by Stephanie Scott

"I love pimping!" Lia Clattenburg shouts. "Pimping," explains the medical student at Johns Hopkins School of Medicine, is an innocuous term she and her peers across the United States use to refer to the rough-and-tumble use of Socratic Method by senior residents and attending physicians. Clattenburg is a strong believer in the use of pimping to elicit learning on the part of medical students. It's about ensuring continuous learning and preparation within a team, she says—and it encourages students to develop and defend a point of view.

Clattenburg's enthusiasm for this provocative method sheds light on a subject which sparked the interest of Judy Rosenblum, then president of Duke Corporate Education, during the summer of 2005. If the Socratic Method—teaching by asking rather than telling—is effective for medical students and interns in the halls of hospitals and at the patient's bedside, she mused, perhaps it could be applied in the professional services realm. Further, she wondered, which elements of a teaching hospital could be refined and applied within the context of a business to encourage the development of leaders?

Parallels between hospitals and professional environments—fast-paced technological advances, the rapid and constant influx of new information, time pressure and economic pressure—affirmed Rosenblum's interest. Also among these parallels, notes Duke CE Executive Director Jared Bleak, are "high risk, high stress, and... increasing and abundant regulation."

To Rosenblum and Bleak, the similarities were profound.

"SimBaby," a computer-controlled mannequin, is used at teaching hospitals to practice medical procedures.

Their initial musings spurred a two-year research project into the learning environment within teaching hospitals. In partnership with PricewaterhouseCoopers (PwC), a Duke CE team led by Bleak began by visiting the nation's best teaching hospitals, as recognized by US News & World Report in 2005. Among these hospitals were The Mount Sinai Hospital, Cleveland Clinic, Washington Hospital Center and Johns Hopkins Hospital. In addition to the team's visits, the comments of an Advisory Board comprised of doctors from each hospital yielded a plethora of information on how students and doctors learn.

Teaching Hospitals

Among the most visible and influential of learning methods employed within teaching hospitals is team-based learning, in which members of a hierarchical team contribute equally, albeit in different ways, both to the investigation and analysis of a problem, and to the development and implementation of its solution. Within a teaching hospital, team-based learning occurs in the context of a medical team, typically consisting of students, interns, residents, attending physicians, nurses, and even social workers or patient case managers. Most often, teams are made up of individuals from different levels and areas of expertise in order to ensure a wide range of knowledge. In the case of top-quality teaching hospitals, these teams often remain intact over a period of several years and together manage the care of an established number and variety of patients.

At Johns Hopkins Hospital, ranked number one on the U.S. News and World Report 2007 Honor Roll of American Hospitals, medical teams are called "firms" and consist of five to ten individuals. Each firm carries the name of a distinguished former Johns Hopkins medical scholar. Although membership shifts over the years, the firms have become long-standing institutions within the hospital, each having its own rich history, traditions, and character. For example, within the Longcope Firm (named for late Chairman of the Johns Hopkins Department of Medicine Warfield T. Longcope) are two or more students, interns and residents; a nurse manager; a social worker; and an attending physician, referred to as the Assistant Chief of Service (ACS).

The assistant chief of service (ACS) discusses cases during medical rounds.

The role of the ACS highlights certain essential elements in the success of teaching hospitals: continuous observation, feedback, coaching and mentoring. At Johns Hopkins, an ACS is nominated by his or her peers and chosen by faculty leadership to serve for one year as the team's formal leader and mentor. As a member of the Johns Hopkins School of Medicine faculty, it is the responsibility of the ACS to actively and conscientiously observe the work and progress of the team as a whole, as well as that of each individual. Based on those observations, the ACS provides feedback to the team as a whole and to individual team members.

At Johns Hopkins and other teaching hospitals, feedback is given continuously during the course of work, as well as formally through performance review meetings. In addition to observing subordinates and providing constructive feedback, the ACS is responsible for being an accessible coach and mentor to the team. The role is at once intellectual and protective.

"It needs to be clear to my residents that I am not solely interested in 'What have you done for me lately?' " notes Eric Schmidt, a former Johns Hopkins ACS. "Rather, my actions need to consistently demonstrate that I am personally invested in their long-term excellence, not only as physicians but also as people. Once this mentoring relationship is established, it becomes much easier for the resident to embrace feedback. They no longer view criticism as a threat—rather, my feedback is interpreted as evidence of my devotion to their long-term well-being. This relationship is palpably paternal, with my teaching and feedback being an expression of my concern and, frankly, my love for 'the kids.' The resultant ACS-resident bond is powerful, and it keeps us focused during the physically and emotionally draining year."

Team-based learning and problem-based learning come together during medical rounds.

The ACS also serves a pivotal role during medical rounds, another crucial element of the learning system within teaching hospitals. Almost universal in the world's hospitals, medical rounds provide one of the most fruitful learning environments in high-quality teaching hospitals, particularly when combined with a commitment to problem-based learning. In problem-based learning, a team rallies around a real or hypothetical problem in order to learn effective methods for conceptualizing the problem and developing its solution. In the context of teaching hospitals, the "problem" is the patient's health concern, the "solution" an effective treatment plan.

