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I am a professor of radiology and I work in a university teaching hospital. My work is teaching radiology courses for undergraduate and postgraduate students, and training residents in our radiology department. The aim of our radiology department is to be sure that the students will gain sufficient amount of knowledge and skills to be able to practice clinical diagnosis and understanding imaging which is an integral part of patient management.
I am graduated since 1989 and I work in teaching Radiology curriculum for more than ten years, it's interesting to look back but I will not start from the beginning as this was many years ago and I will discuss what I do during teaching and reflect it for further development. In our department, the teaching design change between teaching basic science such as radiological anatomy, pathology, radiobiology and radiological physics and teaching radiologic imaging of various systems and the role of imaging in clinical management. So I use different teaching methods which are suitable to the intended learning outcomes of our radiology curriculum. These methods include formal lecture to emphasize on basic science elements, small groups teaching (like: case study, seminar, tutorial, conference and problem based learning) which is the standard teaching form for teaching radiology curriculum in which we use different radiological images as a learning focus, and clinical teaching for training our residents how to attain different skills of radiological examination. I will focus my writing on problem based learning (PBL) as an example of small group teaching and on clinical teaching of radiological skills.
Problem based learning
We apply problem based learning as a teaching method in some parts of postgraduate foundation programme; I have a deep concept that PBL is an important way for teaching radiology curriculum due to the presence of radiological subspecialties of system based way which is relevant to problem based strategy.
Barrows and Tamblyn1 suggest that "Problem-based learning can be defined best as the learning that results from the process of working towards the understanding or resolution of a problem". Albanese and Mitchell2 provide another view "PBL at its most fundamental level is an instructional method characterized by the use of patient's problems as a context for students to learn problem-solving skills and acquire knowledge about the basic and clinical science".
There is no single concept about the theoretical basis of practicing problem based learning.3 Savin-Baden4 suggests different dimensions of problem based learning and identify that the best differentiation in which the knowledge, learning and the student role are manifested and conceptualized in the curriculum.
Self direct learning is an active process and high efficient approach for continuing medical education as the learning is based on the students previous knowledge, the new knowledge and understanding which can be blended through the personal and professional context of the person.5 Spencer and Jordan6 suggested that in PBL, new knowledge and understanding comes from working on the problem while in traditional learning the new knowledge is essential for working on the problem. I agree with those authors and I follow self directed theory, as PBL is student centered learning I direct the students for self learning and motivate them to increase their self confidence, also I consider the previous experience a useful resource for building more information through reading , all these make the learner able to be confronted with many tasks.
The constructivism view of learning is concerned on the meaning of understanding is built up through a process include the specific knowledge foundations and cognitive operation.7 Mayes and Freitas8 suggested that constructivism learning is based on knowledge which must be constructed through achieving understanding to allow students relate new experience to existing knowledge. The constructivism is the other theory which I follow in problem based learning by emphasizing on activation, building on previous experience and engaging the current understanding and the new experience through active relevant problem and group interaction.
With many searching about problem based learning, I found another concept which is illustrated by Norman and Schmidt9 who show that problem based learning has relevant areas including: activation on prior knowledge, learning in context, elaboration of knowledge and fostering of competence by using inquisitive style of learning. Considering the previous concept, I have to concentrate more on those relevant areas which are needed for problem based learning and are closely related to constructivism.
Implanting problem based learning without a prepared plan about the environment of the learning including the role of the teacher, student group organization, scenario development, creating the resources and assessing students performance will lead to confusion between the teachers and students without achieving PBL goals.3
Firstly, I will analyze the role of teacher in our department, in the first meeting I apply the problem scenario to the students which include radiological images related to the PBL object , full clinical history and related medical, surgical and pathological information. I do my best to encourage all students to ask questions which explain topics of the scenario and guide the students towards developing learning objectives. After dividing the tasks on the students, I direct the students for the needed resource and help them for research, also I take care about the time allowed to the student's research to be sufficient for their self directed learning about the tasks divided on them. In the second meeting, the students return back after collecting the needed information, I do my effort to maintain all students presenting their new information, synthesis explanation and apply the new acquired information into the problem. As I am thinking about my previous performance, I find that sometimes I face some students who have loose bad attitude which cause dysfunctional group behaviors, so I have to take care about cues which denote the disturbed behavior inbetween the students, give opportunity to maintain regular interpersonal dynamics and control the challenge level of the students.
