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Doctors as teachers: Introduction
The association between doctors and teaching is well established. The very word 'doctor' means 'teacher', originating from the Latin verb "docre", to teach. The responsibility of the doctor to educate and share learned knowledge with patients, peers and students has been apparent from an early stage of my medical degree.
The General Medical Council (GMC), who regulate medical education and training in the United Kingdom, recognises the importance of competency within this professional area, stating;
'You must keep your knowledge and skills up to date throughout your working life' and 'â€¦work with colleagues and patients to maintain and improve the quality of your work and promote patient safety'.
While this competence within your field is an important part of being a good doctor, the usefulness of your knowledge, skills and experience are finite if limited to yourself. If however, your experience can be effectively transferred to others, its use of can literally become infinite. For this very reason, medical schools and the GMC recognise;
'Teaching, training, appraising and assessing doctors and students are important for the care of patients now and in the future'.
While each of us had experienced teachers who we judged particularly good or particularly bad, few of us spend time to reflect on what elements of the encounter made us come to our conclusions. It is important to recognise that the ability to be an 'effective teacher' and a 'good learner' is complex, made harder in medicine due to the variety in learners encountered (patients, general public, students, other professionals) and the vast breadth, depth and ever expanding field on medical knowledge and understanding..
The GMC stipulates;
'If you are involved in teaching you must develop the skills, attitudes and practices of a competent teacher'.
To help achieve this goal, part of this SSU will explore the theory behind learning and teaching and after reflection, the major components and areas I need to develop, to become a competent teacher during my medical career.
Good Medical Practice: Teaching and training, appraising and assessing. GMC, 2006.
Tomorrow's Doctors: Standards for the delivery of teaching, learning and assessment. GMC, 2009.
Teaching is a more demanding and complex task than might first appear. This becomes apparent when we reflect on our own experience of 'good' and 'bad' teachers, and try to fathom what qualities, habits and practices they incorporated to deserve our given assessment. The question therefore arises, what makes a good teacher? From my own experience qualities include: confidence, enthusiasm, ability to pitch material level to audience aptitude and knowledge and the flexibility to incorporate the learner's needs into their session.
This section of my portfolio aims to summarise my learning, understanding and reflections gained following a literary review on teaching theory and practice. This need stems from my initial learning needs assessment, which highlighted the need to understand the theory behind successful teaching.
As I explain theories and best practice, I reflect on some of my prior successes and downfalls while teaching. Actions that I identify as necessary to improve, are highlighted in red and given an alphabetical superscript (e.g. gain written feedback c). The superscript links directly with the action/s in my development plan (section 2) e.g. j (PDP 5).
The science of learning
The actual 'art and science of helping adults to learn', was termed Andragogy by Malcolm Knowles in 1950. He was the first person to propose adults learn in a different way to children and created a theory based upon his assumptions. These later developed into seven principles on how to teach adult learners (figure 1)
Â Establish an effective learning climate, where learners feel safe and comfortable expressing themselves
Involve learners in mutual planning of relevant methods and curricular content
Â Involve learners in diagnosing their own needs-this will help to trigger internal motivation.
Â Encourage learners to formulate their own learning objectives-this gives them more control of their learning
Â Encourage learners to identify resources and devise strategies for using the resources to achieve their objectives
Â Support learners in carrying out their learning plans
Â Involve learners in evaluating their own learning -this can develop their skills of critical reflection.
Many of these principles make certain assumptions about the learner e.g. that they are motivated to learn. It is also important to remember that as a medical teacher, not all my learners have the same needs. For instance, some patients will not want this structure and may require a more didactic approach to facilitate their understanding.
While this was a good start regarding the methodology to adult learning, it was a couple of decades before frameworks of thinking about what and how adults learn became popular.
Knowles M. Informal Adult Education. Guide for educators based on the writer's experience as a programme organizer in the YMCA, New York: Association Press 1950.
Keston C. Independent Learning: A Common Essential Learning: Saskatchewan Department of Education Core Curriculum Investigation Project 1997.
Extensive literature is available theorising how different individuals learn. In 1984 David Kolb published his learning styles model. The idea was that we learn during life firstly through doing, then by reflecting on the outcome. This gives us the option to alter future practice through better understanding our experience. The very act of reflection allows the reinforcement of ideas, generalisations and the formation of new ideas or concepts to occur (figure 2 )
Figure 2 . The four key elements of the Kolb cycle of experimental learning.
Concrete experience*. Doing/ experiencing.
