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Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers, Incorporated,
Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers, Incorporated,
EDUCATION IN A COMPETITIVE AND GLOBALIZING WORLD
Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.
MEDICAL EDUCATION: THE STATE OF THE ART
No part of this digital document may be reproduced, stored in a retrieval system or transmitted in any form or by any means. The publisher has taken reasonable care in the preparation of this digital document, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained herein. This digital document is sold with the clear understanding that the publisher is not engaged in Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of theservices. Art : The State of the Art, Nova Science Publishers, rendering legal, medical or any other professional
EDUCATION IN A COMPETITIVE AND GLOBALIZING WORLD Additional books in this series can be found on Nova‘s website under the Series tab.
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Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
EDUCATION IN A COMPETITIVE AND GLOBALIZING WORLD
MEDICAL EDUCATION THE STATE OF THE ART
ROSSANA SALERNO-KENNEDY
Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.
AND
SIÚN O’FLYNN EDITORS
Nova
Nova Science Publishers, Inc. New York Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
Copyright © 2010 by Nova Science Publishers, Inc.
All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. For permission to use material from this book please contact us: Telephone 631-231-7269; Fax 631-231-8175 Web Site: http://www.novapublishers.com NOTICE TO THE READER The Publisher has taken reasonable care in the preparation of this book, but makes no expressed or implied warranty of any kind and assumes no responsibility for any errors or omissions. No liability is assumed for incidental or consequential damages in connection with or arising out of information contained in this book. The Publisher shall not be liable for any special, consequential, or exemplary damages resulting, in whole or in part, from the readers‘ use of, or reliance upon, this material.
Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.
Independent verification should be sought for any data, advice or recommendations contained in this book. In addition, no responsibility is assumed by the publisher for any injury and/or damage to persons or property arising from any methods, products, instructions, ideas or otherwise contained in this publication. This publication is designed to provide accurate and authoritative information with regard to the subject matter covered herein. It is sold with the clear understanding that the Publisher is not engaged in rendering legal or any other professional services. If legal or any other expert assistance is required, the services of a competent person should be sought. FROM A DECLARATION OF PARTICIPANTS JOINTLY ADOPTED BY A COMMITTEE OF THE AMERICAN BAR ASSOCIATION AND A COMMITTEE OF PUBLISHERS. LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA Medical education : the state of the art / [edited by] Rossana Salerno-Kennedy and Siún O'Flynn. p. ; cm. Includes bibliographical references and index. ISBN H%RRN 1. Medical education. I. Salerno-Kennedy, Rossana. II. O'Flynn, Siún, 1969[DNLM: 1. Education, Medical--methods--United States. 2. Learning--United States. 3. Teaching--methods--United States. W 18 M4878 2009] R735.A6.M43 2009 610.71'173--dc22 2009030341
Published by Nova Science Publishers, Inc. New York
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
CONTENTS Preface
vii
About the Editors
ix
Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.
Chapter 1
The Virtual Learning Enviroment in Medical Education – Past, Present and Future Ronald M. Harden
Chapter 2
Theory in Medical Education David Kaufman
Chapter 3
Entry and Selection to Medical School – Do We Know What We Should Measure and How We Should Measure It? Siún O‘Flynn
1 11
19
Chapter 4
Learning and Teaching in Different Clinical Environments John Spencer
31
Chapter 5
Interprofessional Education Marilyn Hammick
47
Chapter 6
Developing Clinical Teachers Peter Cantillon
57
Chapter 7
Teaching Clinical and Communication Skills and Giving Effective Feedback Simon Edgar and Iain Lamb
69
Chapter 8
Small Group Learning: Problem-based-Learning Approach Rossana Salerno-Kennedy
81
Chapter 9
Assessment Strategies in Medical Education Kevin W. Eva
93
Chapter 10
The Role of Portfolios in Teaching and Assessing Professionalism Martina Kelly
107
Chapter 11
Cultural Competence in Medical Education Patrick Henn
121
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
vi
Contents
Chapter 12
Student Choice in Medical Education Geraldine Boylan and Áine Hyland
Chapter 13
From Dry Ice to Plutarch‘s Fire – The Integration of Research and Teaching and Learning Marian McCarthy, Bettie Higgs, Jennifer Murphy and Grace Neville
131
139
149
Index
153
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Contributor List
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.
