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.

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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.