20Q: Instruction and Precepting in Clinical Audiology

From the Desk of Gus Mueller

Welcome to August.  A good month for gladioluses and family vacations. If you’re a parent, August also may be “Back-To- School” time.  It’s Back-To-School time for 2400 or so students enrolled in AuD programs across the U.S.  While classroom education is critical, a big part of becoming an AuD involves training in the day-to-day clinical work with patients.  Learning to be a good clinician also requires dedicated one-on-one mentoring from a preceptor.  In many AuD programs, much of this clinical training occurs away from the university, conducted by volunteer audiologists in affiliated hospitals, clinics and private practice offices.

Gus Mueller

While it usually is a refreshing and rewarding experience to have students in the clinic, being an effective preceptor doesn’t come naturally for most of us.  What we might view as “excessive supervision” might not be viewed as enough.  Feedback that we thought was instructive and helpful may have been perceived quite differently. What we may think of as “common sense,” often isn’t.

Fortunately, we have audiologists who understand the importance of the clinical preceptor and are willing to provide guidance to help increase our effectiveness.  One of these is Virginia Ramachandran, AuD, PhD, who works with AuD students daily, both in the classroom and in the clinic. Dr. Ramachandran is senior staff audiologist and research coordinator in the Division of Audiology, Department of Otolaryngology – Head and Neck Surgery of the Henry Ford Health System in Detroit, Michigan. She also in on the faculty at Wayne State University where she coordinates the clinical education experiences of the audiology students.

Virginia is an associate editor for Plural Publishing and has co-authored and edited several textbooks.  She has served on many different committees for the American Academy of Audiology, and presently is a member of the American Academy of Audiology’s Board of Directors.

So yes, it’s time to get prepared for “Back To School” and I’m sure that all of you serving as clinical instructors will find this article helpful.  And, it’s not just student training.  Much of what Virginia talks about also applies to the clinical instruction of audiologists just getting started in their careers, and to some extent, clinical audiology mentoring at all levels. 

Gus Mueller, PhD

Contributing Editor
August, 2015

To browse the complete collection of 20Q with Gus Mueller CEU articles, please visit www.audiologyonline.com/20Q

20Q: Instruction and Precepting in Clinical Audiology

Virginia Ramachandran

1.   I guess you and I are going to talk about the supervision of audiologists and audiology students, right?

Well, yes and no. Terminology is important, because it defines your role. The definition of a supervisor is a person who watches and directs what someone does or how something is done. It is typically used in the context of employment, and the connotation is that the person is doing a job that requires oversight. I think that the term supervisor is better applied to the role of what an audiologist does with an audiologist assistant rather than a student.

2.   But don’t many of the skills required for the clinical instruction of new AuDs and students also apply to the supervision of audiologist assistants?

In some aspects, yes, but the roles are fundamentally different. Assistants often require initial and ongoing training, during which times the supervision skills required would be similar to those used with students. However, on a day-to-day basis the purpose of an assistant is to perform certain functions independently, allowing the audiologist time to perform other tasks. The audiologist supervises the work of the assistant to ensure that the job is being done correctly. In contrast, when training students, the goal is to actively teach audiologic skills. The audiologist oversight ensures that the patient is well cared for during the training. But training students and overseeing assistants have distinct purposes and processes.   

3.   I see. So what term would you prefer when we use when we are talking about audiology students?

When talking about students, I prefer to use the term clinical instructor; a person who teaches a subject or skill. Another good term is preceptor; a teacher or tutor. In fact, the Merriam-Webster online dictionary includes the “medical definition” of preceptor to mean “a practicing physician who gives personal instruction, training, and supervision to a medical student or young physician”. You easily could substitute “audiologist” for physician in this definition.  The role of a clinical educator or preceptor includes supervision, but it is also much more than that.

