Beliefs, Attitudes, and Behaviors That Facilitate Learning in the Orthopedic Clinical Setting: A Case Study of an Exemplary Educator

Michael Jeanfavre

Stanford Health Care, Department of Outpatient Physical Therapy Orthopedic and Sports Rehabilitation, 440 Broadway, Suite 3B, Redwood City, CA 94063

*Correspondence to: Dr. Michael Jeanfavre, Stanford Health Care, Department of Outpatient Physical Therapy Orthopedic and Sports Rehabilitation, 440 Broadway, Suite 3B, Redwood City, CA 94063.

Copyright © 2022 Dr. Michael Jeanfavre. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
In recent decades American higher education has undergone a paradigm shift. Moving from an instructional paradigm (where higher education institutions “created complex structures to provide for the activity of teaching conceived primarily as delivering” instruction and the transfer of knowledge) to the learning paradigm (emphasizes the active process of learning on behalf of the students, while envisioning the institution itself as a learner - “over time, it continuously learns how to produce more learning with each graduating class, each entering student.”) (Delvin, 2009) [1] Subsequently, research advances in cognitive science, psychology, neuroscience, and teaching theory have offered greater insights into the science of human learning and how educators can enhance learning, motivation, and student engagement [2-7]. These learning and teaching advances have helped establish a set of skills and knowledge that consistently achieve better learning outcomes than the traditional and still predominant teaching methods practices [8].

Despite higher education’s shift to emphasize and align with the science of learning, there is comparatively scarce application of these principles in clinical education [9,10]. Previous research has identified a correlation between teachers’ understanding of what and how their students learn and the teachers’ success in teaching [11,9]. According to Falk (2017) [9], “there is reason to believe that a good knowledge of the basics of pedagogy can sensitize health care personnel to develop a pedagogical practice among health care personnel in the clinical setting.” [9,12-14] The results of previous literature reviews of what makes an effective clinical educator identify general trends of teaching skills, attitudes, communication competencies, and personalities [15,16]. Though necessary skills and knowledge for effective clinical education, these characteristics may not enough for exemplary clinical education as they do not cover the full breadth of the concepts, techniques, and methods of science of learning and instruction.

Clinical educators have an “extremely important role in the effectiveness of clinical education in supporting learners” that requires incorporating the research-based theory of how people learn and evidence-based principles for how to design effective instruction. However, given the minimal research into how this is executed in post-graduate clinical, and educational programs (i.e., residency and fellowships), the purpose of the present study is to examine the integration of the science of instruction and learning in the clinical setting. The research question guiding the study is: “What are the beliefs, attitudes, and behaviors of an exemplary clinical educator?”

Methods
Research Design
The current study was a case study using qualitative methods, consisting of structured interviews and direct subject observation, to investigate an exemplary clinical educator’s attitudes, beliefs, and behavioral characteristics. A case study design enabled the investigator to explore a singular process, person, or circumstance through the lens of an individual instance or situation [17]. A qualitative approach was used as the investigation’s primary focus was to explore a field-based, recent case over time, through detailed, indepth data collection involving multiple sources of information and reports on clinical education description and themes [18]. The reporting of the methods and findings of the current study is consistent with the Consolidated Criteria for reporting qualitative research (COREQ) and the current consensus of reporting qualitative research findings [17,19,20].

functional recovery post-hip fracture surgery are available, thus more preventive efforts to secure the health and safety of the older community-dwelling adult at present may be strongly indicated.

The current study was conducted through a post-positivist approach (i.e., emphasizing independence between the researcher and the researched person) involving a prospective case study protocol, structured interview process, and careful consideration of validity and potential bias [21,22]. (See Appendix A for the respective structured interview protocols.) Such personal factors, characteristics, and experiences of the investigator that could potentially influence the current investigation’s execution are candidly disclosed in the limitations section of the manuscript.

Setting and Context
The study was conducted at a nationally recognized medical center and teaching hospital in northern California in the United States. The study setting was a hospital-based, outpatient orthopedic and sports medicine, physical therapy clinic with sixteen full-time therapists, unanimously provide-on-one one patient care while seeing an average of 130 patients per day. The clinic hosts an average of ten doctors of physical therapy students per year. It is a home site of an American Physical Therapy Association (APTA) accredited physical therapy orthopedic clinical residency. The residency accepts two residents per annual cohort and has recently (2020) been accredited by the American Board of Physical Therapy Residency and Fellowship Education (ABPTRFE) through 2030.

Exemplary Clinical Educator Observation: The observation of the exemplary educator took place in the 1500-square-foot physical therapy clinic. To provide candid details of the space and a 360° perspective of the teaching space, panoramic photos from the instructor’s, students’, and the investigator’s perspectives were, and two videos are provided in Figures 4a-4e of Appendix B.

Student Interview: The student interview was conducted one on one, in a conference room located in the same medical building and pavilion as the physical therapy clinic. For clarity of the space and full transparency, a panoramic photo and subsequent video of the room are provided in Appendix B.