PREFACE Drs Salerno-Kennedy and O‘Flynn have approached a topic that is of fundamental importance to the practice of medicine. Their textbook Medical Education: the State of the Art addresses the topics that are central to the provision of medical education. They have brought together a group of experts who present a state-of-the- art review on a broad, and comprehensive, range of topics. These cover issues that have a broad application to all students, and also for the specific challenges that relate to medical education. Importantly they have collected a group of experts from within, and from outside their home institution, the Medical School at University College Cork. Thus, in addition to providing a comprehensive review of contemporary principles of medical education, they provide a practical basis demonstrating how these principles have been applied in the comprehensive process of curricular reform at a single institution. The depth and the breadth of topics covered in their book are a reflection of their consideration of the key concepts that influence the thinking behind delivery of the medical curriculum. They and their authors are to be congratulated on the quality of their contributions. The medical students of today will be the medical professionals of tomorrow. Medical Schools have a responsibility to provide a broad ranging currriculum that prepares their graduates, at both an individual level, and at a community level, to provide quality health care services, and to develop quality health care policies. The practice of medicine, and thus by necessity medical education, is evolving at a rapid pace. It is also important to recognise that it is impossible to develop a curriculum that can teach the medical students everything that they may need to know for the duration of their medical careers. Accordingly medical education focuses on providing students with the necessary knowledge, skills and attitudes to attain a central core of knowledge. A large focus of medical education, as discussed in this book, lies on the application of contemporary pedagogic principles to the specific challenges, and opportunities, that apply in medical education. Medical education has evolved from an historically passive to a more active involvement of students in learning. Such an approach is also more demanding on resources. Reviews, such as those presented in Medical Education: State of the Art provide a rational, and evidence based foundation for these approaches. Although the practice of medical education begins once the students enter medical school, it should not be forgotten that the process of selection of medical students will inevitably influence the outcome. The academic, and non-academic, factors that are applied in entry and selection are currently under review in a variety of jurisdictions. An analysis of the
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.
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Rossana Salerno-Kennedy and Siún O‘Flynn
background behind such changes, and an assessment of their consequences is central if the future of medical education is to attract the best possible students and future clinicians. In the course of their careers as medical students it is important that they are provided with an environment that prepares them for the multidisciplinary environment in which they will practice. In the contemporary practice of medicine being professional means being interprofessional. In addition to exposing the students to a contemporary curriculum, it is also important to prepare them for a process of life-long learning that benefits from - maintenance and improvement through a process of regular reflection and the maintenance of a learning portfolio. The challenge of ensuring that clinical teaching is valuable, enjoyable and exciting rather than alien and hostile is explored and that the realisation of the potential of this educational experience is discussed. Modern approaches to clinical training include the use of an early clinical experience leading to with improvements in self awareness and the development of empathic attitudes.These help to motivate the student with a resultant enhancement in confidence and satisfation. Such experiences appear to reduce the stress during subsequent transition to the clinical environment. It is also of importance that medical schools engage in a process of teacher development, with a particular focus on the specific needs of clinical educators. Ultimately the goals of medical educators are to graduate reflective practitioners who provide health care for patients that present with an increased diversity in terms of their cultural, religious and racial backgrounds. It is vital that we arm our students with the appropriate competence to reduce health disparities betwen the ethnic minorities and the remainder of the population. Drs Salerno-Kennedy and O‘Flynn have provided a synthesis of information that ultimately will help all of us in our ambitions to help our students in their identification of what, when, where and how to learn. This will assist us in providing an environment that supports personalized adaptive learning. Ultimately this will translate into the optimal education of tomorrow‘s doctors.
