Teaching on the Fly: Efficient and Effective Clinical Pedagogy for the Fellow

Helping Fellows Develop Their Own Teaching Skills as They Supervise Residents and Medical Students

Dr Neeraj Manikath , claude.ai

Abstract

As clinical fellows transition from pure learners to educator-clinicians, they face the dual challenge of advancing their own expertise while developing the pedagogical skills necessary to teach residents and medical students effectively. Teaching in busy clinical environments requires structured, evidence-based approaches that maximize educational impact within severe time constraints. This review examines practical frameworks for "teaching on the fly," including the One-Minute Preceptor model, high-quality feedback techniques, strategies for creating psychologically safe learning environments, and principles of effective delegation. We provide actionable pearls and clinical hacks to help fellows become exceptional bedside educators while maintaining clinical efficiency.

Introduction

The fellow occupies a unique position in academic medicine's educational hierarchy—simultaneously a senior trainee, a near-peer educator, and often the frontline clinical supervisor for residents and medical students. Despite spending up to 25% of their clinical time teaching, most fellows receive minimal formal training in educational methods.1,2 This pedagogical gap is particularly problematic given that teaching effectiveness significantly impacts not only trainee learning outcomes but also patient safety, clinical efficiency, and the fellow's own professional development.3,4

The clinical environment presents distinct challenges for teaching: time pressure, competing demands, acuity of illness, and the need to balance education with service obligations. Traditional didactic approaches are ill-suited to this context. Instead, fellows must master "teaching on the fly"—brief, structured, high-yield educational interventions that can be delivered during clinical workflows.5,6

This review synthesizes evidence-based approaches to clinical teaching specifically tailored to the fellow's role, with emphasis on practical implementation strategies and common pitfalls.

The One-Minute Preceptor Model: A Structured Framework for Teaching in a Busy Clinical Environment

Overview and Evidence Base

The One-Minute Preceptor (OMP), also known as the "microskills" model, was developed by Neher et al. in 1992 specifically to address the tension between teaching and clinical efficiency.7 Despite its name, the model typically requires 5-8 minutes but can be adapted for briefer encounters. Multiple studies demonstrate that OMP improves teaching effectiveness without increasing clinical time and enhances both educator satisfaction and learner outcomes.8,9

The model consists of five deliberate microskills:

Get a commitment - "What do you think is going on?"
Probe for supporting evidence - "What led you to that conclusion?"
Teach general rules - "In patients with syncope..."
Reinforce what was done right - "You identified the key finding..."
Correct mistakes - "Next time, also consider..."

Practical Implementation

Microskill 1: Getting a Commitment

Rather than asking "What's the differential?" (which often generates unfocused lists), ask commitment-forcing questions:

"What's your leading diagnosis?"
"What do you want to do next?"
"Should we admit or discharge this patient?"

Pearl: Frame questions at the appropriate level—ask students for diagnoses, interns for initial management plans, and senior residents for disposition decisions and prognostic assessments.10

Oyster: Many fellows skip directly to teaching without first assessing the learner's reasoning, missing the opportunity for active learning and diagnostic error identification.

Microskill 2: Probing for Supporting Evidence

This reveals the learner's clinical reasoning process:

"Walk me through your thought process."
"What clinical findings support that diagnosis?"
"What were you most worried about?"

Hack: Use the "SNAPPS" bridge—when learners present using the SNAPPS format (Summarize, Narrow, Analyze, Probe, Plan, Select learning issues), the commitment and evidence steps are already built in.11

Microskill 3: Teaching General Rules

Focus on broadly applicable principles rather than case-specific facts:

"In septic shock, the priorities are always..."
"When you see thrombocytopenia with schistocytes, think..."
"Unprovoked VTE in young patients warrants evaluation for..."

Pearl: The "Rule of Three"—teach no more than 3 key points per encounter. Cognitive load research demonstrates that learners retain 2-3 teaching points effectively but experience rapidly diminishing returns beyond this.12

Microskills 4 & 5: Reinforcement and Correction

Always identify something done well before addressing errors. This isn't merely psychological cushioning—positive reinforcement shapes future behavior more effectively than pure criticism.13

Hack: Use "SHARP" feedback:

Specific behavior (not vague praise)
Honest assessment
Actionable recommendations
Reason given (why it matters)
Prompt delivery (immediate or very soon after)

Common Pitfalls and Solutions

Pitfall: Asking yes/no questions rather than open-ended commitment questions. Solution: Replace "Do you think this is pneumonia?" with "What do you think is causing his hypoxia?"