Exemplary Clinical Educator Interview: The exemplary clinical educator interview was conducted one on one, in Ben’s office’s privacy and comfort, which is a 15 x 12 square foot room directly connected to the physical therapy clinic space. Photos and videos of Ben’s office were not taken to preserve Ben’s identity and privacy. A prospective, structured protocol with open-ended questions related to the questions asked in the student interview was used to elicit Ben’s candid responses and safeguard against unduly influencing her replies. The interview lasted sixty minutes.

Participants Selection
The selected residency program has had twelve graduates. Of those twelve, eight prior residents were available for questioning. Each available resident was asked to identify a residency faculty member whom they deemed to be an exemplary educator (operationally defined as an individual who is especially successful at promoting student learning) and why that person was selected, and what behaviors are most evident in his/her teaching. From the prior residents questioned, one resident was selected for the current case study based on the learner’s ability to name a specific professor and articulate how that person has helped him, or her learn.

The identified exemplary clinical educator was informed of his nomination, the purpose of the study, and whether he would be willing to participate in the case study. Using a pre-scripted informed consent document, the investigator described in full detail the nature of the study, the exemplary clinical educator’s role, and the willingness to allow the researcher to conduct a participatory classroom observation and subsequent one-on-one recorded structured interview. After the educator verbally acknowledged his understanding and signed the consent form, the selected student was also notified, briefed again on the study’s nature, signed the respective consent form, and arranged for an interview time. (See Appendix C for a blank copy of the student and educator informed consent forms. Both informed consent forms were approved by the Institutional Review Board (IRB) of Azusa Pacific University).

Participants
Note that for confidentiality, the names of both participants have been falsified. The student participant, Alex, is a 29-year-old, Caucasian male from the mid-west. After completing a Bachelor of Science (B.S.) in biology in 2013, a clinical doctorate in physical therapy (DPT) in 2019, and being licensed as a physical therapist in the state of California (2019), Alex was offered and accepted a position at Stanford Health Care’s Orthopedic Clinical Residency from September 2019 through October 2020. A Daktronics National Association of Intercollegiate Athletics (NAIA) Scholar, NAIA Academic All-American, and most outstanding college male athlete award recipient, Alex has consistently demonstrated his dedication to academic and athletic excellence.

The exemplary clinical educator, Ben, who received multiple recommendations from residents as an exemplary educator, is a 39-year-old Caucasian male, Assistant Clinic Manager of the respective physical therapy clinic, the Residency Committee Program Coordinator, and Advanced Clinical Instructor through the APTA. Since earning his DPT in 2007, Ben has over 13 years of outpatient orthopedics and sports medicine physical therapy clinical experience and is dual credentialed as a board-certified orthopedic and sports clinical specialist through the APTA. He oversees the Outpatient Orthopaedics and Sports Medicine Physical Therapy team. Committed to education, he performs numerous lectures on shoulder and knee evaluation and treatment and has published a book chapter on such topics. Ben is a co-founder, appointed faculty, committee chairperson, and program coordinator of Stanford Health Care’s Orthopedics Physical Therapy Residency program since 2013. He has also assisted in the development of the Accredited Stanford Geriatric and Hands Therapy residency programs. In 2015, Ben won the prestigious clinical instructor of excellence award through the Northern California Clinical Education Consortium (NCCEC). Ben has performed numerous lectures and published multiple articles related to orthopedic clinical expertise in addition to his clinical and educational pursuits. Ben was humble, responsive, and genuinely interested when asked to participate in the current case study of an exemplary clinical educator.

Procedures
Consent: Formal verbal and written consent of voluntary study participation of both the student and the educator was obtained prior to any data collection (See Appendix C for blank copies of informed consent documents).

Data Collection: The investigator observed the exemplary clinical educator in a classroom instructional role during a six-hour residency lecture titled “Shoulder Examination and Evaluation.” The course syllabus described the course as follows: “This course will prepare the resident to perform a comprehensive shoulder examination. The resident will be taught algorithmic shoulder assessment to appraise the shoulder and surrounding joints clinically. Emphasis will be placed on discerning clinically relevant information versus simple data gathering to make an advanced practice clinical decision, diagnosis, and prognosis. Where applicable, evidence will be utilized to support decision-making related to the diagnosis and prognosis of the patient. The course will emphasize the integration of individual clinical expertise, best available evidence, and patient values in a clinically relevant way” (SHC, 2020) [23]. A prospective observational assessment form that had been pre-piloted by prior graduate school students was used by the investigator to rate on a standard scale the educator’s verbal and non-verbal behaviors, expressions, and attitudes while teaching. In addition to rating the frequency of behaviors, the investigator also took extensive, hand-written notes about participants’ reactions, the classroom atmosphere, and the content delivered. A completed electronic version observational assessment form with ratings and field notes can be accessed in the supplementary material provided in Appendix D.

There were four-course attendees (not including the investigator), two orthopedic physical therapy residents, a staff physical therapist, and an occupational therapy resident from the same institution. As to avoid the participants’ testimony influencing the investigator’s perceptions of the classroom session, the teaching field observation occurred two months before the interview.

Prospective structured protocols with open-ended questions were used for both the student (50 minutes) and the educator (60 minutes) interviews to elicit authentic responses and safeguard against unduly influencing participant responses. See Appendix A for the respective structured interview protocols. The interviews were conducted on the same day, and both interview sessions were recorded in their entirety. As described in the informed consent form, before completing the data analysis, the respective audio recordings of their respective interview sessions were provided to the student and the educator. Upon reviewing the recording, the participants were given the opportunity to make any necessary corrections or clarifications of their responses.