Reflective observation*. Reviewing and analysing the experience and your judgements of event/s. This stage includes the discussion about learning and teaching and can be heavily influenced by feedback from others.
Abstract conceptualisation*. This is the time where we bring our theories and the analysis of past action together, allowing us to reflect, conclude and learn.
Active experimentation*. If change was theorised from the previous stage, then at this stage we can plan and experiment with our learned knowledge, thus completing the circle by taking us back to stage a new concrete experience.
**** Where I use example of the three stages of experimental learning within my project, I use the four coloured terms above.
This process happens at a sub conscious level most of the time and can simply be described as trial and error. This ability, however, to question, probe and learn from our experiences is valued within medicine and reflective practice is encouraged during medical training.
Kolb expanded his cycle by arguing that where an individual starts on the cycle depends on their learning style or approach to learning situations (diverging, assimilating, converging or accommodating) and made learning suggestions relating to their group;
Divergent: Sensitive people who prefer to watch rather than do, are interested in people, tend to be imaginative and emotional, tend to be strong in the arts, and like to work in groups.
Assimilative: Prefer a concise, logical approach; require good clear explanation rather than practical opportunity. Prefer readings, lectures, exploring analytical models, and having time to think things through.
Convergent: Quite analytical in nature, can solve problems, prefer technical tasks, and are less concerned with people and interpersonal issues.
Accommodative: 'hands-on', and relies on intuition rather than logic. These people use other people's analysis, and prefer to take a practical, experiential approach. This learning style is prevalent and useful in roles requiring action and initiative. People with an accommodating learning style prefer to work in teams to complete tasks.
http://www.businessballs.com/kolblearningstyles.htm Not referenced
What I find most interesting, is not where you start on the cycle, it was Kolb's idea that individuals have very different learning styles, preferences and subsequently learning needs. While many of these 'style' descriptions read a little like horoscopes to me, I have had difficulties working in teams with certain team members in the past. On reflection, it seems likely these individuals had a different preference to learning to me, which generated conflict. This idea of grouping individuals and suggesting advice to learner was further explored by Honey and Mumford.
Kolb, D. Experiential Learning experience as a source of learning and development. New Jersey: Prentice Hall, 1984.
Cantillion P, Hutchinson L and Wood D. ABC of learning and teaching medicine. BMJ publishing 2004.
Hillier Y. Reflective teaching in further and adult education. Continuum 2005.
Contemporary model of adult learning picture not referenced
The idea that many people exhibit strong preferences for a given style of learning was expanded by the well known contemporary model of adult learning styles by Honey and Mumford. They used a questionnaire to explore learning and preferences, to categorise people into the following groups;
Activist. Also called drivers, respond to working on projects which include creative thinking, reflecting and planning. May need to improve ability to listen and work with others.
Reflector. Prefer structured learning activities where they are provided with time to observe reflect and are then allowed to work in a detailed manner. Might need to develop abilities to set priorities and make decisions.
Theorist. Respond well to logical, rational structure with clear aims, where they are given time for methodical exploration and opportunities to question their intellect. May need to work on their creative and lateral thinking.
Pragmatist. Respond best to practically based, immediately relevant learning activities, which allow scope for practice and previously learned theory. May need to work on their analytical and critical thinking.
As with all behavioural models, this is a guide not a strict set of rules. While it is important not to 'label' yourself or other learners, many people will recognise some of their tendencies, and importantly, practical applications are suggested to facilitate learning.
This is something which I can directly relate to my style of learning. I decided that it might be useful to improve the knowledge of my own learning preferences by taking their questionnaire a (PDP 4). The website from which I answered the questions, suggested that I predominantly fell into the pragmatic group. Their suggestions included that;
'I gain satisfaction from practising skills rather than theorising'
'I need clear objectives and guidelines in my head before I attempt a task'
'I find learning ' theory' difficult without conceptualising its practical application'
Understanding your own traits is important as a learner and interesting these suggestions do fit traits and preferences I have observed in myself. I had, however, never given thought to how as a teacher and team member, understanding your learner's likes and dislikes can help. I can see that some of the most difficult groups I have worked in contain members with different styles from me (reflective observation), often reflectors/ theorists. From looking at the suggestions for pragmatists (abstract conceptualisation), in future teaching sessions/ presentations, I need to slow the pace of delivery and be patient while reflectors/ theorists think abstractly b (PDP 6). I also need to consider the groups individual learning styles and tailor my talk/ future talks if necessary c (PDP 6). This time to think will also allow learner the opportunity to review and reflect on what I have said, the reflective observation stage of the cycle of learning.