The depth of the student/preceptor teaching and learning experience is reflected in one of my favorite and rather poetic quotes from the groundbreaking Flexner Report:

“…the student brings his own faculties into play at close range, — gathering his own data, making his own construction, proposing his own course, and taking the consequences when the instructor who has worked through exactly the same process calls him to account: the instructor, no longer a fountain pouring forth a full stream of knowledge, nor a showman exhibiting marvelous sights, but by turns an aid or an antagonist in a strenuous contest with disease.”

Just between you and me, I’m kind of a geek about this topic.

4.   You don’t say…So what is this Flexner Report?

The Flexner Report, short for “Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching”, is a study published back in 1910 by Abraham Flexner. The purpose of the study was to survey the condition of medical education in the United States and Canada. The outcome was a scathing appraisal that recommended closure of about 80% of the medical schools in the country for failure to meet minimum standards to ensure competency of clinicians. It is a fascinating read. Apart from recommendations for minimum entry-level requirements for medical school, such as having a high-school diploma, the report reflected the need for medical students to actually engage in clinical activities as a component of their training, rather than simply reading, memorizing facts, and attending lectures.

5.   Those recommendations seem sort of obvious, no?

In hindsight, of course. I can’t help but wonder, though, what future generations will think of our current educational standards and of our clinical training models for audiology. We have come a long way by creating the AuD to expand the scope of education and to bring clinical training under the auspices of university programs. We have also created an accrediting body for audiology programs; the Accreditation Commission for Audiology Education which has begun to accredit programs in audiology. That said, every audiology program continues to maintain accreditation by an entity where the decisions are made by a speech-language pathology majority.

6.   What?  You’re saying that audiology training programs are being accredited by speech language pathologists?  Is that right?

I find it surprising too. The Council on Academic Accreditation in Audiology and Speech-Language Pathology (CAA) accredits both AuD and SLP programs. There is a single set of standards that is actually the same for both the masters degree in SLP and the doctoral degree in audiology. The only difference is in the specific skills that are to be taught and some other details, such as the length of the program. Decisions regarding whether or not a program is accredited are the responsibility of the Council of the CAA. It is mandated that the Council be composed of 18 members, ten of whom represent the field of speech-language pathology and seven of whom represent the field of audiology (American Speech-Language Hearing Association, 2015).  It seems like a poor design to expect people with a background in an entirely different profession to make appropriate decisions about whether programs are sufficiently equipped to produce competent professionals in another profession. Similarly, audiologists probably shouldn’t be asked to make appropriate decisions about whether speech-language pathology programs are graduating competent SLPs. But it is even more concerning that SLPs have a majority vote in the decision about whether audiology programs are graduating competent audiologists.

Another problem is that some programs require proprietary credentials for clinical educators that are unrelated to the preceptor’s ability to provide quality clinical education, such as the Certificate of Clinical Competence in Audiology (CCC-A). What we really need is a unified and systemic approach to ensuring excellence of clinical education of students once they are being trained at sites outside the university’s purview. The continued evolution of the AuD model is important when we consider the sort of educational system that we need in order to be truly autonomous in a rapidly evolving health system.

7.   Sounds like we still have some serious challenges to tackle. So what advice is there for current clinical instructors?

To start with, I want to say that anyone who provides clinical education to audiology students deserves a huge pat on the back! Clinical educators are almost always volunteers, and our profession would not be nearly as good as it is without their efforts.

The other thing I’d like to emphasize is that we should strive to base our clinical education models and processes on evidence-based strategies. Unfortunately, there is currently an underdeveloped body of evidence for clinical education in general, and that includes the field of audiology. Furthermore, there is no one right way to do clinical education. My answers to some of your questions likely will be evidence-based, but most of it is based on my experiences and opinions. I think the first and most important task for clinical instruction is to set expectations. I mean two things by this. The first is that rules and expectations for behavior in the clinic should be provided explicitly. This is more of a supervisory task that can be applied to new employees, students and audiology assistants. The notion that students or assistants “should” know something about professional behavior is seldom helpful and will likely only lead to frustration. Experience with students and assistants will eventually lead to an understanding of what many may not know coming into the practice, and these common issues should be addressed at the outset.