Data Analysis: Both the interview and observational field notes required editing, reformatting, and clarification before analysis. Though initially typed, the notes and scaled responses on the observational assessment form were synthesized, formatted, and edited to produce the final electronic document referenced in the Data Collection section above. The two interview audio files were recorded using Voice Recording App [24]; the MP3 files were downloaded to a PC, copied and pasted into Microsoft© PowerPoint slide, and converted to an MP4 through exporting the slide show as a video. After uploading the MP4 file to an unlisted YouTube© video, each interview transcript was generated by copying and pasting the video subheadings into Microsoft Word©. The transcripts were reviewed multiple times by the investigator for editing, formatting, and clarity. During the transcript editing and formatting, the audio files were simultaneously referenced to ensure transcription accuracy. Once edited and formatted, the transcripts and the completed observational assessment form were used for the final analysis. (See the supplemental materials provided in Appendix D for full interview audio recordings and the completed interview transcripts.)

After ensuring the interview transcripts’ accuracy, a preliminary exploratory analysis of the data was completed prior to coding and analyzing them for themes [25]. First, the interview transcripts were read through and annotated with comments in Microsoft Word©. The transcripts were reread to generate preliminary codes. The identified preliminary codes were aggregated into categories that were organized into four subcategories. Finally, each of the categories was indexed under five major themes. The operational definitions of beliefs, values, versus attitudes for the data analysis, findings, and discussion are defined below. An attitude “is a psychological construct, a mental and emotional entity that inheres in, or characterizes a person” [26], while a belief is “an attitude that something is the case, or that some proposition about the world is true or false.” (Primer 2018) [27]. Values are “relatively stable beliefs that are infused with effect” and can belong to an agent, be it an individual, group, culture, or other beings [28].

To overcome the limitations of limited exposure to participants through single interviews, grasp a comprehensive understanding of the exemplary clinical educator’s attitudes, beliefs, and behaviors, and ensure the validity of findings, two measures were implemented as recommended by Creswell (2012) [25]. First, a triangulation level was built into the research design through data collection of a resident interview, extensive field observation, and faculty interview. Second, member checking was a second source of validation where the exemplary clinical educator was invited to review the identified categories, subcategories, and themes and provide feedback on accuracy [25,29].

Findings
Description of the Class Observation
The teaching observation took place mid-morning (9:00 am) on a Saturday in the clinic gym, as is custom for the residency lectures. The traditionally used space for clinical care is re-arranged to accommodate a combination of the didactic and lab practice aspects of the Shoulder Evaluation and Examination course. Ben arrived twenty minutes ahead of the scheduled start time to set up space and rearrange the treatment tables to accommodate the planned learning activities. One resident, Alex, had also arrived well before the scheduled start time to set up his laptop and prepare for the class. The other three participants arrived sequentially within ten minutes of the start time. The teaching space, pre and post-lecture setup, a 360° view of the learning environment, and vantage points from the educator, the students, and the investigator are shown in Figures 4a-e in Appendix B.

For several weeks leading up to the class, Ben had been a one-on-one mentor for Alex during clinical hours. Beyond the rigors of the residency program’s academic and professional demands, Ben had strongly encouraged Alex to take the time to watch one romantic comedy movie per week. Something that Ben had said would help Alex to disengage and relax while also observing and learning nuances of communication styles and interpersonal relationships. These details are relevant as Ben initially engaged the students with a humorous and entertaining five-questions pre-test of The Devil Wears Prada [30]. During the interview, Ben would describe how his intention in initiating the teaching session was to bring positive and relaxed emotions into the classroom while simultaneously grasping the audience’s attention.

Ben then transitioned to asking prompting questions of the audience regarding their current shoulder examination. “What does your current shoulder exam look like? Do you have a consistent shoulder physical examination flow? Why or why not? What is your rationale for having that particular test sequence? These questions were seemingly rhetorical and intended to prompt the audience’s internal processing as there were no volunteers who immediately spoke up with an answer. Ben further prompted, “Let us see what your current shoulder examination looks like.” He had the participants pair up, and over the initial fifteen minutes, the participants took turns performing their current shoulder examinations on one another. Though each student demonstrated a meaningful and logical flow to the sequence of their testing, the testing sequence of their exams was not automatic as the students would intermittently pause between assessments to determine what test(s) they would perform next. Ben silently orbited the groups- observing techniques. Upon the class coming back together, Ben asked for a volunteer to perform their shoulder examination sequence for all to observe and with a five-minute time limit. “How much information can you glean in the first five minutes of the physical examination?” Ben inquired. It was apparent from learners physically replicating specific movements and the dialogue between learners. The initial lab breakout and the volunteer’s five-minute examination sequence stimulated the learners to self-reflect on the sequence and the physical execution of the current shoulder examinations.