EOP: I identified my learning need (lacking awareness of personal learning preferences), taken the test (concrete experience), thought about group problems experienced in the past (reflective observation) and decided how my learning style affected this (abstract conceptualisation). By setting an action (b,c) to improve group dynamics in the future (active experimentation), I hope to reflect on the result, thus completing the cycle.
Fewing J. Rough and ready learning styles. Brainboxx 2005. http://www.brainboxx.co.uk/a2_learnstyles/pages/roughandready.htm Last accessed 10/10/10
Honey P & Mumford A. The Manual of Learning Styles. Peter Honey Publications 1982.
Harden R and Crosby J. The good teacher is more than a lecturer: The twelve roles of the teacher. Amee education guide 2000. 4 (22): 334-347.
Fleming's VARK model
Other proposals make additional suggestions to compliment individual learning. Neil Fleming proposed the popular idea that we each have individual sensory preferences to how we learn. The Fleming's VARK (visual, auditory, reading/writing and kinesthetic) model can allow teachers to prepare sessions which appeal to an individual's favoured mode or modality of learning or try to include different sensory modalities to appeal to a wider audience of learners. This model is especially useful because it is easy to conceptualize and offers advice to facilitate learning. As a visual learner, I find it hard to work at home with the children around (visual and auditory disturbance) and prefer to work in the silent study room of the library. I commonly employ multi-media and mind maps to aid my studying, often adding notes to diagrams rather than producing text notes. To aid the learning of others, I will try to incorporate different modalities to suit all learners. I often use white board mindmaps in group sessions, I will try to practise using more reading/writing and kinesthetic modalities d (PDP 6). The latter might include ward-based learning where we are 'hands-on' with the patient.
Wood D.Â ABC of learning and teaching in medicine. BMJ 2003; 326: 95-97.
One to one teaching
One to one teaching is at the opposite pole to the traditional lecture. In terms of knowledge transfer, its efficiency is very low, but when measured in terms of active learning, evaluation, feedback opportunities and the ability to model behaviour, it scored very highly. In the one to one scenario, understanding the learner's needs, objectives and incorporating their favoured learning styles within the encounter, become the most effective. Good one to one sessions need to be well prepared, interesting and contain constructive advice.
A strong relationship can also be fostered within such a personal setting. This can allow the personal and professional views of the learner to be openly discussed, and offers the strongest platform for influence and modification in a trusting teacher/student relationship. This is important to allow the open discussion of serious issues or to given constructive feedback, discussed later.
What I find most useful from one to one tutor sessions is the personal, individualised feedback and the opportunity to reflect on ideas and understanding. Identified deficiencies either can be remedied or a strong clinical reason to seek the correct answer can be given, which promotes active, independent learning.
Gordon J. ABC of learning and teaching in medicine: One to one teaching and feedback. BMJ 2003; 326: 543-545.
There are several advantages to teaching smaller groups compared to larger ones. A handle of prior knowledge, expectations and personal objectives can be obtained. By addressing these issues, motivation and involvement can be increased during the session. This relies heavily upon the skill of the provider to alter material, be flexible and use 'ad hoc' teaching methods/ materials to meet suitable objectives and expectations.
Smaller numbers also allows for group discussion. This can offer a wealth of learning opportunity for both student/s and provider. Understanding and meanings can be verbalized, interpersonal skills (listening, negotiation, communication, persuading, presentation, teamwork) can be practised and individual evaluation can be made.
Personally, I find substandard teaching, specifically poor facilitation, most noticeable within the smaller group setting. Common errors include providers simply presenting information without inviting or encouraging learner participation, or as discussed later, giving answers to questions rather than encouraging any depth of thinking. While these sessions still provide information, they miss the opportunities which group discussion and group interaction offers. During the most memorable and effective small group sessions I have attended, the teacher acts as a group leader, simply facilitating the discussion of the topic rather than delivering it.
Difficulties for the provider include students being unprepared/ uncooperative or dominance of a single student. By setting ground rules (e.g. not talking at the same time as another group member) or encouraging individual participation through direct questioning, these obstacles can be managed. It is, however, important to get the balance of structure and intervention correct. This can be achieved by only intervening where necessary e.g. to clarify unknown, incorrect ideas or to move topics forward or link to related concepts.
Inadequate intervention, however, can allow groups to become side tracked or lose their flow. To help maintain interest and energy, separating students into pairs or small groups with specific tasks, or giving them prearranged involvement (e.g. short presentations) can help reduce your internal involvement within the group and encourage their own autonomy.