The second task regarding expectations is that the roles of the clinical instructor and student should be elucidated. It is ideal to be as explicit as possible when explaining intentions to students. Students should be made aware that you expect for them to be engaged and to work hard to learn the skills that you are teaching. They should also be told when and where it would be appropriate to ask more probing questions, and what your expectations are regarding independent learning. In my experience, students who are enrolled in a clinical doctorate program have tended to be excellent performers in an academic setting with fairly high grades. These are often not the sort of students who have been given a lot of detailed or critical feedback throughout their academic careers. Such students will benefit from being reminded that your role as an instructor is to provide feedback and instruction on performance for improving future outcomes and that receiving instruction is not a reflection of poor performance on the part of the student. Using the analogy of a personal trainer can be helpful. Would the student want a trainer who simply rubber-stamps performance, or would they want someone who pushes them toward greater performance through critical appraisal and feedback?

8.   In my experience, providing feedback, particularly if it is somewhat negative, can be very difficult in some cases. Are there ways to make it easier?

Yes, it is a common experience for instructor and student alike to feel uncomfortable with feedback. One way to make this less of a challenge is to use a standardized assessment tool at regularly-scheduled intervals. A written tool with pre-defined skills does a lot to take the pressure off of the instructor by de-personalizing the nature of the feedback. In most cases the instructor would have affirmatory comments to make about some skills and corrective suggestions about others. A pre-defined list of skills allows students to understand what they will be assessed on ahead of time, and provides a predictable template against which to gauge their own performance. Clinical instructors can create their own tools or request one from the university program. At Henry Ford Hospital we have created a formative assessment tool for both diagnostic and treatment clinical skills that we use with all of the students we train, and we are happy to share them.

9.   You used the term “formative assessment”. What does that mean?

Formative assessment is assessment used for the purpose of diagnosis of current understanding. It is feedback for the purpose of improving future performance. This is in contrast to summative assessment, which is feedback for the purpose of judging how well performance meets criteria. In the context of a student taking a course, you could think of formative assessment as feedback without an associated grade and summative assessment as feedback that results in a grade.

10.  I expect students would be much more receptive to formative assessment than to summative assessment?

Exactly. Students tend to perform in an adaptive manner, and we have taught them from a very early age that certain behaviors are rewarded. It is natural and right for a student to strive toward obtaining an excellent summative assessment review. In the case where summative assessment points to deficiencies, the adaptive behavior of the student would be to try to convince the instructor that he or she is incorrect in their assessment. On the other hand, formative assessment may often be perceived as very valuable to students, as it not only prepares their future clinical skills but also provides them guidance for better performance when it comes to summative assessment.

The frequency with which you provide more formal assessment depends on the student and the situation. The first year students that we work with receive a formal assessment with every patient. The fourth-year students receive formal assessments about twice per week.

11.  When I’ve worked with students, it seems like I am providing feedback all the time. Why do we need to make it formal?

True, in reality clinical instructors provide verbal feedback on nearly every patient that a student sees, but the informal nature of such exchanges does not always seem to result in the same level of reflection on the part of the student as a more formal process. Interestingly, students often report that they do not get enough feedback, while clinical instructors report that they provide it continuously. Because of this disparity, it is often helpful to simply state “I’d like to give you some feedback now about your last patient”. It may seem silly, but this is surprisingly effective at helping the student to realize that you are providing instruction rather than just “discussing” the situation.

12. What about addressing “professional” or “behavioral” issues? 

Those can certainly be more intimidating to address. One option is to use a rather time-limited and scripted format. An example would be a case in which a student is late. I might say something such as, “Gus, you were 15 minutes late to clinic this morning. I don’t need to know the reason, but I want to make sure you understand that when you are late it causes problems with the clinic flow and interferes with your learning opportunities. Please make every effort not to be late in the future. I have faith that you’ll manage things so that we won’t need to discuss this again”.

