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.

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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.

Activity theory, agency and medical education reform

This post was stimulated by an interesting twitter exchange today, about using activity theory in research and, in particular, how issues of individual agency are addressed. I am interested in activity theory (and, in particular, Engestrom’s 3^rd generation activity theory ) having drawn upon it in my doctoral studies. In the first study, I analysed medical student learning on attachments, seeking to make sense of the ways in which they engaged with the learning cultures of the medical school and the workplace. In the second study, I set out to make sense of the emergence of ‘faculty development’ as a new set of practices within secondary care medicine. I was interested in the discourse around the so-called ‘professionalisation of medical education’ – for me an interesting phrase, given that medicine is one of the oldest professions with centuries old traditions of apprenticeship. 

In this study, I analysed 20 years of government policy and the grey literatures of professional bodies (eg GMC, PMETB) in three areas – the NHS, Postgraduate Medical Education and Undergraduate Medical Education. This led me to conclude that constant reform of the NHS had systematically dismantled medical apprenticeship, leaving doctors in a position where they were asked to adopt training practices that were antithetical to their own learning histories. In particular, I noted the growing disconnect (conceptually, practically) between ‘work’ and ‘learning’, no longer seen as mutually constitutive. The shift to formal curriculum in PGME, with ‘competences’ to be gained, tools to evidence their acquisition etc, signaled a profound culture shift, discussed, in part, in previous blog postings.

My analysis led me to argue that there had been a shift from time-served apprenticeship to time-measured training, creating a series of structurally accumulating tensions. For example, an increasingly risk averse culture (with consultant led services) sits uncomfortably with training practices which rely on the delegation of medical work to those in training grades. My analysis left me concluding that the medical profession found themselves in a contradictory positioning (an activity theory concept). Training practices of old were unsustainable in a reformed NHS, yet the solution put forward by the regulators, to ‘professionalise’ medical education, was unlikely to offer the creative, expansive solutions necessary to reconcile these tensions.  Compulsory, regulated, faculty development activity was offered up as the means to professionalise medical education, with the ‘curriculum’ being focused on rather instrumental trainer-trainee interactions e.g. the use of WPBA tools, how to give feedback, ‘managing the trainee-in-difficulty’ and so forth. The question for me, was how would deaneries respond to this positioning? Go with the grain (ensuring all trainers were ‘trained’) or seek more creative solutions that would genuinely help trainers find ways of sustaining high quality training practices in a reformed NHS. This is where, for me at least, the question of agency sets in.

My research led me to an analysis of one deaneries response and a series of in-depth interviews with a new ‘faculty development workforce’. I explored their sense making, talked to them about their faculty development practices, and the types of theoretical and biographical tools they drew upon in their work. In so doing I was able to trace a range of responses to the call to professionalise. For some there was a ‘conforming’ response, meeting the regulators requirement to ensure that all trainers were trained. Typical methods involved short, central workshops, across all specialties, covering key aspects of educational supervision practice. Others were a little more creative in their response (which I label as a ‘reforming’ response). They worked with doctors in a range of ways, always seeking to offer/elicit a medical context to their work, working with teams on site, offering up teaching observation type activity, so individual doctors had a chance to review existing educational practices and adapt them in light of new requirements. The third ‘transforming’ response involved a radical re-thinking of training practices. Here colleagues came together to explore what was working on the ground but also where the difficulties lay. They adopted and generated new forms of faculty development practices including team observations, faculty groups and  joint development activity between trainers and trainees to find solutions to the problems being encountered post reform.

So, how does this relate to the initial query i.e.  how the issue of agency is dealt with in activity theory? In activity theory the world is understood as partially conceptualized, the world acts on us but we also act upon the world. In finding themselves positioned to act in a particular way (to professionalise medical education through faculty development), the doctors and educators I spoke to chose to respond in a range of ways. They showed agency. This agency was influenced by the biographical and theoretical tools they had to draw upon, and the extent to which they were willing to go with, or against, the grain of reform.

Simulation, orthodoxy and doctrine...

Over the past year or so, I have been involved in a range of faculty development activity for medical and healthcare educators using simulation in Higher Education and NHS contexts. The emphasis of my work has been on enhancing the educational value of simulation, shifting the gaze from technical and clinical aspects. In doing this, I have found myself grappling with what I can only call simulation ‘orthodoxy’… my observations on the 'simulation doctrine' follow.

Simulation improves patient safety.