Medical rounds allow a team to address a patient problem while also absorbing new (or reviewing previously learned) medical concepts. At Johns Hopkins, team-based learning and problem-based learning come together during rounds. Through debate and dialogue, a firm tackles a patient problem together, collectively determining its most effective solution.

Adam Spivak, another former Johns Hopkins ACS, explains: "Each case—each patient that comes in—could be considered, in essence, a problem-based learning experience in which we are both caring for that individual patient, but also forming a larger framework for interns and residents to think about a particular disease process, how to work it up, the various aspects that may or may not be present."

The Point of the Wedge

When the PwC/Duke CE research team observed medical rounds within teaching hospitals, specifically at Johns Hopkins, they were struck by the fact that the youngest and most inexperienced team members spoke most often, confidently presenting a point of view regarding a patient's diagnosis and potential treatment plan. When asked pointed questions, the team members—typically interns—eagerly and readily offered relevant information.

An intern "at the point of the wedge" is often asked for his or her point of view on treatment options.

This phenomenon, referred to as being "at the point of the wedge" by Dr. Charles Wiener, Director of the Osler Medical Training Program at Johns Hopkins, encourages medical students and doctors to prepare vigorously to present a patient, thereby contributing to improved patient care.

Similarly, the knowledge that they must present a patient case to their team encourages students and interns to develop a cogent point of view or, says Dr. Wiener, to "tell a good story." Over time, presentations to the team enhance communication skills, instill confidence, and deepen an intern's medical knowledge. In spite of the intense pressure to perform, Dr. Wiener notes, interns at Johns Hopkins feel comfortable with the knowledge that their entire team, from medical students to nurses and experienced doctors, will support them.

"The moment [students] get out of medical school and come here as interns, we want them to adopt the ethos that they are at the point of this gigantic wedge of people taking care of the patient," says Dr. Wiener. "If you are the one who feels responsible for that patient's welfare, it makes you be very honest with yourself about what you do know, what you don't know.
It makes you more willing to ask questions and be less passive because you know that, by not asking a question, you may impact someone's health."

As an intern's role in medical rounds illustrates, the best teaching hospitals encourage even their newest doctors to embrace a philosophy of "owning the patient." While the hospital and medical team are ultimately accountable for the patient's well-being, the novice is pushed to take ownership for his or her patient's health. Consequently, these individuals have the most frequent interaction with patients and learn at an astonishing pace.

Although the intern "owns the patient," every member of the medical team, regardless of hierarchy, learns when caring for patients. As Dr. Wiener emphasizes, at Johns Hopkins, "the learners are the teachers. That's what's cool about this place. Everybody feels like, at the end of the day, if they can go home and say 'I've learned something from somebody,' they've had a good day. And you can learn from your patients, you can learn from faculty, you can learn from nursing. You can learn from anybody. But at the end of the day, if you've learned something, you've had a good day."

Treating Error

Formal Errors Conferences allow medical personnel to discuss mistakes in a non-punitive forum.

In the best teaching hospitals, even mistakes are considered fodder for learning. During medical rounds, teams openly and non-punitively discuss mistakes and how they might be avoided in the future.

Similarly, formal Errors Conferences review "morbidity and mortality" topics related to recent mistakes made throughout the hospital. These conferences allow doctors and interns to collectively acknowledge and learn from medical errors without laying blame or instilling fear that might prevent individuals from asking questions in the future.

Teaching Professionals

Based on their research, Bleak and his team believe that many of the team-based learning methods employed within teaching hospitals offer the opportunity for more relevant and accelerated learning in business environments. Duke CE is currently testing this belief by applying several of the aforementioned methods with its clients. Thus far, says Rosenblum, "the results have been highly positive, as professionals use these tools to learn problem-solving, point-of-view development, presentation skills, interpersonal skills, difficult-conversation skills, and coaching skills." Not only are professionals learning to be more effective thinkers and communicators, she notes, but they are also learning to apply technical knowledge in real-time.

Diagnose and Treat Your Organization

The questions below should serve as food for thought in considering whether your organization might experience more relevant and rapid on-the-job learning by leveraging the Teaching Hospital Model:

• Do your managers view employee development as a task, separate from
  day-to-day work? Is the development plan portion of your appraisal
  form the most difficult to complete?
• Do you spend a substantial portion of your educational budget on
  programs designed to instill presentation and communication skills?
• Do your younger employees feel underutilized?
• Do your more experienced employees illustrate confidence and an
  ability to present a point-of-view under difficult circumstances?
• Is coaching viewed as "directing" or "telling employees what to do"?
  Is coaching synonymous with employee evaluation?
• Are you under pressure to reduce the amount of time that employees
  spend in the classroom? Are you pressured to increase the relevance
  of your employee training to customer and client service?

By valuing patient care and learning equally, teaching hospitals have created an environment in which students and doctors alike learn continually and rapidly in the context of their daily work. Through team-based and problem-based learning, individuals learn interpersonal and technical skills simultaneously. Reflects Dr. Wiener, teaching hospitals build leaders—both inside the hospital and beyond.

By applying the Teaching Hospital Model to your organization, you can create immediately relevant, accelerated, and cost-effective learning for all employees, thereby guaranteeing the improvement of client service and enhancing the outcomes of your business.