The class proceeded with alternating lab sessions with fifty to sixty-minute didactic (PowerPoint © guided lecture) covering the clinically relevant shoulder anatomy, cervical spine screening, scapula assessment, shoulder range of motion sequencing, and a logical, algorithmic-based diagnostic clinical testing sequence of the shoulder complex. Ben was well prepared for the presentation. He rarely had to look at the slides, consistently scanning the audience and intermittently making eye contact with each of the learners while conversationally identifying the critical take of slides (never reading the content verbatim). The didactic blocks of time were peppered with specific case examples offered by Ben and intermittent questions from the learners that lead to an unplanned, open dialogue of the material. There was a reciprocal balance of communication and inquiry between Ben and the audience. Ben would pause strategic at crucial time points to ask open-ended and application-based questions of the audience regarding the current material. There were also time points where the learners would share a clinical case that they had or were experiencing and asked how assessments may provide them more clarity about the patient’s condition. It was evident that the learners simultaneously acquired the content knowledge and translated it to real-world scenarios and applications.

The didactic blocks were broken up by either ten-minute breaks (for the participants to hydrate, informally chat, or use the facilities) or by more hands-on lab practical sessions that allowed the learners to practice the recently covered material and/or content that had been previously discussed in the lecture. During the lab sessions, learners were encouraged to switch partners, assess and “feel” different shoulders and bodies, refine specific tests, and/or run through a series of tests. Ben would bounce back and forth between the groups and provided specific and timely feedback on handholds, vectors of manual force, and clinically relevant tips. Learners had the opportunity to perform the techniques on one another, on Ben, and have Ben perform their techniques. The subsequent lab sessions followed a similar format; the small group breakout period would be followed by everyone coming together and observing Ben or a volunteer perform the particular skill. The learners were active, engaged, enthusiastic, and inquisitory during the lab sessions. There were freeflowing questions, dialogue, and unprompted peer-feedback amongst partners. Of particular importance was the final lab session that mimicked the initial breakout. There was a stark difference in the sequence and the execution of the learners’ shoulder examinations but the confidence and the intentional flow that they demonstrated from one assessment to the next were the most evident. Overall, the PowerPoint© format composed 3.5 hours, and the lab-style composed 2.5 hours of the entire course.

Beyond the class’s organization, the elaborate explanations, the deconstructing of the research content, and the detailed, timely feedback that Ben provided during the session were his non-verbal gestures and communication. Ben was rarely completely stationary, often transitioning across the front of the teaching space as if on stage or demonstrating animatedly with his hands and upper extremities. Between his lecture, power-point slides, and discussion. Ben’s passion and enthusiasm for the material and his joy of teaching were clearly expressed in his animated tone of voice and physical movements, whether this is telling a story, describing a prior patient, or demonstrating a typical movement pattern of the shoulder and upper extremity. The attentive gazes, thoughtful expressions, and intermittent yet consistent note-taking gave all indications that they were absorbed in the learning environment that Ben was creating. Frequently, he stepped from behind the podium and walked towards the students to thoughtfully pose a well-formed question.

Ben concluded class, summarized the key concepts, and provided ample opportunity for lingering questions, comments, concerns, and any open loops that the learners may have had. He emphasized the necessity of continual practice and refinement of skills and assessments presented in the class period are essential for ongoing mastery and expertise. The learners nodded to themselves and seemed motivated. Ben shared his journey and development briefly in becoming more competent in examining and evaluating the shoulder through deliberate practice and self-reflection. See the Supplemental Data Collection Files in Appendix D for the completed Observation Assessment Form that provides candid notes taken during the didactic observation.

Description of the Interviews
Student Interview: The interview with Alex took place in a conference room that is adjacent to the physical therapy clinic. (See Figures 2a and 2b in Appendix C for visuals of the conference room.) It was apparent in his thoughtful and deliberate responses that Alex saw value in taking part in the interview and the study as a whole. He maintained a pensive and professional demeanor throughout the interview’s duration, yet would often smirk, laugh, and bemused emotions as he recounted Ben’s individual experiences and characteristics.

Through sharing specific stories and via his non-verbal communication, Alex projected the positive relationship that he fostered with Ben through a combination of one-on-one mentoring, didactic lecture sessions, and through the day-to-day interactions within the clinic. Alex’s reverence and affinity for Ben as an instructor and therapist were quite evident. He concluded that he saw Ben as a role model in the clinical environment and beyond. The audio recording of the interview (see Figure 5a) and transcript are available in Appendix D.

Exemplary Educator Interview: When asked to conduct the interview, Ben readily agreed with a sense of humility and intrigue. He expressed similar emotions during the initial answers to the interview. With each subsequent question, Ben seemed to become more absorbed in the responses providing thorough and comprehensive answers and, at times, even circling back to elaborate on answers to related questions. Amidst Ben’s calm and professional demeanor, his passion and enjoyment of teaching, learning, and assisting clinicians and residents to become the very best versions of themselves was exact. It was notable in multiple answers how Ben spoke about the development of his affection for teaching and learning across time. The stories that he told spanned the duration of his professional career and stretched back to his adolescence during competitive athletics and to the foreseeable future the ongoing role that Ben has in enhancing the teaching of residency faculty, teaching teachers essentially.

