Will there ever be a panacea for medical education

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Introduction

Medical teaching has undergone several changes over the past few years. From the large group based teaching which I was taught in to the current concepts of problem based learning (PBL), the changes are enormous. Despite this there is no current evidence to support curriculum outcome benefits for students graduating from PBL over traditional curriculums (Wood, 2003). The other challenges facing medical education are the increasing clinical demands of medical teachers which limits the time available for teaching. The introduction of the European working time directives (EWTD) has further reduced the time and the opportunities for training and education. Therefore there is a need for a system of medical education which is concise, stimulating, measurable and reproducible. This assignment looks at the various teaching methods and argues why one teaching method cannot be the panacea for all the problems currently facing medical education.

Literature review:

Adult learning methods and medical education:

Adult learning theories have helped the evolution of new teaching methods and techniques. Malcolm Shepherd Knowles (2005) explains that "experience" is the core of adult learning. He also argues that the role of the teacher in adult education is to facilitate the process of learning and not to merely attempt transfer of knowledge. Another important point which has significance to medical education is that individual differences are more marked in adult learners and therefore their education should provide for the differences in their speed, place, time and style.

Several Psychologists have also contributed to our understanding of adult teaching methods. These include Sigmund Freud (id, ego and super ego theories), Carl Jung, Erik Erikson, Abraham Maslow and Carl Rogers. Their work has led to the understanding that facilitating learning is more helpful than direct teaching (Rogers, 1983). It has also become very clear that an adult learns significantly when he is involved in the teaching process (Rogers, 1983).

Large group teaching:

A good lecture can deliver significant information to a large group of students and thus is an effective way of delivering the curriculum (London deanery N. L.). A good lecturer can inspire students and enthuse students in a particular area. Lectures are also more cost effective.

Online lectures are another useful educational tool as they offer a choice of time and place to the student in addition to being a resource efficient (Spickard A, 2002). Online lectures are as effective as live lectures.

Large group teaching in the form of lectures has been widely criticized (London deanery N. L.) (Mandin, 2001) (Rogers, 1983). Lectures typically have a short concentration time. There is also evidence that retention, transfer and application of information after a lecture is poor (Paul M. Krueger, 2004). In fact several authors have described the concept of 'lecturalgia' (Mandin, 2001) (Chan) (Duquesne University). Lecturalgia literally means lecture pain and can either cause anger and frustration or lead to apathy and somnolence (Mandin, 2001).

There have been several suggestions about how lectures can be made more interesting. The lecturer should be aware of the knowledge of the learners; the lecturer should be knowledgeable and aim to enhance understanding and knowledge (Mandin, 2001). The lecture itself can be more interesting and focussed by using techniques to discourage passivity, encourage interaction and by varying the tone and content every 15-20 minutes. Seeking feedback and reflecting on the lecture will help the lecturer improve his teaching performance.

The concept of lecture is against the theory of cognitive psychology which says that leaners are more likely to remember information if they talk, think and relate to things they know (Paul M. Krueger, 2004). Therefore discussion especially small group is likely to be more effective in retention of information.

Small group discussion:

The exact definition of a "small group" is quite variable. One view is that it contains 8-12 learners (London deanery). However in clinical settings this number might be much smaller and in higher education this might rise to as much as 25-30 students. McCrory (2006) has described small group teaching as learner centred with all students taking part in a free discussion on a particular topic.

The usual difference between a large group and a small group based teaching is that large group teaching usually means lectures and small group teaching tends to be discussion and problem solving and is more helpful for the ability to apply knowledge (London deanery). Small group discussion empowers the student to learn with in a framework of discussion, feedback, reflection and understanding. In addition to the knowledge gained, students also learn communication skills, team working and problem solving skills. Therefore it is more in line with the concepts of adult learning (London deanery). There is evidence that small group discussion is superior to the large group passive learning (Lawry GV, 1999).

On the flip side the discussion may be dominated some person(s) with some others being passive and not actually involved (London deanery). The teacher should act as a facilitator and guide the discussion to prevent it from losing direction. Therefore this mode of teaching is highly demanding on the limited resources available for teaching.

Problem based learning (PBL):

Problem based learning has been used both in the UK and in other parts of the world (Wood, 2003). It has been widely acclaimed by several authors (Mark Albanese, 1993) (Wood, 2003) while others have questioned its benefits over traditional teaching methods (Colliver, 2000).