It seems to me that many of the claims about simulation are based on assumptions of transfer, from one context to another. For example, we note that simulation has improved safety in the aviation industry and assume it will do the same in medicine. We see that performance is enhanced in simulation and assume that this enhanced performance will readily transfer to the workplace. Yet we know that transfer is a problematic concept in education generally, and medical education specifically. Studies of transition to greater levels of medical responsibility, for example, show dips in performance in new jobs, because transfer from one context, setting or team to another is not a straightforward process.  How sure are we really that simulation achieves all that is claimed in its name?

Fidelity matters.

Beware the seductive appeal of new technologies...fidelity does not appear to be a significant determiner of the learning experienced. Can I suggest we start a dialogue about authenticity, which I suspect is more important? By authenticity, I mean the extent to which participants are able to engage in a simulation experience that feels meaningful, congruent and close to their lived experiences of working in clinical teams, in clinical contexts. Which brings me on to the next point…

Role-play is accepted as a proxy for actual performance

Too often in simulation we bring together a group of learners, all at the same stage in training, typically all within the same professional grouping, and give them parts to play. We ask a group of FY1s to ‘play’ the registrar, the nurse, the consultant and so on. In so doing, we ask them to play out their understandings of ways of being, thinking and acting…fine, if the goal is to work with their stereotypes! If simulation is to be meaningful, I think we need to stop thinking about role play, and move into role-rehearsal. We need to give opportunities to rehearse the types of work activity that are at the level of expectation (or just beyond) the learners point in development. We need to construct scenarios that seek authenticity in terms of roles, responsibilities and contexts. 

We are missing a real opportunity to bring ‘real’ teams into the simulated space, to run through scenarios they have already experienced, to consider different ways of being and acting in order to improve practice. Simulation is used in ways that are anticipatory of future action, why not use them to re-think the past? Which leads us to consider the types of learning experience we offer in simulation.

All simulated scenarios involve ‘surprises’ and ‘challenges’

From observation and discussion, it appears to me that the typical simulated scenario involves a moment (or several) of surprise, placing the learner in a position of uncertainty and challenge. Typically I witness a short briefing, a scenario that plays out to the agreed conclusion, with faculty observing and intervening only to lead the debrief. This is, of course, a perfectly legitimate use of simulation, if the intended learning outcome is to develop approaches to dealing with uncertainty /acute clinical situations. I fear this downplays much of the learning value of simulation.

• How would it be if we used simulation to explore a range of responses to more typical situations? 
• How would it be if we involved learners in choosing or shaping the scenario, so they could rehearse situations they are daunted by? 
• How would it be if in the briefing, we gave an account of what was going to be encountered, and talk through possible ways of responding before the scenario? 
• How would it be if faculty came alongside the learner, with an option on both sides to ‘freeze’ the scenario, to discuss possible options for action before moving on? 

Such variations would allow us to maximize the learning value of simulation.

Debrief and feedback are inter-changeable

In the past 6 months I have asked faculty to provide me with a simple definition of each of these terms and an account of the pedagogic strategies they use for each. The answers suggest that distinctions are unclear and that strategies merge into each other. The simulation literatures aren’t that helpful in this regards either! I do think they serve different purposes and require different actions as result. My working distinctions are as follows…

Feedback, is for me at least, a developmental conversation. This conversation (dialogue, not monologue) builds upon what is known (or shared) about performance, as a basis for moving forward. Whilst group feedback is possible (if the performance of the whole group is the focus), feedback is typically about the development of an individual. So, after a simulation session, this would mean finding time to talk to the individual about their performance and what they might do to develop their practice in light of that. With their consent, this might be ‘in the round’, so that peers might offer suggestions and benefit from listening in to tutor guidance. It is not ‘a given’ that an individual’s performance in the simulated scenario is open for discussion in the group (no more than it would be on a ward round, for example).

The term debrief has military origins – according to one on-line dictionary, to debrief means to question someone (typically a soldier or spy) about a completed mission or undertaking. The soldier provides a vivid account of what s/he has experienced (sight, sound, smell, sense). The purpose of the debrief, in this case, is for the unit to gain inside information, and, together, to consider next steps for action. 

Translating this into medical simulation, the debrief is a pedagogic strategy where  the lived experience of one team member is offered up to the whole group as a shared resources for learning. By inviting the learner to provide a narrative account, which includes affective responses to their experience of simulation, they are offering a gift to the group. Together they analyse ways of responding. Together they seek to make connections between the simulated experience and those experienced in vivo. Together they identify the learning arising from the scenario that they each can benefit from. This kind of debrief would be particularly powerful when bringing teams in to analyse existing practices and try out new ways of working to enhance patient care.

