medicine at the University of Alabama School of Medicine, Centor completed the since-discontinued preventive care course in 1991.

Centor says the framework opened his eyes. "Before, I could say 'So-and-so's a good teacher' but I couldn't say why. The program provides a tool that allows you to critically examine your teaching, to identify your strengths and weaknesses."

Centor had always been knowledgeable and passionate about what he taught. But when he reviewed his videotaped teaching sessions and analyzed them according to the framework – an exercise early in the course – he realized some aspects of his teaching were ineffective: He rarely asked questions to gauge students' comprehension of the material; he avoided discussing subjects he didn't know about; he responded bluntly to students' incorrect answers; and he generally remained aloof from students.

"If I didn't agree with what a student said, I'd say, 'That's wrong,' "Centor says. "Ultimately, I realized I was intimidating my students." The course taught Centor more effective teaching behaviors, such as using personal examples to explain material, and giving positive feedback along with negative.

Centor then practiced these strategies in the role playing sessions that are a core element of the program. Course participants take turns playing the roles of students (for instance, a distracted intern, a timid medical student, or an opinionated resident who's been up all night) and of the teacher (the attending physician).

After playing their roles for three minutes, the group reviews the scene on videotape, discusses how effectively the attending physician dealt with the challenges presented and brainstorms alternate strategies. The group repeats the role play, with the teacher trying out the suggested behaviors.

The exercise can be painful, Centor admits. "The first time you see yourself on videotape, you cringe. You say 'My god, do I really do that?' But once you get used to the idea that you weren't as good as you thought, you can accept that and move forward."

Stratos – who oversees the Faculty Development Center's day-to-day operations – says the program can be "a very transformational experience. People are making themselves vulnerable. They're looking at themselves in a way they haven't before, and that helps them make changes."

Today, Centor's teaching style is much different – largely due to the Stanford course. He routinely gives and seeks feedback. If he doesn't know the answer to a question, he admits it – something "I was too cocky to do before."

Since completing the Stanford course, Centor has won several teaching awards and says he enjoys teaching more. And the medical school's residents rank his division as the best at teaching – something Centor attributes partly to the fact that most of its faculty have been exposed to the Stanford course, directly or indirectly.

The course continues to elicit praise from its graduates, years after they've participated. "It was a turning point in my personal and career development," says Louis Pangaro, MD, a 1987 graduate of the clinical teaching course, now vice chairman for educational programs in the Department of Medicine at the Uniformed Services University's medical school. Pangaro offers the faculty development course to all of the school's residency program directors.



	Teaching at the bedside: Professor Ted Harris, MD, the attending physician for these Stanford rounds (second from left), is a teaching program graduate.

Going local

Ironically, the Stanford Faculty Development Center, situated in the Stanford Barn, is relatively little known at Stanford. But this low profile on campus should change soon: Stanford is the test site for offering the course to basic science faculty. Since August 2001, 27 Stanford basic science teachers have completed the 15-hour teaching seminar.

"The course is terrific. It changes the way you think as a teacher," says Eric Knudsen, PhD, chairman of Stanford's neurobiology department, who attended the seminar in August. "I think all our faculty should take it as a prerequisite for joining the faculty."

Another irony: Even as more attention is paid to faculty development in medical education, academic medicine faces mounting pressures – regulatory, financial and time pressures – that make it difficult for faculty to devote themselves to good teaching. "There are lots of academics who care intensely about teaching, but they can't teach as much or as well as they'd like," Skeff laments.

The upshot is that all this seems to make Skeff's efforts that much more relevant. "All the pressures make it even more important that this kind of program continue," Levinson says. "There's still so much work to do."

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