PHM17 session summary: Tools for engaging learners of all levels


At PHM 2017

NASHVILLE, TENN. – Various instructional tools and techniques can help hospitalists teach medical learners at a variety of levels, according to experts who spoke at Pediatric Hospital Medicine 2017, sponsored by the Society of Hospital Medicine, the American Academy of Pediatrics, and the Academic Pediatric Association.


Tools for Engaging Learners of All Levels: Multilevel Teaching Techniques & Cognitive Apprenticeship


Dr. Amanda Rogers

Jacqueline Walker, MD, Jessica Bettenhausen, MD, Sangeeta Krishna, MD, Jamie Pinto, MD, Caroline Rassbach, MD, Neha Shah, MD

Session summary

Hospitalists are commonly charged with teaching learners at a variety of levels. There are various tools that can be used to accomplish this including multilevel teaching and cognitive apprenticeship.

Multilevel teaching is defined as teaching multiple levels of learners simultaneously. The goal is to maintain engagement without being boring or teaching over any learner’s head. Examples include:

1. Broadening: Change the case to make it more challenging or interesting such as asking what to do if the patient was a different age or had a comorbid condition.

2. Targeting: Target questions at specific team members depending on difficulty such as asking students common causes of bacterial meningitis and asking residents about admission criteria.

3. Novelty: Provide new data such as a recent journal article.

4. Up the Ladder: Ask the same question to all team members, starting with the most junior.

5. Student as Teacher: Ask a senior learner to teach a junior learner.

6. Multi-Answer: Seek multiple answers to one question such as asking each learner to contribute an item to a differential diagnosis.

7. No Right Answer: Ask questions that do not have a single correct answer such as how to approach a difficult conversation.

8. Teaching to the Top: Teach to the level of the most senior learner.

9. Extreme Challenge: Teach at a level above all learners on the team.

Laura Certain, MD, PhD, et al1 found that most trainees feel Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are most effective. No Right Answer, Teaching to the Top, and Extreme Challenge were felt to be least effective.

Another concept for engaging learners at all levels is cognitive apprenticeship, which is an instructional model whereby teachers make explicit their generally tacit cognitive processes. Examples include:

1. Modeling: Actively demonstrate skills such as performing a procedure while verbalizing the steps and thought processes.

2. Couching: Observe learners and provide feedback on their performance.

3. Scaffolding: Inquire about past experiences and provide opportunity for independent activities, while also providing help for activities that are difficult for learners.

4. Articulation: Ask learners to explain their thought processes.

5. Reflection: Prompt students to deliberately consider their strengths and weaknesses.

6. Exploration: Encourage students to set personal learning goals.

Coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

Key takeaways for Pediatric HM

• Multilevel teaching can be used to engage a variety of learners simultaneously. Targeting, Up the Ladder, Student as Teacher, and Multi-Answer are effective methods to achieve this goal.

• Cognitive apprenticeship can be used in clinical teaching to make a tacit cognitive process explicit. Methods such as coaching and articulation have been found to be more useful for novice learners. Reflection and exploration are more useful for advanced learners.

• Regardless of the method used, teachers should demonstrate interest in the learners’ education and treat them with respect.

Dr. Rogers is assistant professor of pediatrics and Section of Hospital Medicine associate program director, Pediatric Residency Program, at the Medical College of Wisconsin, Milwaukee.


1. Certain LK, Guarino AJ, Greenwald JL. Effective multilevel teaching techniques on attending rounds: a pilot survey and systematic review of the literature. Med Teach. 2011;33(12),e644-650. doi: 10.3109/0142159X.2011.610844.

Recommended Reading

Hospitalist meta-leader: Your new mission has arrived
The Hospitalist
Meet the two newest SHM board members
The Hospitalist
Everything We Say and Do: Take time to leave a good impression
The Hospitalist
Sneak Peek: The Hospital Leader blog - July 2017
The Hospitalist
QI enthusiast to QI leader: John Bulger, DO
The Hospitalist
Pediatrics Committee’s role amplified with subspecialty’s evolution
The Hospitalist
The role of NPs and PAs in hospital medicine programs
The Hospitalist
Student Hospitalist Scholars: Preventing unplanned PICU transfers
The Hospitalist
Student Hospitalist Scholars: The importance of communication
The Hospitalist
Student Hospitalist Scholars: Discovering a passion for research
The Hospitalist
   Comments ()