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. 

Lecturing for learning

It’s that time of year again! Lecture halls are filling with eager new learners and those a little less keen, having been there before. Lecturers blow the dust of their slides (symbolically, if not actually) and start a process of refreshing materials,  in order to show that they are absolutely up to date, have read all the right journals and are ‘experts in their field’. Lectures are undoubtedly good for the lecturer’s learning, but what about the often passive recipients of their academic prowess, beautifully displayed on power-points up and down the country? 

Are lectures good for learners’ learning? What is the nature of the relationship between ‘a good lecture’ and ‘good learning’?

Kugel (2003) provides an interesting account of how professors develop as teachers, noting shifts from teacher-centric to learner-centric behaviours over time. Novice teachers are concerned about their own preparation and performance, preoccupied with the content of their lecturers, and ways to put together audio visual materials to impress and entertain! More experienced teachers however,  start with their learners, seeking to establish what they already know, what their learning needs might be and how they can make new ideas and information accessible– re-contextualising knowledge so it can be put to use.  In other words, they are preoccupied with making lectures good for learning.

If you are preoccupied with ways to make lectures good for learning, I have a few suggestions.

Establish learners’ needs.

Don’t treat a group of 100 learners as if they were of one mind and don’t assume that because something has been ‘taught’ it has been learned. This was a salutary lesson for me, when I asked a group of speech therapy students to quickly sketch a picture showing pre and post operative anatomy of a patient having a total largyngectomy, as a basis for discussing voice restoration. 6 hours of ENT lecturers left 5 out of 80 students able to complete the task! A quick quiz with a show of hands at the start of a lecture, primes students for what is about to follow and offers you some information about where to concentrate your efforts.

Structure your lectures

Brown and Manogue (2001) share insights into observed medical and dental lectures and the structures often used. How often do you resort to the ‘classical iterative’ structure in clinical teaching, following signs, symptoms, diagnoses, management and prognosis? It may mirror how classic medical textbooks are organized, but does that mirror how you think when faced with a new patient? The problem-centred /case-based lecture, where you start with a clinical case as a trigger for thinking through options engages students in diagnostic reasoning processes before they meet patients on the wards and in clinics. In doing this, you are showing how clinicians put knowledge to use in practice.

Build in interaction

 For me this is perhaps the most important element in increasing the learning value of lectures, but is often avoided. Learners need opportunities to think in lectures, to test out new ideas, to explore their relevance and put them to use. Interaction can be in a variety of forms.

Interaction with the lecturer is most obvious but not necessarily the best strategy. Too often questioning becomes a series of one-to-one teaching interactions in a whole group. Those asked questions go into panic /show off mode, the remaining 99 breathe a sigh of relief and switch off. Only the brave dare ask questions, which may not reflect where the whole group is. There are ways to get round this. Asking students to talk to each other for a couple of minutes and come up with a really good question to ask you works well. If they write them on a slip of paper, you can gather them and get excellent in-task feedback about what they are understanding (or otherwise).

Interaction with each other works well too. Set them a challenge, a question to answer or give them some clinical material to analyse (spot the fracture, identify the anomaly).

Interaction with data is important - a graph to interpret, a dataset to consider a set of symptoms to think through.

Interaction with their own ideas is seldom included but really valuable. Offering students 3 minutes to write down their key learning points from the lecture so far keeps them on track and allows you a moment to gather your thoughts.

Provide a clinical context

Finally, and perhaps most importantly, offer your learners what a text book can’t – your experience and professional wisdom. We know medical students are incredibly bright, they have shown their capacity for book learning long before they reach you. They can distill and regurgitate facts much quicker than those of us with aging brains can. What they can’t do quite so readily is put their knowledge to use. You can bring the clinic into the classroom through your use of examples, of clinical situations and scenarios, through stories of patients and patient care.  Bring lectures to life by sharing your lived experiences.

-------------------------------------------------------------------

Addendum: in response to twitter chat, some other 'tips'

'Managing' lectures

Always set the scene so learners know what to expect. If using interactive methods, explain why (goal is to encourage them to develop understanding of subject matter, not memorise) and what will happen when (a road map). 

Set ground rules about when 'talk' is ok and how you will get them back on track. I use 'blank' screen - so if powerpoint goes blank (press b or w on keys) this means silence. You can also have row monitors who have to pay attention and 'sh' the rest of their row. You can use bells, whistles too!

Further examples of interactive strategies

Quiz /voting - use show of hands if you don't have whizzy technology. You can do hands up with the 'right answer' or use likert scales and ask them to put hand up to show strength of agreement/disagreement. 

Ask a question post its - all students collect a post it note on way in, which they can use to ask a question at any point. They write their question and pass to end of row. You collect when they are doing another interactive task, then answer most popular questions in a plenary.