Pitfall: Teaching everything about a topic rather than high-yield principles. Solution: Ask yourself "What's the one thing they must remember about this?" Teach that.

Pitfall: Using the OMP as an interrogation rather than a teaching conversation. Solution: Maintain a curious, collaborative tone. Say "Tell me your thinking" not "Defend your diagnosis."

Giving High-Quality Feedback: The "Ask-Tell-Ask" and "Feedback Sandwich" Methods

The Critical Role of Feedback

Feedback is the most powerful educational intervention available to clinical teachers, yet it remains poorly executed in medical education.14,15 Studies demonstrate that trainees frequently cannot recall receiving any feedback despite supervisors believing they provide it regularly—a phenomenon termed the "feedback gap."16 Effective feedback requires deliberate structure, appropriate timing, and psychological safety.

The Ask-Tell-Ask Framework

This three-step model addresses the feedback gap by promoting dialogue rather than monologue.17

Step 1: Ask - Invite self-assessment

"How do you think that went?"
"What would you do differently next time?"
"What felt challenging about that encounter?"

Rationale: Self-assessment activates metacognition, reveals the learner's insight level, and creates cognitive dissonance that enhances receptiveness to feedback.18

Step 2: Tell - Provide your observed assessment

"Here's what I noticed..."
"From my perspective..."
"The data shows..."

Key elements:

Use specific behavioral observations, not character judgments
Focus on actions, not intentions
Include both reinforcing and corrective feedback
Explain the impact of observed behaviors

Pearl: Use the "feedback equation": Observed behavior + Impact + Suggested alternative

Example: "When you didn't introduce yourself to Mr. Johnson (behavior), he seemed uncertain about your role and asked the nurse afterward who you were (impact). Try starting with 'I'm Dr. Smith, the senior resident caring for you today' (alternative)."

Step 3: Ask - Confirm understanding and create action plan

"What's your take on what we discussed?"
"What will you try differently?"
"What support do you need to work on this?"

Hack: The "commitment to change" statement—ask learners to articulate one specific behavior they'll modify. Written commitments enhance follow-through by 30-40%.19

The Feedback Sandwich: Evidence and Evolution

The traditional "feedback sandwich" (positive-negative-positive) has fallen from favor among medical educators due to concerns that negative feedback becomes diluted or dismissed.20 However, research reveals the approach remains effective when properly executed.21

The Modern Feedback Sandwich:

Specific positive observation (not generic praise)
Growth-oriented constructive feedback (not criticism)
Forward-looking encouragement (not empty reassurance)

Oyster: The sandwich fails when the "bread" is too thick (excessive praise) or too thin (perfunctory compliments), or when the "filling" is vague ("you could improve your physical exam skills").

Alternative Framework: The Pendleton Model

For fellows who find the sandwich approach inauthentic, Pendleton's rules offer an alternative:22

Learner identifies strengths
Teacher reinforces and adds observed strengths
Learner identifies areas for development
Teacher adds constructive observations
Create collaborative action plan

Feedback Timing and Frequency

Pearl: The "24-hour rule"—deliver feedback within 24 hours when possible. Immediacy increases specificity and emotional resonance. For significant performance concerns, same-day feedback is essential.23

Hack: "Feedback rounds"—dedicate 5 minutes at the end of each clinical session for brief feedback exchanges. This normalizes feedback as routine rather than punitive.

Documentation of Feedback

Fellows should maintain brief records of significant feedback conversations, noting:

Date and context
Key behaviors discussed
Agreed-upon action items
Follow-up plan

This documentation protects both educator and learner, enables longitudinal assessment, and demonstrates progressive improvement or persistent concerns requiring escalation.