Problem based learning can be defined as an educational method where patient problems are used as a tool by the students to learn problem solving skills and also to acquire knowledge about basic and clinical sciences (Mark Albanese, 1993). Group learning in PBL facilitates not only knowledge development but also promotes the development of communication skills, problem solving abilities, mutual respect , team working, presentation skills and application of knowledge in basic sciences into clinical situations (Wood, 2003). Theoretically PBL is more likely to benefit medical students as it is based on the adult learning theory (Albanese, 2000). PBL has been integrated into the curriculum of several medical schools (Mark Albanese, 1993). Students graduating from a PBL based curriculum tend to have better information retention (Wood, 2003).

However PBL alone cannot offer a panacea to medical education. Tutors who have been used to traditional teaching styles need support and training to facilitate a group discussion (Wood, 2003). In the absence of a trained facilitator it is possible that students may complete their discussion with a lot of information which may not be relevant. Students may also be deprived of an inspirational teacher who might have taught them in the traditional curriculum. Also the group dynamics might lead to friction and conflict and result in a dysfunctional group where no knowledge is gained.

This has led to some new techniques in PBL like the use of a wrap up lecture at the end of a PBL session (Bradley, 2010). This might be one way of exposing the students to the best of both methods of learning.

Simulation

Simulation based training is widely used in medical and surgical fields as it offers trainees the opportunity to perfect skills before use on a real patient. It is also popular with trainers as it allows training and evaluation of a trainee in complex decision making, in time sensitive tasks and in rare scenarios (Maya M. Hammoud, 2008). One classification of these simulators could be as high fidelity and low fidelity simulators. The difference is in the level fidelity or reality in these stimulators. Low fidelity stimulators are low cost like the models used for learning suturing and tissue dissection. High fidelity simulators like animal models are more likely to be expensive although they offer more 'real' experience. Simulators can be used for assessing trainees. This has been described as OSATS (Objective structured assessment of surgical training skills) (Martin, 2005). A combination of OSATS and assessment of trainees operating on a real patient could provide robust assessment of surgical training programmes (Maya M. Hammoud, 2008).

Some other authors classify simulations as technical and non- technical (Kathleen. R.Rosen, 2009).Technical simulations include plastic models of body parts, computer simulations and manikins. These authors have described PBL, case based discussions and role modelling as non-technical simulations. Another form of simulation is the standardized patient who is a lay person and can play the role of a patient, family member or healthcare professional to help with medical student education and evaluation.

Simulations can be highly educational with the added benefit of protecting the patient while allowing trainee education and evaluation. However they cannot replace the real life situations and therefore other methods are needed for medical education.

Other methods

E learning has been described as a useful method of medical education as it offers students flexibility (Eline Agnes' Dubois, 2009). The authors have suggested that a curriculum- wide e-learning programme could be successful if integrated with other subjects. There need to be processes to ensure easy accessibility and quality control.

Feedback and reflection

Feedback and reflection are two very important tools in clinical education. Students often feel they do not get enough feedback (William T. Branch, 2002). There is also a view that reflection is much less used than feedback.

Feedback can be classified as brief feedback, formal feedback and major feedback. Brief feedback is usually provided either during history presentation or following examination of a patient. This is often provided but students might benefit if they are specifically told that they are receiving feedback before it is provided (William T. Branch, 2002).

Formal feedback involves setting aside time varying between 5-20 minutes to discuss a difficult case, a medical mistake, an out-patient encounter or presentation of a case. It is a good practice to elicit self -feedback from the student. This usually brings up the topics which the trainer would have wanted to discuss and in addition the trainer can reinforce the points without the trainee feeling overwhelmed (William T. Branch, 2002).

Major feedback is usually done either at mid-point or end of post meetings. It is usually conducted in private with the trainee fully aware that they can reflect on their performance. The trainer can also utilize a major feedback to address inadequate performance (William T. Branch, 2002).

Feedback is central to training and places the onus on trainers to observe their trainee closely so that feedback can be specific and useful to the trainee.

Branch (2002) has defined reflection as a process to understand the meaning, implication and larger context of an act. Teachers who have the trust of their students and are good role models are more likely to facilitate reflection among trainees. As a teacher becomes more experienced he can use reflection to improve the team performance.