In discussing the role of the teacher as a facilitator in the tutorial of November 11 2010 (group 2), there is a debate about who is the best facilitator, I understand from it a new concept as some institute use a biomedical scientist with rich science base as a facilitator not the clinician as they believe that the clinicians aren't very good facilitators as they may overstate the case and intend to develop what they think. But in our department the radiological doctor is the only facilitator for PBL sessions as he almost understand the radiological curriculum and expected to have facilitation skills in his specialty. With more deep view, I think we need more staff development to avoid difficulties which may face some of the staff in managing PBL sessions, so we have to activate our self study by reading more books and article about PBL management, and apply new facilitator to attain many PBL sessions with another experienced facilitator.
Newman3 showed that the tutorial process have a certain frame to allow the development and practice of cognitive and metacognitive skills. There are many models of problem based learning tutorial process that give greater anchor to detect gaps in knowledge and self-directed learning plan to attain needed knowledge.10 When I begin a PBL session with a new scenario, I direct the students to explore the problem and analyze it to identify what they don't know, determine which task they will do and be engaged in self directed research for knowledge. At the second meeting the students presents their new information that they have learnt from research, synthesis it and reflect this information on the process of learning.
Venon and Blake11 identified that different problem based learning showed that the feedback is limited. The feedback is related to the method by which the learning objectives are classified between the students.3 In the tutorial of November 11 2010 (group 2) in which Fred Pender was discussing PBL, he explains the importance of PBL feedback as certain institute apply four electronic peer assessment feedback per year and he considered peer assessment is one of the important transferable skills which the students will gain during PBL, in which each student is able to mention the difference of other students attitude by giving remarks about his peers to assess them with regard to their professional attitude. Regarding to the previous concept, we don't apply peer assessment as an evaluative method due to our limited experience about this method, but now I think we need adequate training in peer assessment strategies and our students have to learn how to perform peer assessment to develop their skills of self-appraisal.
Benson etal12 suggested that for the improvement of communication skills and the development of collaboration, it is best to make learning group within five and ten members. In particular for maintaining all students sharing and allowing deep learning, in the last PBL session I divide the students into two groups, in each one eight students are involved instead of sixteen students per session.
In some models, the structure of PBL includes sharing a different student to facilitate the session. Newman3 argued that, as this reinforces the message that the students take the responsibility of learning and the function as a facilitator. Benson etal12 showed that when the students take the role of facilitator in a supporting environment, this will help them to practice and develop facilitation skills. Looking at this concept from Benson etal view, I make the first trial by applying one student to be a chair of the group, at the start of the session the student chair reads the scenario and try to encourage other students under my supervision. Although this is the first trial, I think it may motivate the group and give them more responsibility, but, I can't assess the benefit of this change for further development.
The problem based learning scenario is referred to the content presented to the students. Evans13 stated that scenario should be written according to the course learning objectives, it allows students to integrate previous knowledge to their current knowledge, encourage students to explore the topics through searching. Some PBL scenarios which I use in teaching focused on generation and interpretation of medical images like images of conventional radiology, computed tomography and magnetic resonance imaging, while other scenarios begin with simple and open review of patient history followed by applying more information in a serial way about the diagnostic procedures with several radiological images are attached to the scenario, also sometimes we apply PBL scenarios which connect radiology to metabolic process by using functional imaging .But in spite of the applied efforts to provoke student interest and challenge, I found myself facing important point as during PBL teaching there is little time to cover basic knowledge related to medical images like discussing radiation safety and radiological physics, as most of the scenario focus on using radiological images as resources for interpretation. So I suppose applying more problem based learning scenario which is relevant to this subject ( like, how to investigate a pregnant woman with acute chest pain, as this will activate the student to gain necessary knowledge about the effect of radiation on the fetus and understanding the physics of different modality to overcome this problem).
Although we apply PBL as an effective teaching method in some parts of postgraduate foundation programme but there are many practical skills which aren't suitable for PBL (like, how to perform a radiological guided biopsy). So we have to encourage our students to learn different practical radiological skills in conjunction with other teaching methods.
Clinical teaching of radiological skills
Secondly, I will focus my writing on clinical training of the residents in Radiology department, Radiology differs from other specialties as trainees are working in a close apprenticeship with their supervisors for gaining knowledge and skills in their workplace until they can perform many procedures according to their level of residency training. During the residents training they will learn many practical and communication skills related to Radiology field.
There are many theories which explain clinical teaching and training. In self determination, there are two primary kinds of motivation: controlled motivation which is brought by external pressure and autonomous motivation in which the learner has internal beliefs and interest.14 According to self determination, our residents spend most of their professional lifetime in a specific radiological environment which is adapted to their needs as they will be motivated and interested when they become more proficient in detecting cases of missing diagnosis. With more deep view, I find that some of residents with higher level of residency training lose some of their motivation once they move into independent practice, so I have to take care about maintaining their internal motivation by encouraging their important role in real-life practice and motivating their feeling about the opportunity of making a difference in the patient life.
