July 19, 2021

Shadowing: Passive observation or interactive educational tool?

Bruce Peyser, MD, FACP
Director of Education and Teaching, Duke Primary and Urgent Care
Professor of Medicine, Duke University School of Medicine
Provider, Duke Primary Care Pickett Road

For some years now, I have preached about the sins of shadowing as an educational experience for learners. I now realize I may have underestimated the value of this experience.

bigstock--209788432.jpgShadowing means different things to different people, but in a health care setting, shadowing commonly refers to the observational activity that occurs when a learner accompanies a clinician who is providing care to patients. When shadowing is happening, the student watches the teacher interact with patients and family. The clinician role models exemplary evaluation, patient care, and communication skills.

In the past, students were mainly assigned shadowing roles while learning in an outpatient setting, and an entire rotation might be characterized by this observational activity that was nearly always passive and limited in scope. But this need not be the case now, and I have witnessed best practices that involve variants of shadowing that I want to share with everyone.

One of the approaches has been used by pediatrician colleagues. This type of teaching has risen at least in part out of necessity. While learners can easily fit into a family or internal medicine practice to help out with patient care and evaluation, the situation is different in pediatric practices, where many visits are characterized as “well child care” visits. It takes a skillful clinician to carry out these evaluations properly, and this is something that would be challenging to any learner rotating through an outpatient pediatric office.

Some colleagues have focused on how learners might best interact with families and patients in a pediatric clinic. Check out this short video detailing how this can work: https://youtu.be/md-dwXFF7yc. Note the learning the provider assigns and the attention to specific educational goals. Shadowing in this manner becomes more interactive and mindful, and learners can become more engaged in their own learning process.

I have experimented with shadowing in my clinic with a variety of learners. I almost always ask new learners to watch and shadow me for several patient evaluations and/or physicals, just so that they can become accustomed to my pace, style, and approach. On a first day with me, I usually limit this to one hour. Then I confer with the learner and carefully pick a patient or two for them to see.

Throughout a half-day of working in my clinic, I almost always have at least one challenging interaction with patients or families. This can vary widely and might involve discussion of an unexpected finding. We might touch upon suboptimal health habits. Or I might have to interact with a difficult patient with a personality disorder. Though in the past I always wanted to carry out these visits in private, I now find that (after first obtaining patient permission) these visits provide a rich opportunity to teach and role model the various skillsets we use in our fields. And the more gnarly the interaction, the greater the opportunity for valuable teaching and education.

Think about how you might employ shadowing opportunities in your clinic. It’s another valuable item to place into your teaching toolbox.

P.S. Coincidentally, the next issue of Academic Medicine includes an article about shadowing. Take a look at an ahead-of-print version of “Illuminating Shadows: The Power of Learning by Observing” by Jack Ende, MD, MACP.