Nevertheless, he never lost the underlying sense of modesty and consistently returned to his development as a teacher as a student of pedagogy. Ben’s final response regarding the one piece of advice that he would pass on to others pursuing a path in education was, “You got to love it!” (i.e., teaching) provides a summary statement that captures what he brought to the interview. The audio recording of the interview (see Figure 5b) and transcript are available in Appendix D.

Themes
The following section describes the five themes identified through the preliminary exploratory analysis and coding of the empirical evidence [25]. For transparency of analysis, how the initial coding and category generation process of the exemplary educator’s interview leads to the five themes is shown in Figure 1. The lines between the codes, categories, and themes represent how each code and category were aggregated and synthesized to derive the next sequence of categories or themes, respectively. The rationale for multiple lines per code or category represents that each one contributed to the generation of more than one category or theme, respectively.

Expertise. By “expertise,” it is meant that the exemplary clinical educator demonstrated clinical practice patterns that were consistent with the operational definition and characteristics that have been associated with an “expert” or “master” clinician in the current literature (see Table 1). Within the teaching session, Ben specifically described the importance of providing the right care to the right patient at the right time and how a thorough and algorithmic assessment can reliably facilitate such acts [31,32]. Ben’s expertise was also evident in detail and extensive knowledge that Ben shared during the shoulder evaluation session was well beyond the common knowledge of a physical therapist, even in comparison to other Orthopedic Clinical Specialized (OCS) therapists [33]. Tangible support of the perceived Ben’s content mastery and comfort level of expressing that knowledge to others is his previously published book chapter [34]. Supporting evidence of Ben exhibiting these characteristics were corroborated through both interviews and the teaching observation session.

The therapeutic alliance and communication qualities of expert and master clinicians (see Table 1) are consistent with the communication skills Alex described of Ben during his interview. In describing how Ben conveys information to patients, Alex stated:

If you know the information and you’re really good at delivering it, you can get people to believe a whole lot. And you know, Ben’s getting the patient to believe what they should be believing. But the confidence and the projection is in a way that is very calming for [patients], and I don’t think I formally appreciated how important it was to have the confidence in the projection. (Student interview transcript, lines 210-215)

Moreover, in his interview, Ben also re-iterated the necessary mastery of communication of clinicians “the most important thing you learn is not the technical skills but is the communication style and how to interact with the patient” (Exemplary clinical educator transcript, lines 85-86).

Ben described an expert skill as having a projected, theoretical mental model of clinical growth within orthopedic rehabilitation and being able to efficiently and accurately assess where on the continuum a learner is and predict the pending barriers to their continued growth. One of his rationales for having the learners perform their physical examination in the initial lab session during his teaching lectures is to “get a baseline of where [the learners] are at.” (Exemplary clinical educator transcript, lines 271). Whether in a one-on-one mentorship or within the class setting, Ben is able to assess the learner competency and adapt in life to time to accommodate:

Where I need to spend my effort in my lecture or where I need to spend my effort in my lab is sort of determined by the feedback that I’ll get on how good, or not so good, they are within that lab. How much feedback I might provide to [the learners]. How much I’m going to have to step in and do it on them and then have them do it to someone else and then have them do it to me so I can make sure they’re doing it right and provide the proper feedback. (Exemplary clinical educator transcript, lines 278-283).

To be able to place a learner along a continuum of clinical growth and tailor their teaching accordingly requires extensive breadth and depth of discipline. A hallmark characteristic of expertise.

Clarity: Two self-identified aspects of Ben’s teaching style that differentiates him from other educators are the “structure” that he brings to the learning environment and the ability to break complex concepts into easily grasped fundamental components. Both aspects enhance the clarity of expectations, content, and theoretical models for the learner(s). For instance, when Ben was asked: “what aspects of yourself come through most clearly in your teaching?” Ben replied:

One of the other [aspects myself that come through] is structure. I don’t know where my desire for structure comes from, maybe growing up in a non-structured household… I really like structure, and I learned that I don’t know [why], but my mind thinks in terms of structure… [For example] when is it time to progress from basic exercises to higher-level exercises?... I like to bring structure to [the student’s clinical] practice pattern because a lot of times [the novice clinician can be] all over the map. (Exemplary clinical educator transcript, lines 156-169).

Ben provides a tangible learning activity where he had a resident map out a periodized eight-week rehabilitation progression with specific exercises and exercises dosage. Ben identified that structured learning activity as a pivotal event in the resident’s learning. It aided in her ability to translate the skills and apply the resident’s knowledge to several other subsequent clinical cases that extended the mentorship’s timeframe. Ben summarizes this example later in the interview with:

My foundational belief is that I can take almost any student, no matter what their skill level is, and if you put them in a structured environment, you can teach them. And teach them up and make them better. And why they’ll walk out of here at least good, if not better, or great. (Exemplary clinical educator transcript, lines 378-81).

