Sunday, 16 December 2012

On clinical teaching and learning theory...

These past few weeks have been all about clinical teaching. I have run a couple of workshops based on the topic of  'on-the-job teaching' for a group of doctors and dentists studying for PgCerts in Medical and Dental Education and  I have also had the joy of undertaking two workplace based teaching observations. One with a dentist running a small group teaching session on dental implants for his multidisciplinary team, the other an anaesthetist helping three FY2s understand blood gasses. Both demonstrated the very best of clinical teaching, putting shared concerns for patient care at the centre of their teaching activity, working with their learners to develop their thinking and to shape their practice. Neither involved whizzy learning technologies nor took the form of slick, over-rehearsed 'presentations'...these were sessions based around listening, dialogue, questioning (self and each other), prompting, guiding, rehearsing ways of thinking and acting. They were authentic, democratic engagements with colleagues.

I was reminded of these teaching sessions, when I engaged in a brief twitter exchange with some medical colleagues questioning the accessibility of educational theory. We mused on its appeal (or lack thereof) and the ways in which it was possible to put theoretical ideas to use, to ‘make sense’ of educational experiences in the past or educational practices in the future. How might I make-sense of clinical teaching I observed, by drawing on educational theories and, in so doing, illustrate why I was so impressed?

Well, I might start with Stephen Billett’s conception of ‘workplace affordances’ and consider the extent to which workplace learning opportunities were evenly distributed in the clinical settings I visited. My dental colleague did a fantastic session on dental implants, engaging an experienced dental nurse just as equally as a newly appointed dental receptionist. Here, learning opportunities were offered to every team member, not just those with explicit learner status (student, trainee) or particular professional roles (other dentists). Is this true of every clinical workplace? Billett’s ideas lead me to question whether some workers gain access to richer, more regular learning opportunities than others. I consider the extent to which medical educators might (unconsciously) favour those who they feel to be a ‘good fit’ to their chosen speciality, offering more hands on experience, taking them under their wing to talk cases and in so doing miss opportunities to invite others into their ways of thinking. 

I might also turn to Lave and Wenger’s work, looking for examples of ways in which ‘newcomers’ to each setting are provided with opportunities for legitimate peripheral participation.  Their analytic viewpoint on learning leads me to consider the extent to which students and trainees are invited to become full participants in the communities they join, through engaging in meaningful work activity.  This extends beyond practical work to cognitive work, in other words, opportunities to rehearse ways of thinking like doctors. 

A recent hospital admission (as a patient) provided me with great opportunities for some ethnographic activity! I saw nursing students, for example, lead drug rounds, with the senior nurse at their shoulder to make sure all was in order. Here, students were able to rehearse (with support) the types of work activity they would shortly be undertaking as qualified nurses. I was left more troubled by the day to day activity of the FY1s, who, a month in, seemed to be engaged in medical work that was quite distinct (and often detached from) the work that more senior colleagues were doing. FY1s took bloods, they chased after surgeons (literally) writing up notes from the ward round consult, but they (unlike the registrars) were never invited into the discussions about my care, nor invited to ask questions (at least within my hearing).  Thankfully, the observed teaching session of FY2s a few weeks ago was quite different. A complex session based on calculating blood gasses had wonderful eureka moments, when ‘paper cases’ of patient presentations offered new insights into the importance of these calculations and inspired those present to go back onto the wards to try out some calculations on their own. 

Every discipline has its own language and invites particular ways of thinking, education is no different to medicine in that respect. Every worker makes choices about the tools or instruments they use to do their job. Educational theories are, for me at least, rich analytical and conceptual tools, which shed light on learning. Challenging to grasp? Yes. Worth the struggle? Undoubtedly.


Footnote: for those interested in ways of enhancing workplace based learning, visit the London Deanery website. In the linked e-learning unit, I draw on socio-cultural ideas about learning (including those mentioned above) to suggest some ways of developing clinical teaching practices. 