Within the small group setting I am strong at facilitating involvement from all members; I do not, however, set session objectives or assess prior knowledge e (PDP 7). I have also never conducted a formal lesson plan e or done a prior learner's needs assessment e (reflective observation), these will also go into my development plan (abstract conceptualisation). These actions can be found in PDP section 7.
Jaques D.Â ABC of learning and teaching in medicine: teaching small groups. BMJ 2003; 326: 492-494.
Lectures are an efficient way of passing on knowledge and experience to large groups of learners. Done well they can ......offer current thinking, help stimulate interest, explain concepts, provide core knowledge, and direct self direct learning (SDL). They are ........less effective at changing attitudes, encouraging higher order thinking, and generally create passive learning. Speech marks for the reference.
When referring to the Kolb cycle of learning, lectures allow very limited time for learners to reflect on the given information, critically appraise it or make conclusions (abstract conceptualisation, figure 2). To prevent your lecture becoming boring or forgotten within hours, there are a number of ways to maximise its effect.
In preparation consider:
Where, and how it fits into the learner's curriculum.
The level of detail to include.
What will they be assessed on (therefore important to mention and include).
What teaching methods the leaners are used to or familiar with.
What technology and other media are available and check in advance your competence using them. (although similar this has been ref and reworded)
To facilitate learning;
Use concrete examples to illustrate abstract principles. - direct quote
Give handouts or provide electronic access in advance.
Allow for pauses in the delivery to give students time to write notes.
Check for understanding by asking questions or by running a mini quiz.
Encourage students to ask questions.
Be clear and humorous (if you can!).
As a student with assessments and clinical responsibility looming, I find my motivation to pay attention is maximised by the phrase 'this always comes up in exams' or 'you will need to know this as a junior doctor'. I will use similar phrases in my teaching to help introduce, and thereby engage, or to set objectives, thereby motivating students f (PDP 7).
There are a number of aspects that are strikingly different from when I attended university for my first degree a decade ago. There are always clear objectives stated at the start and reminded at the end, a clear summary page and details of further learning material/ sites. As a teacher of my peers, now I can see how these help learners focus on the topic and help the recall and retention of knowledge. Finally, remembering to evaluate your own performance and asking for learner feedback g helps facilitate the cycle of learning and ultimately improve your teaching. I have never proactively sought evaluation and never actively changed the few talks I have delivered twice. To improve my teaching skills and quality of my sessions, this is something I will seek to do g (PDP 7).
Cantillon P. Clinical review ABC of learning and teaching in medicine :Teaching large groups. BMJ 2003 326:437
Adapted from Winston Churchill, a favourite military saying is 'Fail to plan, plan to fail'. For the vast majority of us, this holds true when it comes to successful teaching. Much of this has been discussed within other areas of my teaching theory section, however, this is the general plan I will follow when preparing and running my teaching sessions;
Consider the topic; why choose it and content. Keep it relevant and avoid information overload
Audience; Expectations, learning styles and modality preferences, numbers, questions, breaks.
Objectives; based on learner's needs
Involvement; questions and activities for learners and teacher.
Location; Materials available and technology to include (e.g. access to x-rays or smart board).
Facilitate SDL; include additional resources and/or homework.
Practice, practice, practice.
Evaluation; self and peer directed
I have not put superscripted action points on all of these so as not to complicate my project any more than is necessary! I will, however, refer to them when planning and preparing my presentations.
Keston C. Independent Learning: A Common Essential Learning: Saskatchewan Department of Education Core Curriculum Investigation Project 1997.
Evaluation is an essential part of the educational process. The focus of evaluation is on local quality improvement and is analogous to clinical audit.
The process of evaluation is essential to the teaching/ learning process and is the basis for clinical audit. Similar, not quite direct, but referenced at end. It allows the demonstration of knowledge, exposes a lack of it, and helps facilitates knowledge recall, which aids long term memory retention. Information gained from the assessor can also be used to develop the curriculum or expose any inadequacies / gaps in certain curriculum topics.
As a student, the most obvious example of this is through direct questioning. Questioning is a powerful tool, used less frequently to humiliate the learner today, however, often still used inadequately. Far too often the questioner is too quick to answer their question without encouraging deeper thinking and recall.
On the busy ward, it is usually the student's questions which are handled poorly by the clinical teacher. Often an immediate answer is given or too much information is given without discussion. When times allows, a better method is to attempt to allow the student to answer their own questions. This can be done by asking the student to clarify, ask them what they think or generally probe their understanding of the topic by asking them related questions (practise good questioning techniques) h (PDP 6). This method encourages recall and links to develop between topics, both aid the storage of long term memory.