Moreover, Ben supplements his structured instruction methods by dividing complex concepts into foundational skills or simplified content that improves the learners’ retention and clinical application. For example, within the observed shoulder evaluation and examination teaching session, Ben provided the residents with a five-minute, reliable and valid, algorithmic assessment of the shoulder that included observation, range of motion, strength testing, and fifteen diagnostic tests. Given the fact there are over 180 shoulder special tests and multiple degrees of freedom of the should complex, Ben’s ability to efficiently and effectively instruct novice clinicians a succinct workflow within a single class session necessitates the ability to distill complexity to easier-to-learn parts [37]. Alex specifically highlighted this point:

So thinking back to the lectures [Ben] gave on the knee and the shoulder. [As students], we had certain ways of doing [the performing examinations] and how we’d go about conducting what would seemingly be a basic evaluation, and then Ben would present information and … show us another way of doing it that would result in better efficacy for technical reasons and then also flow for time-saving reasons… One thing that’s really stuck home about [Ben’s and my] time together is … the importance of mastering the fundamentals (Student transcript, lines 171-175).

Not only does Ben intestinally seek to bring clarity into the clinical learning environment, but he believes that is a fundamental principle of excellent teaching that allows nearly all students to learn effectively.

Self-Concept: Shlegel et al. (2009) [38] define the operational definition of self-concept that is used here: “a cognitive schema representing those aspects of the self that are considered, by the person, to be most emblematic of his or her true nature.” During his review of the validation and feedback of the themes, Ben was asked to label each of the categories as guiding principles of ” “teaching,” “learning,” “the discipline” (i.e., clinical practice), “fundamental truth” (i.e., a principle that extended beyond the confines of teaching, learning, of the discipline) or “Other.” Ben’s purpose to do so allowed the investigator to determine which of the beliefs that Ben shared were specific to teaching and learning or were more personal fundamental truths, values, and morals. Ben identified six of the nine categories has to be fundamental truths that he associated as part of, in his words, his self-identity. This association, in addition to his agreement to affirmed agreement with Parker Palmer’s quote, “We teach who we are.” suggests that Ben believes that infusing our authentic self and personal principles into our pedagogy is an essential aspect of exemplary clinical education.

Ben’s case is ironic that several of the aspects he associated have also been identified as favorable beliefs, attitudes, and behaviors of some of the best educators [2]. His teaching aspect that Ben associates with his self-identity include his “grit,” having a growth mindset, and a commitment to excellence. He simultaneously balances these ambitious characteristics with cornerstones of humility, effective communication, and a love for teaching. Ben has captured his continual improvement mindset and tenacity during the interview: … that’s sort of how I see my life transpiring; is having to really work hard to get to where I’m at and finding those people and being able to put pressure on them and say you’re going… you know, I’ve always strived to be the best I can be in everything (Exemplary clinical educator transcript, lines 126-128). This is Stanford. We’re going to be one of the best. If not, we’re going to strive to be the best academic medical center, and I’m going to [challenge learners] to the limit to make [them] the best version of [themselves] that [they] can possibly be… I personally have always felt like I’ve tried to do that in anything that I’ve committed to. You know and so I see myself as that, but I see trying to pull that out of people. (Exemplary clinical educator transcript, lines 136-140).

There are multiple other time points where Ben consistently discusses the importance of incremental improvements in not only his students and residents but in his own development as a therapist and educator. For instance, the word “growth” is used over twenty times throughout the interview; that’s once every two and a half minutes.

A key to Ben being able to stretch and challenge learners without overwhelming them is that he can individualize expectations for each learner. He tempers that competitive nature with the nurturing aspects of communication, humility, and love for helping students be the best versions of themselves. One way that Ben connects with his students is through strategically revealing moments of his own vulnerability.

[Instances] where the [educator/mentor] can convey… their past difficulties. I sometimes think when you come in after an evaluation and [learner] is just like, “Oh my god. I have no idea what to do. [The Patient] has got these 12 problems. I’m not sure which they’re here for.” It’s chaos, and you (as the mentor) go. “Yeah, I agree. I have no idea what to do. So what’s the easiest thing we can work on? That’s a moment that [student/resident] needs to see because not always do you (the mentor) have the correct answer. (Exemplary educator transcript, lines 465 - 471)

Alex described how Ben balanced high expectations with establishing an authentic teacher-student alliance through “being able to know someone as the whole person and establishing a solid context and where they are at, what their goals are, and where that all fits into the picture.” Alex attributed the strength of the teacher-student alliance, at least in part, to Ben’s humility. Alex recounts:

One thing that I really appreciated was Ben being vulnerable enough to share his own mistakes because he can throw out a lot of information. And you’re like man this guy’s a genius! He can be like “Dude, I screwed this up for the first three years of my career and I did horrible with this and it’s like okay.” This is kind of nice, you know? This guy’s not like infallible, right? And that he like is human here and it… yes, so it’s human. It humanizes him when sometimes he seems like someone who is very well-established in their path. (Student transcript, lines 348-353).

Ben’s ability to bring his authentic self and personal values of ambition and humility into the clinical, and educational environment and inter-personal dynamic was another key theme that was recognized and appreciated by both Ben and Alex.

Enthusiasm. A consistent theme across both interviews, and the teaching observation session was Ben’s energy and enthusiasm that filled the learning environment. Part of Ben’s intrigue for the shoulder likely stems from his prior participation in high-level, competitive tennis, and being nationally ranked during his adolescents. His personal connection with the shoulder in combination with a personal mission the help others, be this student or patient and be the best that they can be was apparent in the energy of his speech and his non-verbal communication through moving around the room and physical demonstrations of upper extremity movements. As noted in the observation assessment form (See Supplementary media in Appendix D), the audience seems to feed off the energy and enthusiasm Ben brought to the didactic and the lab sessions. Ben corroborated that his behaviors and enthusiasm were intentional as he believes these strategies lead to effective learning. “I think having a teacher or mentor that’s passionate and is engaged [leads to effective learning] because the more engaged you are, the more engaged [students/residents] will become.”