Kolb15 explained that learning occur in four stage cycle and immediate experience is the base for observation and reflection, also he stated that for effective learning the learner needs four different kinds of abilities "concrete experience, reflective observation, abstract conceptualization and active experimentation". I follow experiential theory of kolb during residents' training as I involved the resident for taking new experience (like, attending a session of chest x-ray interpretation), after that I guide him to observe and reflect these new experience from many views by asking and thinking about this new experience ( like, what this finding means, what the relation between it and other findings and if it is related to previous case findings), then the resident begin to create a concept that integrate his observation and helping him for diagnosing chest x-ray, after that he will be able to use this new applications for next chest x-ray interpretation. Kolb15 suggested that experiential learning can begin at any of the four stages while the learner cycles continuously through these four stages. Following this concept, I will motivate the residents to look in the literature and read new information (like, reading about chest x-ray interpretation) and discuss it with their colleges, to begin learning from the third step by understanding the general principles and then they will complete the cycle.
The Honey and Mumford learning style inventory is based on Kolb's learning cycle and they identify four main learning styles which are activist, reflector, theorist and pragmatist.16 I believe that no one has single preferred style of learning, with following Kolb's learning cycle I found that when the resident take a new experience he is in activist style as he learn by involvement in an activity, but when he pass to the reflective stage he learn by reflecting and observing on his experience, while when he begin the abstract conceptualization stage he learn through theorist style by developing explanation of the underlying reasons and concepts, and when he pass to the active experimentation stage he learn directly from his experience through pragmatist style. With deep thinking, I usually begin the learning cycle by displaying the activist style, but I have to direct the resident to begin his learning at any step of the learning cycle as this will display different learning styles which will fit him.
Community of practice emphasize on the importance of integrating certain individual in a professional community and the role of community in reinforcing and correcting individual practice.17 I follow community of practice during my clinical teaching, as the resident starts as an observer and gradually he becomes a participant in group activity, this occur when the resident joins our radiology department and begins his training we allow him to take parts of work activity and by this way he will acquire knowledge and skills and he will move from legitimate peripheral participant into core participant. But sometimes I find some residents lose their interest ant try to escape from group participation so I have to follow these residents and apply continuous encouragement to them to increase their enthusiasm and improve their participation.
Ramani and Leinster16 stated that clinical teaching must deliver knowledge and acquisition of skills to the learner and they emphasis the stages in which the learner pass from unskilled to skilled which begin by awareness, acquisition then development and end by elaboration. I follow the previous steps during training the residents, for example, when I teach the resident how to do barium study, at first I aware the residents about the importance of these examination through active discussion as this help them in detecting their gaps in knowledge, then I begin to introduce the new information either in the tutorial, during discussing barium images or during performing the barium examination. Gradually the new knowledge will develop and the residents will perform the procedure. I usually follow my residents during performing the procedure to be sure that they will progress well and for continuous improvement.
With regards to my performance, I think that my important role is how transfer the resident from conscious incompetent stage to conscious competent stage, I usually allow the resident to ask any question and I help him for self study, mentoring him and follow his progress until he can do the skill, and gradually with more practice and follow up the resident will transfer into unconscious competent stage as he can perform the skill without conscious. But I find that some older residents fall into unconscious incompetent stage, so I have to take care about the residents' performance in all study years by pushing them to continuous self study for more mature practice.
Understanding the psychomotor teaching principles is necessary for teaching clinical skills, these principles are based on Taxonomy of the psychomotor domain which are conceptualization, visualization, verbalization, practice, correction, skill mastery and skill autonomy.18 I was thinking that I follow the previous principles during clinical training of the resident, as at the beginning of the training, I perform the examination in front of the resident while explaining what I do and allow him to ask questions, after that I perform the skills several times while the resident provide explanation about what I do and I provide correction for any misunderstanding until I become satisfied that the resident full understand the skill, then I allow the resident to perform the examination under my supervision while he describe each step before it is taken. But when I look about my previous performance, I find that I miss an important stage as I don't demonstrate the practical skill without explanation and I run through this stage quickly in spite of its importance. So I have to take care of this step and begin my clinical teaching by performing the procedure with no comment to allow the resident observe the steps of the procedure which is important for visual learner. Also for accommodating different learning styles I have to increase the resident-patient interaction as patient-centered teaching maintain the approach for visual- auditory - kinesthetic learning style of the learner through observing the patient, examining him and carrying out radiological procedures.