Simulation has the potential to be a powerful educational tool, if seen as that, a tool that supports learning of individuals (hence feedback) and development of teams and practice (hence debrief). It is time to take a critical stance to simulation and consider how it might make a meaningful, authentic contribution to developing patient care.

Lost in translation? Postgraduate Medical Training Curricula

In a previous blog on WPBA, I observed there has been a culture shift in postgraduate medical education, from that of a time-served apprenticeship, to one of time-measured training. This observation arises from my doctoral research part of which involved an analysis of 20 years of policy relating to the training of doctors. I was interested in tracing the ways in which NHS and postgraduate training reform had ‘dismantled’ medical apprenticeship. My analysis led me to observe a gradual decoupling of ‘working’ and ‘training’. at least conceptually. To explain…

Historically, in a time-served apprenticeship, work was the curriculum for medical training; through engaging in increasingly complex work activity doctors made transitions to greater levels of responsibility. Supported by their ‘firms’, to greater or lesser extent, transitions were made on the basis of readiness to progress, in the eyes of those closest to their work activity. There are close parallels here with Lave and Wenger’s (1991) accounts of communities of practice, where newcomers to a community are invited to engage in the shared work of the communities they join. The goal of training, in this case, is full participation in the work of the community.  

In more recent years, we have witnessed the move to a national curriculum for postgraduate training, expressed in terms of competences to be acquired, or outcomes to be evidenced. The modernized time-measured curriculum for medical education stipulates much more closely the anticipated length of time for each stage of training; those who do not progress at a predetermined point are at risk of being seen as ‘failing’. The tension here of course, is that certain posts may afford greater opportunities to learn than others, simply in terms of the scope and amount of ‘suitable’ work available. Failure to progress may be a failure of the workplace to support the development of the trainee. The ultimate goal of any stage of training is expressed here in terms of ‘sign off’; doctors in training have demonstrated the acquisition of pre-determined outcomes, competences, knowledge, skill or attitudes, however these are expressed. Those familiar with Sfard’s (1998) account of two metaphors for learning might see time-served apprenticeship in terms of ‘learning-as-participation’ and time-measured training as ‘learning-as-acquisition’.

Does this distinction matter, other than conceptually? I think it does. I believe that the postgraduate medical training curriculum introduced over the past 5 or 6 years got ‘lost in translation’. Ultimately, doctors, whatever stage they are in their career, learn through working: work is the curriculum. The challenge is ensuring that the amount, range and complexity of work activity undertaken is both within the trainee’s capability and stretches them to be more capable. One way to do that is to develop a curriculum map, that captures where they have been, where they are going and where they might go next. In this way, it is possible to make explicit and surface up the learning that arises while working and to make adjustments, where needed, to offer a richer learning journey (to keep the mapping metaphor going). The map does not need to be too prescriptive; there are, after all, many possible routes to the same destination. Some trainers have a natural sense of direction, have walked the journey with trainees on many occasions and only need check in, from time to time, to make sure they are both still on track. Others may prefer to plan the itinerary much more tightly, checking in on a regular basis that all is going according to plan. This kind of mapping process, overlaid on the workplace, had real potential to guide training. Unfortunately, the associated mechanics of the new curriculum models, workplace based assessments, compulsory ‘reflections’, log books, portfolios etc got in the way. These new ‘souvenirs’ from the journey too readily became the journey. 'Trainer-trainee' relationships became enacted through these tools of curriculum engagement. The training curriculum moved from being the trainees work, to additional work for the doctor in training.

So where next for postgraduate medical education? I take some comfort in the revised foundation curriculum, although I believe it has some way to go.

The move away from competences is encouraging, although the scuttle back to the security of outcomes statements is, for me at least, a missed opportunity. I think the discourse around EPAs (entrustable professional activities) is worth extending. It is much more meaningful to think in terms of what you are confident in delegating to a more junior colleague, than relying on the competences they have once demonstrated.

The move away from workplace based assessments to supervised learning events, conceptually at least, is also promising. The value of having a more knowledgeable other (in Vygotsky’s terms) observing your work and engaging in a meaningful dialogue about it has rich learning potential. I am not sure we need the forms to evidence these conversations have happened, but that is a topic for another blog perhaps.

Finally, the new curriculum revives 'the firm', placing much more emphasis on the professional wisdom of clinical supervisors, educational supervisors and the clinical team in terms of guidance, support and decisions about readiness to progress.