Ben sees passion (i.e., enthusiasm), not only for the subject matter but also for teaching, and an essential component of effective clinical education. In his own words.

Right, you have to have passion for [teaching]. If you put yourself in the learners’ shoes, but you’re not passionate, you’re not going to care enough to continue to dig. To dig. To get better at teaching.” (Exemplary educator transcript, lines 761-763). There are people that have to [teach]. There are people that don’t like doing it. There are people that don’t think they’re good at doing it or don’t think they’re good enough to do it, and I think those people don’t love doing it because of those reasons. So, I think you’ve got to just love it, or you’ve got to really enjoy it or be passionate about it. (Exemplary educator transcript, lines 777-781).

Ben’s passion and enthusiasm for teaching and discipline translate into making the learner’s experience “fun.” According to Alex, Ben’s positive demeanor allowed him to thoroughly enjoy the mentorship, “celebrating the successes along the way” while establishing further confidence in the learner’s beliefs and self-confidence (Student transcript, lines 43-49).

Empathy. At multiple time points during the interview, Ben expressed the importance of the teacher’s ability to relate to the learners’ perspective and experience. This is consistent with Berger’s (1987) definition of empathy: “Empathy is the capacity to understand what another person is experiencing from within the other person’s frame of reference, i.e., the capacity to place oneself in another’s shoes.” Ben recounts:

I refuse to forget what it’s like to be a student. I said that really early on in my career when I had a really negative experience with a clinical instructor. I said, “I’m never going to forget this moment.” And I don’t. And when I start to; when I feel like I’m doing it and I’m starting to forget a little bit, I go back to that moment. I think about it. I internalize it. (Exemplary educator, lines 366-369).

The above testimony, in combination with Ben’s closing remarks (where he states that the one, most important thing it takes to be an effective teacher is passionate empathy), capitalizes on how much he profoundly values teachers being able to see the world through the eyes of their students.

From the learner’s perspective, Alex described Ben’s empathy as a sixth sense. A sixth sense extended beyond the mentor-to-mentee but to the therapist-patient relationship as well.

[Ben] does a really good job of being able to sort of interpret what someone is thinking or feeling without them saying it. He has almost this like sixth sense about him… Being able to kind of get inside someone else’s head and then even anticipate what they’re feeling. And then how that may translate to whether or not they’re comfortable.

According to Alex, Ben’s empathy enabled Ben to recognize what particular social or contextual factors Alex was most uncomfortable with and then ask probing questions to foster Alex’s recognition of these patterns through self-reflection and metacognition. It was apparent from the interviews that Ben not only highly valued empathy but also effectively related to the feelings and perspectives of others, but that he was able to use his ability to connect to improve learning.

Discussion
The results of this exemplary clinical educator case study several attitudes and behaviors were identified through the structured interviews and teaching observation. Through the exploratory analysis and coding process, the attitudes and behaviors were organized into five themes: expertise, clarity, self-concept, enthusiasm, and empathy. Each theme and the respective associated categories are analyzed using existing literature on teaching and learning below. With the intent to translate the findings into real-world applications, the discussion concludes with specific recommendations for clinical educators.

For conceptual ease and improved efficiency in comparing Ben’s attitudes and behaviors with the current evidence for each theme are analyzed using a table format. See Tables 2-6. Within each table, the major categories and/or codes are labeled as attitudes or behaviors. (Keep in mind that the operational definition of an attitude consists of values and beliefs.) Each of the categories and/or codes are substantiated with supporting evidence from teaching and learning literature. It is important to note that the supporting evidence offered for each code or category is by no means exhaustive. It is beyond the scope of the current analysis to provide a comprehensive review of the literature for each code or category. Readers are encouraged to continue seeking the growing body of teaching and learning research to pursue each of these concepts in further detail.

Note. The empirical evidence categories and codes were explicitly identified by Ben as “fundamental beliefs” that were part of his self-identity. The evidence provided in the far-right column represents the concept of educators infusing their self-identity into their teaching philosophy and practice, rather than specific evidence for supporting the unique codes or categories listed.

The expertise of one’s discipline and teaching matters have been identified as essential criteria in effective teaching [2,8]. Within the empirical evidence collected, Ben had established his expertise through (1) approaching teaching as a lifelong learner, (2) a growth mindset, (3) translating knowledge through real-world application of content, (4) using self-reflective questioning in the process of preparing for lectures, and (5) ensuring the sufficient practice of the material within the didactic and lab sessions. These instructional methods are not only identified as consistent practices of the best college teachers [2,52] and means of enhancing the motivation of adult learners [5] - but they are also supported by psychology and learning science research [7,49].