  1. Hi Claire
    Done a few observations recently myself for our PGCert. One about physical examination sticks in my mind when I asked the 'teacher' about why he did what he did. Answer was because that was the way he was taught – and also he thought I meant content (saying that’s how McLeod’s says to do it!) as opposed to process. It was not that it was ‘bad’ or ‘wrong’ quite the opposite, but he was not aware that what he was doing had a theoretical evidence base. (We discussed Fitts and Posner etc) Some would say - is that a bad thing? (That he did teach well without knowing ‘the theory’). Your discussion suggests that to be inclusive for all learners, awareness of the different theories of clinical learning can improve the process – not just a case of being scholarly for an essay – but only if you as the ‘teacher’ learns ie change the way you do things. I fundamentally agree with you; however as with most things, personally can say is not easy to do!

    1. Hi Kirsty,
      This is an interesting story to consider and evokes a number of responses from me. The first, I guess, is the distinction between being able to 'do' something and understanding what it is you are doing. An extreme comparison might be training someone how to do a routine (surgical) procedure without teaching them about anatomy and physiology as part of that process. Being able to deconstruct one's own thoughts and activities as a teacher enables you to purposefully adapt approaches according to situation, circumstance and need. For me the most vital time to have theoretical tools to put to use, is when the 'routine' no longer works. So, fundamental shifts in the ways in which patient care is organised and delivered, loosening of strong bonds between trainer and trainee etc means
      doctors need to re-think how they approach training. This is where conceptual tools are needed! Easy? Medicine isn't... so why should medical education be any different!

  2. My ‘easy’ was around change behaviour. Actually much of the knowledge of medical education is easy, often common sense. As theory is often based on observation of practice am never quite sure why it is so indigestible/long winded. Not sure your comparison with surgery is applicable as struggling to know the different theories of anatomy. My example would be; I have to understand research for my medical evidence based practice but do not have to know the names of all theories related to that research. I rely on others, the scholarly people in that practice, to know this.
    We are talking about ‘teaching about teaching’ while most of those we talk to are thinking about ‘teaching about medicine’. I agree with your thoughts on meta-learning but know that many are put off by the use of the term theory. One of our roles is to make the theory more accessible/interpretable. I believe this is not by more people knowing the names of theories but as you say encouraging reflection in and on practice - don’t have to mention the name ;-).

  3. For me, learning theory = the knowledge base of the discipline. Few medics dispute the need to know their anatomical structures (although the extent to which this is knowledge readily put to use is perhaps another debate). In order to make sense of medical education, the historical, cultural practices I observe on the wards, or in theatre, I need some conceptual tools. My educational knowledge (the conceptual tools) allow me to analyse practices, explain practices and work with colleagues to develop practices. My experience of sharing these conceptual tools with others (the HCP studying (medical) education Iwork with) is it provides them with ways of thinking about what they do, provide a rationale for what they do, so they can approach their practice (as educators) more meaningfully. Names aren't the issue, rather ways of understanding...
    Interesting to think about ways in which we put knowledge to work in different disciplinary fields.

  4. Hi
    Happy new year! Think we are saying same thing?
    Alan B says what i am trying to say much better!
    'conceptual language can be overwrought and may alienate practitioners. Theory can be developed with practitioners themselves to avoid widening the gap between experience and the understanding and explanation of experience'
    Read More:

    Still think big hurdle is that we are discussing teaching (about teaching) while the most clinicians are wanting to know about teaching medicine. That the two are intertwined and not hierarchical is the barrier we need to over come.

  5. Oh to be as eloquent as Alan B! More similarities than differences in our stance :) happy new year to you too!

  6. An academic essay may be on a point that the confirmation may give you. Then again, the affirmation may require you to write about your profession goals, scholastic accomplishments and explanations why you are applying to that school.

  7. In order to create sense of medical education, the historical, cultural practices I observe on the wards, or in theatre, i would like some abstract tools

  8. I am a student of clinical Research and i learned lot of about this topic. Thanks for sharing and keep posting this interesting and useful post.

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