Creating a "Psychologically Safe" Learning Environment Where Trainees Feel Comfortable Admitting Knowledge Gaps

The Foundation of Psychological Safety

Psychological safety—defined as a belief that one will not be punished or humiliated for speaking up with ideas, questions, concerns, or mistakes—is the bedrock of effective clinical learning.24,25 In healthcare, psychological safety directly impacts patient safety: trainees who fear judgment are less likely to ask clarifying questions, admit uncertainty, or report errors.26

The fellow's behavior powerfully shapes team psychological safety. Unlike attending physicians who may be perceived as distant authority figures, fellows occupy a "near-peer" position that makes their modeling particularly influential.27

Strategies for Building Psychological Safety

1. Model Fallibility and Uncertainty

Pearl: Deliberately verbalize your own uncertainty and learning process:

"I'm not certain about the optimal antibiotic choice here. Let me look this up."
"I initially thought this was X, but this finding made me reconsider."
"I don't know the answer to that question—let's figure it out together."

Research demonstrates that admitting uncertainty enhances rather than diminishes learner trust when accompanied by appropriate knowledge-seeking behavior.28

Hack: The "public learning moment"—when you look something up, do it visibly rather than privately, narrating your search strategy and information evaluation process.

2. Normalize "I Don't Know"

Explicitly state expectations about knowledge gaps:

"On this rotation, I expect you won't know many answers—that's why you're here."
"The smartest thing you can say is 'I don't know but I'll find out.'"
"There's no penalty for admitting what you don't know; there are serious consequences for pretending you do."

Oyster: Many fellows inadvertently create psychological threat by expressing surprise or disappointment when learners don't know expected information ("You don't know how to interpret an ABG?!"). This discourages future disclosure.

Reframe: "This is important foundational knowledge—let's review it together now."

3. Establish Ground Rules Explicitly

On the first day with new learners, articulate behavioral expectations:

"Questions are always welcome, even if they seem basic."
"If you're uncomfortable with a procedure, speak up immediately."
"I'll never embarrass you in front of patients or other staff."
"Mistakes are learning opportunities, not character defects."

Pearl: The "amnesty statement"—"If you're ever uncertain about something I've asked you to do, you have complete amnesty to question it or ask for clarification, even if it delays care slightly. Patient safety trumps efficiency."

4. Respond to Questions With Curiosity, Not Judgment

Replace judgmental responses with curious inquiry:

Instead of: "That's a basic question you should know." Try: "That's an important concept—what have you learned about it so far?"

Instead of: "Why did you do it that way?" Try: "Walk me through your reasoning for that approach."

Hack: The "3-second pause"—when a learner asks a question or makes an error, pause for 3 seconds before responding. This prevents reflexive defensive or critical reactions and allows for thoughtful, constructive responses.

5. Create Safe Spaces for Debriefing

Pearl: Use the "PEARLS" debriefing framework after challenging cases:29

Promoting psychological safety
Establishing rules for engagement
Actively managing reactions
Reviewing performance data
Learning from experience
Safety focus

Hack: The "exit ticket"—at the end of the shift, ask each team member: "What's one thing you learned today?" and "What's one thing that could have gone better?" This surfaces learning needs and systemic issues in a non-threatening format.

6. Address Mistreatment Immediately

Fellows must intervene when they observe hierarchy-based mistreatment:

Public humiliation
Dismissal of legitimate questions
Sarcasm or belittling comments
Assigning "punishment" work

Script: "I need to interrupt. In our learning environment, we treat each other with respect. [Specific behavior] isn't acceptable. Let's reset and approach this differently."

Delegating Effectively: How to Assign Tasks That Are Educational, Not Just Scut Work

The Delegation Dilemma

Fellows face competing pressures: clinical efficiency demands task delegation, yet meaningful education requires thoughtful task selection and supervision. Poor delegation leads to two failure modes: (1) over-delegation of menial tasks without educational value ("scut work"), breeding resentment and disengagement, or (2) under-delegation, with fellows becoming bottlenecks while trainees remain underutilized.30

Effective delegation is not simply task assignment—it's a pedagogical tool that promotes progressive autonomy, develops clinical judgment, and prepares trainees for graduated responsibility.31

The Principles of Educational Delegation

1. Match Task Complexity to Learner Level

Use an entrustment framework based on supervision level:32

Medical Students:

Observation with participation (Level 2)
Example tasks: Focused histories, supervised procedures, care coordination

Junior Residents:

Direct supervision available (Level 3a)
Example tasks: Initial management plans, supervised ICU admissions, basic procedures

Senior Residents:

Indirect supervision available (Level 3b)
Example tasks: Complex diagnostic workups, independent patient management, teaching junior team members

Pearl: Use the "I do, we do, you do" progression for procedural and cognitive tasks. The fellow demonstrates, then co-performs with the trainee, then observes the trainee performing independently.