Ben’s expertise likely augmented his ability to offer clarity to learners in his teaching and mentoring. To convey complex concepts, Ben was intentional in how he communicated verbally with the students but also in the way that the educational resources illustrated the content. Moreover, Ben’s use of elaboration and spiraling methods is substantiated by the current literature for higher-level education, health care professional academic programs, and by cognitive science research on learning (Brown et al., 2014) [54-57]. Ben used several of the principles to garner expertise in his discipline of orthopedic rehabilitation and teaching and to provide clarity in his instruction and mentoring part of Ben’s self-identity. Identity coherence is an essential characteristic in experienced educators who are fully invested in their craft [53,59,60, 62,63 ,67].

Given the fact that educators who self-identify with their teaching role are emotionally attached to their role, it is likely that this explains, in part, Ben’s enthusiasm expressed during his teaching and mentoring [67]. A consistent trait among award-winning higher education teachers is their ability to infuse enthusiasm into the educational environment [68]. The energy that Ben brings to his teaching is aligned with fundamental principles of motivational theory in adult education, perseverance for long-term goals, and the theory of establishing a psychological flow state [5,63,65].

The final theme of empathy and Ben’s ability to reduce the power dynamic between him and the learners through humility and the teacher-student alliance has consistently been identified as a hallmark of excellent teaching [2,59,64]. Theodore Roosevelt stated that “People don’t care how much you know until they know how much you care.” If excellent teaching and exemplary education are determined by the impression that educators leave on their students and how well the lessons imparted upon them are applied to novel situations and challenges, then perhaps an educator’s ability to empathize and connect with them is the highest necessity. Building trusting and nurturing relationships that foster psychological safety and invite the learner to make mistakes as they stretch their comfort zone is described as essential prerequisites for enhancing learning [2,59,64,69].

It is evident that the identified themes from the studied exemplary educator have merit when compared to the current cognitive, psychology, learning, and teaching sciences. The findings suggest that similar teaching methods, attitudes, and behaviors advocated for in the traditional academic environment can be successful when implemented within the clinical education setting.

RecommendationsJust as outcome goals are rarely actionable, the themes identified by this exemplary educator do not in themselves provide actionable steps that clinical educators can take to enhance their clinical pedagogy. In accordance with prioritizing learning over performance goals [53], process versus outcome-oriented performance [70], and incremental (growth) over entity (fixed) mindset [7,71,72], this section provides a summary of recommended actionable steps that clinical educators can take away from this case study and current evidence in learning sciences. See Table 7 for a categorized list of the recommended behaviors and actions that clinical educators can take away and apply based upon those exemplified from the empirical evidence and substantiated by the current research.

Limitations
The current study’s findings provide valuable insights into how clinical educators and post-professional didactic programs can transfer the learning paradigm and modern cognitive sciences from the traditional higher educational, academic setting to the clinical setting. However, it is important to acknowledge the limitations of the current investigation. The qualitative case study design classifies this research report as level five evidence, according to the Oxford Center of Evidence-Based Medicine (CEBM) [73]. Moreover, the analysis included only a single exemplary educator from a small sampling within a single post-professional residency program. The current study provides a framework for future research that can be extended to include multiple exemplary clinical educators across multiple post-professional specialty programs.

Additionally, the researcher’s characteristics and reflexivity need to be acknowledged in the findings and analysis of the current results. The investigator is an alumnus and current faculty member of the residency used for sampling residents to identify the exemplary educator. Thus, though objectivity was sought to analyze the findings, the investigator’s prior experiences as a learner and now as a teaching colleague with the exemplary educator may have unknown influences on the findings.

Finally, the primary investigator had no prior study of how students learn, how educators can effectively enhance learning, and what some of the best educators do to facilitate and foster student learning. Such prior knowledge of theories and practices may have influenced the labeling categorization and derivation of the themes. Akin to the effect that a student’s prior knowledge has on novel learning experiences, investigators’ prior experiences and mental models may provide a filtered lens through which the results of any research study are interpreted [74-81].

Conclusion
The research question guiding this study concerned the attitudes, behaviors, and beliefs of an exemplary clinical educator. Triangulation of observation and interview data and an evaluation of the existing literature indicated that many of the same advancing principles of cognitive science, learning research, and teaching theory have advocated for formal classroom study are effective and transferrable in the clinical education environment. Clinical educators, instructors, and post-professional program faculty are encouraged to use the current case as an example of how the current science of teaching and learning can be implemented to enhance clinical education of physical therapy and rehabilitation students, residents, and fellows. While Doctor of Physical Therapy faculty, Center Coordinators of Clinical Education (CCCE), and directors of post-professional clinical programs (i.e., residencies and fellowships) can use the current findings to stimulate systemic changes to program designs and curricula to engage and facilitate translational learning of their leaners. Moreover, future research initiatives should consider qualitative case series of beliefs, attitudes, and clinical instructors’ behaviors across clinical sites or programs. Future investigations may also examine the feasibility or action design studies to gather information about, subsequently improve, how respective clinical, and educational setting(s) operate, conduct their teaching, and their resident and student learning [25].

Acknowledgments
A gracious acknowledgement and appreciation for to Dr. Bill Seringer, Dr. Andrew Libs, and Dr. Shawna L. Lafreniere for their participation, guidance, time and resources for making the completion of this project and manuscript possible.

Conflicts of Interests
The author declares no conflict(s) of interest with the writing and publication of this research and manuscript.

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