How Pediatric Educators Know What to Teach: The Use of Teaching Scripts

Objective. Expert clinical teachers in medicine use teaching scripts. The aim of this study was to determine whether pediatricians also use common components of teaching scripts. Methods. Seventy-three pediatric clerkship directors identified anticipated errors and teaching points in response to two short vignettes. The content analysis of responses, which we completed, was analyzed by rank and receipt of teaching awards. Results. Greater than 87% of respondents identified at least one of three anticipated learner errors and greater than 80% of respondents identified at least one of three to four teaching points. Teaching points related directly to anticipated errors in 60% of responses. Level of experience and receipt of teaching awards had no impact on response content. Conclusions. Consistent with findings on the use of teaching scripts, pediatrics’ educators achieved high congruence on anticipated errors and teaching points on two teaching vignettes. These findings support the hypothesis that developing teaching expertise is associated with other script components. Pediatrics 1999;104:148– 150; medical education, teaching scripts, clinical teaching, pediatrics. We have all known excellent teachers, but what makes them excel is not always clear. Traditionally, studies of effective teachers have focused on behavioral characteristics (eg, clear and organized)1 and/or teacher roles (eg, supervisor).2 Recently, several researchers have begun to identify the cognitive processes that distinguish experienced from novice teachers. Schulman and others3,4 recognize that experienced teachers have an extremely extensive and interrelated knowledge of teaching organized in the form of “scripts.” These teaching scripts help teachers anticipate learners’ actions and enable them to respond quickly during an instructional episode. Just as movie scripts contain detailed information about dialogue, character traits, and staging, teachers’ internalized scripts contain detailed information about the learner, the goals of a session, specific teaching points for given topics, and effective educational strategies keyed to different learner levels.3,4 In his seminal study of expert physician educators, Irby5 elaborated on the use of teaching scripts in medical education. The internists observed in his study combined their extensive knowledge base of patients and diseases with a broad knowledge of the learner and teaching methods. For these physicians, teaching scripts were activated in response to a simple stimulus (eg, a patient presenting with diabetic ketoacidosis). These expert teachers then used knowledge about the learner (level, strengths, and weaknesses) to anticipate errors (eg, inadequate history of diet), enabling them to adapt their internalized, disease-specific lesson plan (impact of diet on diabetes) to this teaching episode. As in procedures used by all experts, the automaticity of the stimulus-activation process reduces the clinician’s cognitive workload,6 allowing the teacher to continually adapt his/her instruction to the specific learners. Irby’s pioneering work in medical education points to several unexplored issues. First, Irby’s subjects were internists preselected as expert teachers, raising the questions of whether clinicians in other specialties or of varying levels of teaching experience use teaching scripts. The stimulus used by Irby was a single case of diabetic ketoacidosis, leaving open the question of whether scripts are generalizable to other conditions. This study sought to build on Irby’s work by examining the generalizability of teaching scripts in teachers of another medical specialty, across medical conditions, and at varying levels of teacher expertise/ experience. Consistent with the initial stages and processes of clinical teaching,7 this study focused on the use of scripts to identify common learner errors (needs assessment) and teaching points (objectives) in response to common clinical scenarios.