Oyster: Assigning tasks beyond competency level without scaffolding creates anxiety and risks patient safety. Assigning tasks below competency level without explanation breeds frustration.

2. Provide Context and Learning Objectives

Transform routine tasks into learning opportunities by articulating educational goals:

Instead of: "Place a central line in bed 4." Try: "Place a central line in bed 4. I want you to focus on ultrasound technique—let's review the vessel anatomy first, and we'll debrief afterward about your approach to avoiding complications."

Instead of: "Call the patient's daughter with the update." Try: "Call the patient's daughter with the update. This is a challenging family conversation—think about how you'll deliver bad news empathetically. We'll debrief your approach afterward."

Hack: The "learning contract"—for complex tasks, explicitly state: (1) what the learner should do, (2) what educational goal it serves, (3) what support is available, and (4) how you'll debrief.

3. Distinguish Educational Tasks from Service Work

Educational tasks:

Develop clinical skills, judgment, or knowledge
Align with rotation learning objectives
Provide appropriate challenge
Include feedback opportunity

Service work:

Primarily administrative
No skill development
Could be done by non-clinical staff
Repetitive without variation

Pearl: The "80/20 rule"—aim for 80% of delegated tasks to have clear educational value, recognizing that 20% service work is inevitable in clinical care. When service work is necessary, distribute it equitably and explain the rationale.

Oyster: Tasks fellows dislike often become dumped on junior trainees. This perpetuates a toxic "hazing" culture. Fellows should model professionalism by occasionally performing menial tasks alongside trainees.

4. Calibrate Autonomy and Supervision

Use the "5 microskills of clinical supervision" when delegating:33

Assess the learner - "Have you managed AKI before?"
Give specific instructions - "Start with the KDIGO guidelines..."
Check for understanding - "Tell me your approach."
Set supervision expectations - "Call me before ordering renal replacement therapy."
Arrange follow-up - "We'll review the case at 3 PM."

Hack: The "autonomy ladder"—progressively increase independence for repeated tasks. First occurrence: high supervision. Second: moderate supervision. Third: independent with check-in. Fourth: fully autonomous with outcome review.

5. Debrief Delegated Tasks

Delegation without feedback is missed educational opportunity. Brief debriefing closes the learning loop:

"How did the family meeting go? What went well?"
"Walk me through your clinical reasoning on that management decision."
"What would you do differently next time?"

Pearl: For time-pressured environments, use "corridor consultations"—60-second debriefings during hallway encounters. Research shows these brief interactions have significant educational impact when structured.34

Special Considerations: Knowing When NOT to Delegate

Don't delegate when:

Patient acuity exceeds trainee competency significantly
Stakes are very high (e.g., critical conversations, high-risk procedures)
You haven't yet assessed the trainee's skill level
Adequate supervision cannot be provided
The task is actually YOUR responsibility to perform

Pearl: The "3 AM rule"—if you wouldn't be comfortable with this decision being made at 3 AM without your input, don't delegate it without explicit supervision parameters.

Managing Delegation Failure

When delegated tasks are performed inadequately:

Assess the failure mode:
- Knowledge gap?
- Skill deficit?
- Systems issue?
- Judgment error?
Address immediately:
- Correct patient care issues first
- Debrief educationally second
Adjust future delegation:
- Decrease autonomy temporarily
- Increase supervision
- Provide remediation
- Reassess competency

Script: "The potassium repletion you ordered was insufficient for this degree of hypokalemia. Let me show you the calculator we use. For the next few cases, run your electrolyte repletion plans by me before ordering until you're comfortable."