Barrows19 defined simulated patients as a "normal person who has been carefully coached to accurately portray a specific patient when given the history and physical examination". I gain a significant information about simulated patient from the tutorial of October 28 2010 (group 5a) in which some colleges emphasize on using simulated patients in their hospital after taking a specific session for training under academic staff supervision to learn them how simulate different medical condition. We don't apply using simulated patients during clinical teaching, but I think we have to plan to apply simulated patients in teaching non invasive procedure like how to perform ultrasound examination as this may facilitate the resident to gain experience from normal ultrasound examination before they proceed to the real patients.
There are great evidence for positive effect of communication skills training, this conclusion is based on large number of studies which show that a different group of medical students improved their ability of interviewing efficacy and gaining information from the patients.20 I have a concept that the relation between the radiologist and the patient who will undergo radiological imaging examination is different from that of other clinical specialist, so for radiologist, learning communication skills is necessary to detect patient's complain and taking care of patient when they come for imaging. Also I think that there is no debate about the effectiveness of communication skills but actual problem is how to transfer such skills to the resident through daily practice.
Aspegren20 concluded that experiential methods of learning are more effective than instructional methods. In the imaging room I become in direct contact with the patient, this relation may occur one time or may be intermittent over long time. I establish this relation by asking the patient why he is presenting to the study, discuss the procedure before performing it, maintaining examination distractions and finally I discuss the results of the examination to the patient. I take care about every step I do as the resident will learn from my behavior the eminent points of radiologist patient interaction in the radiology imaging room during these meetings.
There are seven essential communication skills which are: "building the doctor-patient relationship, open the discussion, gather information, understanding the patient's perspective, share information, reach an agreement on problem and plan and provide closure".21 As it is clear that adequate patient-centered relation between the doctor and patient will enhance the quality of the patient care I usually try to maintain a clear patient-centered environment. Firstly, I respect the patient confidentiality and I avoid taking the patient history, discussing the examination or making the procedure in a busy room as the examination room must be safe and comfort. When I see the patient at the first time I greet him by his name and warm smile, I spend few minutes in looking to the patient with close eyes contact and emphasize to him that the results of examination are totally confidential. I never rush the patient into the examination and I take my time in getting the patient history, discussing the steps of the examination and answering any vague question for him.
Beck etal22 perform a systematic review of studies of GP-patients interactions to measure specific behaviors reliably and provide evidence of their influence on patients outcomes, they found fourteen studies of verbal and eight studies of non-verbal communication which had an effect on patient outcomes. I agree with the authors about the importance of verbal phrases and body languages, as I usually use verbs which evoke empathy, support, reassurance, explanation and sometimes humor and courtesy, but I change my verbal language when my patient is a child as the words which I use with children must related to cognitive level of the child. I remember a previous bad communication, in which I was performing intravenous urography examination to a young child, while I asked the child to fill his bladder like a balloon he become so distressed as he think his bladder will explode. After this time, I make a frame of references which are easily understood by the child.
Many observations show that there is no single communication skill but different aspect of patient and physician interaction need to be learnt.20 Many radiological procedures distress the patients like performing radiologic guided interventional procedures, with this patient I direct him during explaining the examination and describe the feeling and sensation of what he might feel, this is what I think it may improve the patient distress along the procedures, but I need more improvement in my communication approach as I don't take continuous patient feedback or peer group feedback to evaluate my performance with the patients. So I have to prove my communication skills by thoughtful reflection from revising patient and peer feedback, and taking more courses in communication skills.
Miller 23 suggested a famous pyramid for assessment of learner's clinical competence, this pyramid is formed of four level, at the lowest level of the pyramid is knowledge (knows), followed by competence level (knows how), then performance level (shows how) and end by action (does). In my concept, the challenging role of the clinical teacher is how to assess the student performance at the highest level of the pyramid in the workplace, in which the patient care take the priority and clinical teacher has to observe the residents interaction with the patient. I usually observe the resident clinical skill's performance at the imaging room when he prepare the patient for examination, do the procedure under my supervision or do it independently, also I take care about the resident behavior during patient interaction. After that I give my resident a frequent feedback about his performance, which is non judgmental, descriptive not phrasing feedback (like; when the patient was telling you about the site of her abdominal pain, you are concentrated on ultrasound screen and you don't look at her), also I try to describe his behavior which can be changed in small quantities and encourage any helpful cues he do. I try to be supportive to my resident by avoiding criticism form of the feedback which makes the resident blamed or rejected.
Regarding my performance, I always do my best for observing and follow up the residents and give them feedback about their performance, but in some occasions I hesitate in giving negative feedback to some residents who view negative feedback as a personal attack and reject it. So I think that we must establish more positive learning environment in which mistakes are acknowledged and feedback is accepted, also I have to help the residents to understand the benefits of effective feedback as when they take insight about what they do either well or poor, they know where they are in comparison to where they must to be and what they must do.