129is one in which the learner progresses from following rules based on limited experi-
ence without comprehension of context, toward intuitive decision making based on
analysis and ultimately intuition as experience grows. As the learner progresses,
they also progress from detached commitment to involved commitment based on
progressive understanding. It is paramount that the teachers recognize, or “diag-
nose,” the learner’s current stage in order to employ techniques that both reinforce
the learner’s existing knowledge base and empower the learner to grow [ 38 ]. This
model of teaching can be used in the clinic, hospital wards, or in the operating room.
Through surgical residency, these early skills are most likely acquired with the
help of a senior resident’s leadership based on the “near-peer” relationship as
described above. It is crucial for the senior resident to see one of his or her primary
duties as teaching the more junior residents on his or her team. The teacher of a
novice learner aids by helping the learner organize their clinical knowledge by
pointing out meaningful diagnostic information in the history and physical exam,
eliminating irrelevant information, and encouraging learners to read about the clini-
cal scenario. A new intern can find the amount of work involved in developing these
skills alongside performing even relatively simple tasks overwhelmingly. At this
novice stage, it is difficult to discern what information is relevant to a patient’s care
and what is extraneous. The senior resident can teach the junior resident strategies
to remain organized and methods to gain efficiency. This can be taught both by
instruction and role modeling.
As the learner progresses to an advanced beginner, the teacher encourages him or
her to formulate and articulate their own differential diagnosis and treatment plan.
In the midst of a busy day with many time constraints, it is often more efficient for
the more senior resident to formulate a patient care plan. However, it is crucial for
the junior residents to develop a plan prior to hearing the senior’s assessment and to
be given the opportunity to synthesize and articulate the plan. The senior resident
should ask, “What is your plan?” This promotes synthesis of information, applica-
tion, and reinforcement of already existing medical knowledge, prioritization and
decision-making skill, and the development of ownership and responsibility in the
patient’s care.
In the Dreyfus model, the teacher of a competent learner must balance supervision
with autonomy in order to allow the learner to become accountable for their deci-
sions. This balance is found by elucidating what tasks the learner can be trusted to
perform well independently and what tasks need guidance. Lev Vygotsky introduced
a concept called the “zone of proximal development,” which defines tasks that the
learner cannot do unaided, but can be completed with guidance [ 39 ]. An attending or
senior resident must discern which tasks the junior resident can be entrusted to per-
form independently versus those that require instruction or close supervision, as well
as those beyond the learner’s capabilities even with assistance. Teachers should strive
to teach in this zone of proximal development, where the benefit of the teacher’s
assistance is neither superfluous nor facilitates danger, but enabling. Here lies the
balance required between autonomy and guidance, which leads to the most growth
and progression—defining the point of maximal teaching impact for the learner.
Further influences on developing resident autonomy will be discussed below.
7 Teaching Residents to Teach: Why and How