Practical Integration: Putting It All Together

The Teaching Encounter Checklist

For busy clinical environments, this mental checklist ensures teaching completeness:

☑ Commitment obtained - Did I ask what they think?
☑ Reasoning probed - Do I understand their thought process?
☑ Teaching delivered - Did I share 1-3 key principles?
☑ Feedback given - Did I identify something done well and something to improve?
☑ Psychological safety maintained - Did I respond constructively to uncertainty?
☑ Appropriate delegation - Is this task educational and properly supervised?

Time-Saving Teaching Strategies

The "Teaching Sprint":

Set a timer for 5 minutes
Use OMP framework
Teach 1-2 key points maximum
Schedule longer discussion for later if needed

The "Batch Teaching" Approach:

Accumulate teaching points throughout the day
Deliver as brief teaching rounds at shift end
Provides spaced repetition and consolidation

The "Just-in-Time" Teaching Moment:

Capture teachable moments as they arise
60-second teaching interventions
Focus on immediately relevant clinical issues

Self-Assessment for Fellows

Periodically evaluate your teaching effectiveness:

Questions to ask yourself:

Do my learners ask questions freely, or do they seem hesitant?
Can I name specific strengths and areas for growth for each team member?
Am I teaching general principles, or just case-specific facts?
Do I provide feedback regularly, or only during formal evaluations?
Are delegated tasks appropriately challenging for learner level?
Do I model the behaviors I expect from trainees?

Pearl: Use a "teaching log"—briefly document teaching encounters for 1 week every 3 months. This reveals patterns in your teaching approach and identifies areas for improvement.

Conclusion

Teaching on the fly is not a compromise born of time pressure—it is a distinct skill set that, when mastered, produces exceptional educational outcomes within clinical workflows. Fellows who develop structured approaches to brief teaching encounters, deliver high-quality feedback consistently, cultivate psychologically safe learning environments, and delegate thoughtfully prepare the next generation of physicians while advancing their own expertise.

The frameworks presented here—the One-Minute Preceptor, Ask-Tell-Ask, psychological safety principles, and educational delegation strategies—provide actionable tools immediately applicable to clinical practice. Excellence in clinical teaching is not innate; it is a learned competency that improves with deliberate practice and reflection.

As you transition from fellow to attending physician, the investment you make in developing teaching skills will yield dividends throughout your career. The residents and students you teach today will become the colleagues who care for your patients—and perhaps for you—tomorrow. Teaching on the fly isn't just efficient; it's essential.