Buzz groups - you don't have to take feedback / comments from every group, rationale is to get them talking, thinking. You can offer to take comments from a certain number of groups who think they have a brilliant contribution to make.

Interactive handouts. i.e handouts with deliberate gaps to fill. Use these creatively! I use these for clinical topics where I am using a problem based structure. A single side of A4 with an empty table. Along the top put diagnosis, down the side put boxes for signs, symptoms, investigation findings, management options, prognosis etc. As the lecture reveals similarities and differences between 'case' being discussed and two differentials, students populate the handout. This way they have a classical handout at the result of a problem based lecture. 

What's the point of faculty development?

In recent weeks, the GMC have laid out their implementation plan for the recognition and approval of medical educators and trainers working in academic and clinical contexts. In future medical trainers should

• be ‘appropriately trained’ for their educational roles,
• evidence their competence against the seven standards originally put forward by the Academy of Medical Educators and
• engage in appraisal processes specific to educational roles.

The intent behind these new processes is to improve the quality of training and patient safety. Laudable goals, but how confident can we be that investing in trainer approval processes has a direct effect on the quality of training and ultimately patient care? Equally importantly, what does ‘appropriate training’ look like?  

Given the proliferation of masters level courses in medical education and the rise of faculty development activity within deaneries, royal colleges and higher educational institutions, you might imagine we already know what ‘appropriate training’ looks like and the impact it has. However, the research base is very limited and the discourse around faculty development very narrow. The long chain of assumed causal relationships (faculty development leads to better training leads to better learning leads to better clinical practice leads to better patient care) has not, to my knowledge at least, been the subject of any large-scale research study.

I should perhaps declare an interest here! For the past 15 years I have been engaged in a range of work activity, which falls into the loose category of ‘faculty development’ within medicine, dentistry and health. I lead a masters’ programme in medical education and support a range of faculty development activity within and across NHS Trusts and Deaneries. I believe faculty development can ‘make a difference’ – but making a difference starts from having a clear sense of purpose and a repertoire of practices that goes beyond typical generic ‘teaching the teachers’ workshops.

What is the point of faculty development?

This is a question I explored in a study tracing the demise of medical apprenticeship and the rise of faculty development in PGME. In the post MMC era, claims about the transformational potential of faculty development were embedded within the ‘professionalisation of medical education’ discourse. As part of my study I had the opportunity to interview medical educators from within and outside medicine, taking forward the faculty development agenda in one deanery. In these professional dialogues with colleagues, a range of orientations towards faculty development emerged and a rich range of development practices revealed. The ways in which colleagues made sense of faculty development, and the practices they adopted, were shaped by the theoretical and biographical resources they drew upon. In my analysis, I traced a continuum of responses to the professionalisation agenda, ranging from conforming, through reforming, to transforming.

A conforming response was one where the need to professionalise medical education through faculty development went unquestioned. Seen largely as a regulatory need (linked to PMETB initially and GMC more recently), faculty development took the form of short workshops, or e-learning modules, focused on ‘core’ or ‘generic’ teaching skills, that participants could acquire and take back to their own workplaces.   Teaching here was perhaps seen as a technical enterprise or craft.

A reforming response was seen where the professionalisation agenda was accepted, but faculty development practices modified to meet the needs of certain professional groups and to be responsive to particular workplace practices. Here, it was recognized that whilst there are perhaps some generic principles, teaching on a ward round is not the same as teaching in theatre, or in general practice, or out patients. Teaching here is perhaps seen more as a social practice, shaped over time in ways that are sensitive to context and practices. Workshops were adopted, but often for certain professional groups (i.e. for surgeons), but other practices, such as workplace based teaching observations were used. 

A transforming response meant adopting a critical stance to the professionalisation agenda and to faculty development itself. Here there was a recognition that training practices of the past could not be sustained as a result of NHS reform, and that a radical re-think of training practices was required. Here, faculty development involved ‘listening to the voices on the ground’, bringing colleagues together to examine and develop training practices in ways that were sustainable in their local context. Here creative faculty development approaches, such as trainer forums, team based teaching observations (involving trainers and trainees) were being developed in order to find solutions to problems arising following implementation of new PGME curriculum. Here too, doctors were engaging in masters programmes in education and educational leadership in order to have access to theoretical tools that would help craft such solutions.

Which leads me back to the question, what is the point of faculty development? If it is merely to satisfy a regulatory need, processes of approval and recognition will suffice. They put education on the agenda, they raise awareness of educational practices and they make trainers accountable for their actions. If however, it is to develop training practices that are sustainable in a reformed, and reforming, NHS, something more educationally sophisticated and meaningful is required.