Questioning also helps to evaluate learner understanding of something explained, just taught or witnessed. Using a closed question like 'Did you understand that', tempts students to say 'yes'. Asking if they can summarise it, however, requires a demonstration of understanding (ask the learner to summarise understanding) h (PDP 6 and 10).
Morrison J. ABC of learning and teaching in medicine: Evaluation. BMJ 2003; 326: 385-387.
Gordon J. ABC of learning and teaching in medicine:One to one teaching and feedback. BMJ 2003; 326: 543-545
Being able to give and receive feedback are skills well established within the medical curriculum and important within the teaching process. This allows the development of an individual's observed performance and the process of managing poor or potentially dangerous/ unprofessional behaviour with minimal conflict.
A system common at the Peninsula Medical School is Pendleton's rules of feedback;
Clarify any points of information/facts.
Ask the learner what went well -identify the performance strengths.
Discuss what went well, adding your own/group observations.
Ask the learner what went less well and how they might improve next time.
Discuss what went less well, adding your own/group observations and recommendations.
This is direct - http://www.gp-training.net/training/educational_theory/feedback/pendleton.htm not referenced
In the context of improving my teaching skills, I will encourage feedback on my own teaching sessions to try and incorporate recommendations into future talks i (PDP section 7). Through doing this differently in practice I come into the active experimentation stage.
Pendleton D, Scofield T, Tate P and Havelock P. The consultation: an approach to learning and teaching. Oxford University Press 1984.
Gordon J. ABC of learning and teaching in medicine:One to one teaching and feedback. BMJ 2003; 326: 543-545
Leadership: teaching by example
Leading by example was an activity emphasised within my military experience and some of my most memorable clinical experiences come from watching good practice. For these reasons, I think leadership and specifically 'teaching by example' is an important topic. To be a good teacher and to allow others to model good behaviour, I believe you should strive to be; honest, reliable, respectful, and enthusiastic, reflect critically on your own learning process/ performance.
Learning in the clinical environment
In preparation for my future role as a junior doctor, time spent on the ward and in outpatient clinics is increasing. The clinical setting offers 'real' patients with 'real' problems, particularly powerful and relevant learning stimuli. This environment also allows the learner to be directly involved in patient care and even taking ownership for some aspects of their management. These experiences are often the most memorable and help inspire SDL to fill exposed gaps in knowledge. They also allow the practical application of clinical skills (examination of pathology) and softer skills (empathy, professionalism) which can be difficult to simulate in the classroom.
There are, however, a number of problems and obstacles posed to both learner and teacher within this environment. On many occasions my teaching has been sub-standard, cut short or cancelled due to staff shortages, emergencies or staff timetabling. Clinical teachers are after all, clinicians first and teachers second. Other less obvious pitfalls relate to patient care. It is important to check how confident / competent learners are at performing tasks (e.g. canullation) before asking them. It is also important to observe how under the 'pressure of observation', the learner obtains consent, maintains privacy and dignity.
In the classroom, the teacher usually has a clearly formulated lesson or objective/s in mind. With the distractions of the working environment, however, it is easy for the teacher to lack direction or become distracted, allowing the learner to become a passive observer rather than active participant. In my experience the 'best' teachers are very flexible on the ward. They make the most of any available opportunities in circumstances less than ideal, encourage learners to get involved and to challenge both their understanding and clinical practice.
Hay R. Teaching and learning in the clinical setting. Radcliff Publishing 2006.
Spencer J.Â ABC of learning and teaching in medicine: learning and teaching in the clinical environment. BMJ 2003; 326: 591-594.
Jacobs J. Teaching in the clinical environment: Guide Supplement. Medical Teacher 2009; 31: (5) 454-456
Technology & teaching materials
The most common mistakes I observe within the teaching environment is incompatibility with multimedia equipment (often memory sticks). This can be avoided by simply checking equipment compatibility well before your talk and have a plan b (e.g. ability to email the talk someone). Other mistakes include; overcrowding of lecture slides, text which is too small and material not relating to the verbal content/ topic title.
Experience and prior training has taught me that minimalistic slides are usually better and slides are simply an aid, you need to have learned the topic well to deliver a good talk. These are not action points, however, because they have become habits of mine. To confirm or deny the assumption that this is good teaching practice, I will specifically ask my small group to evaluate the slides for one of my talks i (PDP section 7).