References

Pasquinelli LM, Greenberg LW. A review of medical school programs that train medical students as teachers (MED-SATS). Teach Learn Med. 2008;20(1):73-81.
Post RE, Quattlebaum RG, Benich JJ. Residents-as-teachers curricula: a critical review. Acad Med. 2009;84(3):374-380.
Busari JO, Scherpbier AJ, Van der Vleuten CP, Essed GG. Residents' perception of their role in teaching undergraduate students in the clinical setting. Med Teach. 2000;22(4):348-353.
Morrison EH, Hafler JP. Yesterday a learner, today a teacher too: residents as teachers in 2000. Pediatrics. 2000;105(1):238-241.
Irby DM. Teaching and learning in ambulatory care settings: a thematic review of the literature. Acad Med. 1995;70(10):898-931.
Ferenchick G, Simpson D, Blackman J, DaRosa D, Dunnington G. Strategies for efficient and effective teaching in the ambulatory care setting. Acad Med. 1997;72(4):277-280.
Neher JO, Gordon KC, Meyer B, Stevens N. A five-step "microskills" model of clinical teaching. J Am Board Fam Pract. 1992;5(4):419-424.
Aagaard E, Teherani A, Irby DM. Effectiveness of the one-minute preceptor model for diagnosing the patient and the learner: proof of concept. Acad Med. 2004;79(1):42-49.
Furney SL, Orsini AN, Orsetti KE, Stern DT, Gruppen LD, Irby DM. Teaching the one-minute preceptor. A randomized controlled trial. J Gen Intern Med. 2001;16(9):620-624.
Wolpaw TM, Wolpaw DR, Papp KK. SNAPPS: a learner-centered model for outpatient education. Acad Med. 2003;78(9):893-898.
Wolpaw T, Papp KK, Bordage G. Using SNAPPS to facilitate the expression of clinical reasoning and uncertainties: a randomized comparison group trial. Acad Med. 2009;84(4):517-524.
van Merriënboer JJ, Sweller J. Cognitive load theory in health professional education: design principles and strategies. Med Educ. 2010;44(1):85-93.
Hattie J, Timperley H. The power of feedback. Rev Educ Res. 2007;77(1):81-112.
Ende J. Feedback in clinical medical education. JAMA. 1983;250(6):777-781.
Archer JC. State of the science in health professional education: effective feedback. Med Educ. 2010;44(1):101-108.
Sender Liberman A, Liberman M, Steinert Y, McLeod P, Meterissian S. Surgery residents and attending surgeons have different perceptions of feedback. Med Teach. 2005;27(5):470-472.
French JC, Colbert CY, Pien LC, Dannefer EF, Taylor CA. Targeted feedback in the ambulatory setting: a qualitative study of pediatric resident perspectives. Acad Med. 2015;90(2):250-255.
Eva KW, Regehr G. Self-assessment in the health professions: a reformulation and research agenda. Acad Med. 2005;80(10 Suppl):S46-54.
Sargeant J, Mann K, van der Vleuten C, Metsemakers J. "Directed" self-assessment: practice and feedback within a social context. J Contin Educ Health Prof. 2008;28(1):47-54.
Dohrenwend A. Serving up the feedback sandwich. Teach Learn Med. 2002;14(3):171-172.
Parkes J, Abercrombie S, McCarty T. Feedback sandwiches affect perceptions but not performance. Adv Health Sci Educ Theory Pract. 2013;18(3):397-407.
Pendleton D, Schofield T, Tate P, Havelock P. The New Consultation: Developing Doctor-Patient Communication. Oxford: Oxford University Press; 2003.
Anderson PA. Giving feedback on clinical skills: are we starving our young? J Grad Med Educ. 2012;4(2):154-158.
Edmondson AC. Psychological safety and learning behavior in work teams. Adm Sci Q. 1999;44(2):350-383.
Edmondson AC, Lei Z. Psychological safety: the history, renaissance, and future of an interpersonal construct. Annu Rev Organ Psychol Organ Behav. 2014;1:23-43.
Okuyama A, Wagner C, Bijnen B. Speaking up for patient safety by hospital-based health care professionals: a literature review. BMC Health Serv Res. 2014;14:61.
Ten Cate O, Durning S. Dimensions and psychology of peer teaching in medical education. Med Teach. 2007;29(6):546-552.
Farnan JM, Johnson JK, Meltzer DO, Humphrey HJ, Arora VM. On-call supervision and resident autonomy: from micromanager to absentee attending. Am J Med. 2009;122(8):784-788.
Eppich W, Cheng A. Promoting Excellence and Reflective Learning in Simulation (PEARLS): development and rationale for a blended approach to health care simulation debriefing. Simul Healthc. 2015;10(2):106-115.
Jamal MH, Wong S, Whalen T. Residents as teachers: a systematic review of efficacy of teaching skills improvement interventions. J Surg Educ. 2012;69(5):693-698.
Kennedy TJ, Regehr G, Baker GR, Lingard L. Progressive independence in clinical training: a tradition worth defending? Acad Med. 2005;80(10 Suppl):S106-111.
Ten Cate O. Entrustability of professional activities and competency-based training. Med Educ. 2005;39(12):1176-1177.
Kilminster SM, Jolly BC. Effective supervision in clinical practice settings: a literature review. Med Educ. 2000;34(10):827-840.
Lake FR, Hamdorf JM. Teaching on the run tips 5: teaching one-to-one. Med J Aust. 2004;181(3):158-160.

Author's Note

This review synthesizes evidence-based approaches to clinical teaching for fellows in internal medicine. The frameworks and strategies presented are drawn from medical education research, cognitive psychology, and the author's experience in academic internal medicine. Fellows are encouraged to adapt these principles to their specific clinical contexts and learning environments. Ongoing self-reflection and solicitation of feedback from trainees remain essential for continuous improvement in teaching effectiveness.