Focusing on the perception that the student has created, rather than assigning intent to the student can also be helpful. As an example,

“Dr. Kemar has told me that she felt that you were not taking her suggestions seriously when she was reviewing your hearing evaluation performance with you. I realize that you did not intend to convey that attitude, but perception is everything when you are working with people. I’d like you to take a day to think through your actions and words and try to understand why she might have had that perception. If you have trouble coming up with an answer yourself, we can talk about it together again on Tuesday. Otherwise, please just adjust your behaviors so that other people won’t have the same impression in the future.” 

If students react emotionally to feedback, simply reflecting and acknowledging their reaction can be helpful. For instance, saying, "I can see that you feel (frustrated/surprised/offended/distressed/stressed/worried/etc.) about this. I can understand why you feel this way” may help to diffuse the emotional reaction and allow the student to be receptive to your input.

13. And if that doesn’t do the trick?

It is surprising how often it does. However, if a behavior of concern persists after your feedback, you should inform the clinical education coordinator at the student’s program and invite participation in helping to correct the behavior. It is the job of this individual and of the university program to ensure that students learn the skills required to participate as professionals and interact appropriately with patients. In some cases, students may need a greater level of intervention than it is your role to provide. Your university contact will appreciate learning of any issues before they become serious and will likely be eager to assist or even take over the management of students, depending on the situation.

14.  So we’ve talked about how to set expectations for student behaviors. But what do we actually do to provide instruction? How do we decide how to teach?

One approach that may help you to decide which instructional techniques to use is to determine a student’s level of understanding of a particular concept or skill. There are dozens of theoretical models to describe the process by which people learn. One model that I like by King and Kitchener (1994) describes learners as being in pre-reflective, quasi-reflective, or reflective stages.

In the pre-reflective stage, knowledge comes from authority and an absolute answer exists. Students at this stage with a given skill or concept are likely to rely on you for explanation and direction. They are likely to accept your explanations without much critical thought.

In the quasi-reflective stage, the students recognize that ill-structured problems exist (such as those in the real clinical world) and they are unsure how to deal with ambiguity. They realize that there is not a single answer but have not yet learned how to develop an answer independently.

In the reflective stage, students have come to realize that our body of knowledge can change over time, and they use criteria to determine the worth of the evidence that they collect to make evidence-based decisions.

The particular strategy that you use when teaching students often depends on their level of development in this hierarchy. Let’s use the example of teaching probe-microphone measures to students. For a student in the pre-reflective stage, you might simply demonstrate and explain how to conduct the procedure and assign students opportunities to practice. For students in the quasi-reflective stage, you might ask questions of the students and engage in discussion about when and why they would make certain measures and how they might troubleshoot when problems arise. For students in the reflective stage, it is often helpful to review cases to understand how performance of measures impacted the care of patients. You could also discuss research related to prescriptive fittings and probe-microphone measures and ask the students to describe how the evidence should be applied clinically.

15. I like it. That model helps explain why some concepts that may be so clear to some students are elusive to others.

Yes, and it helps to recall that we should not assume that saying something once means that it was effectively comprehended, synthesized, and remembered for application in a variety of novel future situations. It is also the case that students do not always recall why they are doing things a certain way, even if they were taught why.

Fortunately, the realities of the clinical world provide abundant opportunities for students to strengthen all of these skill stages beyond what they learn in the classroom. From clinical experiences, students learn that there is more than one way to do things, there is often no one right way, and the answer is often “it depends”.

16. What other techniques can be used to help students learn?

One technique that we use extensively at Henry Ford Hospital is case review or grand rounds. This can be done any number of ways, but the point is to honestly and critically review all aspects of a particular case to learn as much as we can from the patient. The way we do it is to come in one hour early each week before clinic begins. Externs and staff take turns presenting cases that they find interesting. This is a fairly informal process, and we discuss anything of interest that arises. We also host a weekly grand rounds session for the audiology students at Wayne State University. This is a more formal process, simply due to the large number of students involved. But the idea is the same - present the data and discuss. The process depends on setting expectations to create a culture of learning and good will. We are not out to criticize anyone’s performance, but rather to learn from their experiences.