Self-reflection on large group teaching

My experience in learning has been mostly in large group settings with a good experience of small group teaching as well. As a teacher I have used mainly short group discussions. Less frequently I have used lectures for teaching medical students. I do not have much experience with problem based learning either as a participant or as a facilitator. In this assignment I will be using the Kolb's learning cycle to critically reflect on my teaching experience.

The learning cycle is illustrated below.

Active experimentation

Kolb learning cycle

Reflective Observation

Abstract conceptualization

Concrete experience

Large group teaching:

As a student I have attended quite a few lectures. I have also lectured on a few topics to undergraduate medical students and trainee doctors.

I will reflect on a recent lecture at the joint paediatric meeting. The topic was a rather unknown test called Quantiferon and its uses in the diagnosis of paediatric tuberculosis. The target audience was a mixture of senior consultants in paediatrics and neonatology and junior trainees. I presented my lecture as a PowerPoint presentation.

As concentration levels in a lecture tend to drift down after 15-20 minutes' time, I had planned to make the lecture about 30 minutes in duration with about 5 minutes for questions and other interactions. I had read the topic thoroughly and was well prepared for any questions which the audience might have. As this is a relatively unknown topic in Paediatrics I expected that the audience would not be aware of great many details on this subject.

At the beginning of the presentation I described the aims of the lecture. My presentation included a serene background and I omitted including any slide animations as in my opinion they are likely to cause distraction. I had placed slides with a humour element at periodic intervals. I had also used some videos in the presentation to both maintain concentration and to assist me in providing the information on Quantiferon. I concluded my presentation with a summary of the points discussed. I also anticipated that there would be some interesting discussions during the presentation and had allowed enough time to include this as well.

Concrete experience

At the lecture presentation I was confident and organised. After the initial few slides I noticed that the concentration of the audience was waning and it was at this time that my slides with the humour element came up. These slides did attract attention and interest but I noticed that people were concentrating on the humour element and not on the actual content of the slides. I felt that as a result the actual information contained in these slides was not passed on.

The videos were very well received and I could notice that concentration levels were quite good. There was lot of interaction during the video slides. I had used carefully selected videos and this was much appreciated.

The topic itself was quite new and interesting to audience and this helped in keeping the interest. As the audience had a very varied experience I found it difficult to keep the interest of the least experienced (junior trainees) when the most experienced (consultants) needed some clarifications and vice versa.

During the presentation there were interactions between the audience and myself which I encouraged and this helped with the information transfer.

At the end of the presentation I sought feedback from the audience.

Reflective Observation and abstract conceptualization

I understand after attending the work based medical education course (WBME) and from the review of literature above that lecture based teaching is the least effective form of adult learning (Paul M. Krueger, 2004). Based on what I have understood during the course, from the review of literature and from the feedback I received, I intend to use the following techniques to optimize the learning I can provide at a lecture:

Lecture durations of not more than 30-35 minutes.

Ideally lectures should be held in a place and a time best suited for the students. Although I would try my best, this is something I have limited control over.

Enhance my knowledge of the topic I am lecturing on so that I can provide the best possible knowledge.

Make a serious attempt to understand the knowledge and expectations of the audience and to adjust the content of the lecture to suit their needs. I understand from the review of literature that adult learning is characterised by the students having different experience and knowledge (Malcolm Shepherd Knowles, 2005).

Have a clear structure to the lecture. Some authors have described this as appetizer (Aims and introduction), main meal (the lecture itself) and dessert (conclusions) (Mandin, 2001).

Clearly define the objectives prior to the lecture and then conclude by listing the main points. This has been described in the US army as "tell em what you wanna tell em, tell em, tell em what you told em" (Mandin, 2001).

Use multimedia to vary the delivery of information.

To enable interaction during a lecture by limiting the information provided and encouraging discussion.

Provide key points to enable discussion and discourage passivity.

To use humour selectively as it is can potentially distract the audience from the message of the lecture.

Seek feedback at the end of the lecture to further improve teaching techniques.

Summary

Medical education has evolved rapidly in the last few years from the era of mainly lecture based teaching to the present age of problem based learning. However the quest for the ideal teaching / learning method continues. As had been discussed each type of learning comes with its' share of advantages and disadvantages. In this era of austerity there are going to be increasing demands on the teaching staff to demonstrate financial effectiveness. There is a need to undertake high quality research in medical education methods to identify the best method(s) which facilitates learning within clearly defined objectives and at the same time makes teaching efficient and cost effective. As of now the question remains: "Will there ever be a panacea for medical education?"……….

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