This technique taps into the reflective-stage skills mentioned previously. The beauty of it is that everyone benefits, even the most experienced clinicians. And students learn that self- and peer-review is a valuable process that should be utilized throughout their careers.

17. As you mentioned, review of our own work is an important clinical skill. What other ways can we facilitate this for students?

One simple tactic is to ask the student “How do you think that went?” If this is too open-ended for a student (who replies “good” without further elaboration), you can refine the question to begin with “What do you think went well in the session?” The next question might be “What do you think could have gone better?”

In some university clinics, students are videotaped so that they can review their own performance after a session. In one private practice setting where our students are trained, the audiologists do role-playing with students. In most clinics or practices, these activities may be too time-consuming to undertake, but I am often impressed by the insight students have when they are able to retrospectively evaluate their own behavior. In some cases, students volunteer information that would have otherwise been provided as instruction. They may have already learned from a mistake, or decided that they would have pursued a different course of action before you have the opportunity to mention it. If the student is focused on a particular area of concern that is different from that of yours, hearing their interpretation of a situation is helpful to demonstrate this so that the student can then be focused in other areas. Basically, hearing what they have to say first can eliminate a lot of miscommunication.

18. Apart from teaching students what we know about in our clinical milieu, how do we prepare them for the future? We won’t always be there to hold their hands.

Very true. I think one of the most valuable things that we can do is to model behaviors and skills to teach students how to learn independently. Nobody has time to spoon feed every bit of knowledge to students, and even if we could, we would be doing so to their detriment. Students will eventually be practicing independently, and technology, methods, and our evidence base will continue to evolve throughout their careers. They must be prepared to be lifelong learners in order to care for patients.

When a student asks a question, rather than answering, it can be helpful to coach them to find the answer or solution on their own. Some phrases to help are:

• “That’s a good question. I don’t know.”
• “Where can we find the answer to that?”
• “What does the literature say?”
• “Can we use our own data or collect data to answer that?”

It is important, however, to make sure to follow up with the student to confirm the accuracy of what he or she found.

19. It takes skill to both manage and instruct students. What resources are available for people who are interested in clinical teaching or who want to improve their skills?

Fortunately, we are entering an era of even greater appreciation of the skills needed for educating students clinically, and there are quite a few opportunities available. The Council of Academic Programs in Communication Sciences and Disorders is in the process of developing a toolkit of clinical training resources that university programs will be able to access and disseminate to their clinical instructors. In addition, the American Board of Audiology is in the process of developing training materials leading to a certificate in audiology clinical precepting. There are a few textbooks on the art and science of clinical education of students in the communication sciences and disorders disciplines and many more published on the instruction of students in other allied health and medical fields. And of course AudiologyOnline features a number of courses on this topic (select the topic "Supervision" in the course library).

20. After all this, given the amount of effort required to be a clinical instructor, why would anyone want to be one?

The answer, of course, is different for everyone. There can be many benefits to serving as a clinical instructor. For example, the fact that you train students in your practice provides credibility to you as a clinician in the eyes of patients. I typically find that patients enjoy being a participant in the education of the student, and it provides them with a satisfying experience. Many clinical instructors report that they enjoy the energy and enthusiasm that students bring to their practice and that they are continually learning new things from their students even as they are teaching them. Rarely, there may be some financial or in-kind compensation for clinical instructors. Overall, and maybe most importantly, there can simply be the good feeling from giving back to the profession and mentoring future colleagues.

References

American Speech-Language Hearing Association. (2015). The Accreditation handbook. Rockville, MD: ASHA.  Retrieved from: https://www.asha.org/uploadedFiles/Accreditation-Handbook.pdf

Flexner, A. (1910). Medical education in the United States and Canada: A report to the Carnegie Foundation for the Advancement of Teaching, Bulletin No. 4., New York City: The Carnegie Foundation for the Advancement of Teaching.

King, P.M., & Kitchener, K.S. (1994). Developing reflective judgment: Understanding and promoting intellectual growth and critical thinking in adolescents and adults. San Francisco: Jossey-Bass.