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
ABOUT THE EDITORS
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Dr. Rossana Salerno-Kennedy was awarded the degree in Medicine and Surgery in 1989 and the Higher Specialist Training Degree in Endocrinology and Metabolism in 1995 by the University of Modena (Italy). She was appointed Consultant Physician in Endocrinology and Metabolism at a regional hospital near Milan and worked in public and private practice until she moved to Ireland. She earned a Doctorate in Medicine (MD) from the National University of Ireland (NUI), for work on the relationship between Nutrition and Dementia. She was awarded a Certificate and Diploma in Teaching & Learning in Higher Education by University College Cork. She has run clinical trials and has published papers, book chapters and a book on topics in endocrinology, metabolism and clinical nutrition. More recently, she has led projects in medical education and has received awards for research into innovative forms of teaching. Dr. Salerno-Kennedy is currently Senior Clinical Lecturer and Head of Clinical Skills at the Centre for Medical and Healthcare Education, St. George's University of London. Contact details: Dr. Rossana Kennedy, MD Senior Clinical Lecturer - Head of Clinical Skills Centre for Medical and Healthcare Education St. George's University of London Cranmer Terrace London, SW17 0RE Email: [email protected] Dr. Siún O‟Flynn was awarded the MB BCh BAO degree in Medicine in University College Cork Ireland in 1994 and spent a number of years in higher specialist training and working in clinical medicine before expanding her role in medical education. This coincided with a period of unprecedented change in medical education in Ireland and she has been very involved in the introduction of a new curriculum in UCC which commenced in October 2005. Dr. O` Flynn is currently the Head of Medical Education in the School of Medicine at University College Cork where she works closely with staff throughout the school to oversee teaching, assessment, curriculum mapping and course evaluation in all medical programmes and ensures that these are informed by evidence-based best practice and also meet the requirements of national and international accreditation bodies. Dr O`Flynn is one of
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the founding members and President of the Irish Network of Medical Educators (INMED) and also sits on the steering group of the International Virtual Medical School (IVIMEDS) and Universities Medical Assessment Partnership (UMAP), as well as being a council member of Association for the Study of Medical Education (ASME).
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Contact details: Dr. Siún O' Flynn, Head of Medical Education, School of Medicine, Brookfield Health Sciences Complex, University College Cork, Ireland. e-mail: [email protected]
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
In: Medical Education: The State of the Art Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 1-10
ISBN: 978-1-60876-194-4 © 2010 Nova Science Publishers, Inc.
Chapter 1
THE VIRTUAL LEARNING ENVIROMENT IN MEDICAL EDUCATION – PAST, PRESENT AND FUTURE Ronald M. Harden
Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved.
ABSTRACT E-learning blended with face-to-face experiences, is now part of the mainstream and plays an increasingly important role in medical education. A virtual learning environment (VLE) provides a framework or infrastructure where learning resources are available and where student activities take place. Functions of a VLE include student management and administration, student support, the provision of a map of the curriculum, delivery of content, access to e-books and journals, collaborative learning, an e-portfolio and assessment. To date, the emphasis has been on the technology of a VLE rather than on the pedagogy. More attention should be paid to the VLE from an educational perspective. Future developments are likely to include personalised adaptive learning customised to the needs of the individual student, a greater emphasis on peer-assisted and collaborative learning, ‗on-the-job‘ and immersive learning in environments such as Second Life and transnational learning as part of a more global approach to medical education.
INTRODUCTION The application to medical education of new learning technologies has developed significantly from the early beginnings. In the period 1960 to 1965, the use of computers was confined to main frame systems and the aim was to develop machines through which the learning instruction process could be supported (Simons and de Laat 2006). Micro-computers became available in the period 1975-1990 and the teaching machines developed into what became known as ‗Computer Assisted Learning (CAL)‘ with more advanced computer-based programs to support the students‘ learning. From 1990, email and the internet entered the field and computer-assisted instruction became web-based instruction and e-learning became part of the main stream of medical education.
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
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Ronald M. Harden
―Web and internet technologies are transforming our world‖, argued Horton (2001, p1), ―presenting opportunities we could only imagine a few years ago. Nowhere are these opportunities greater than in training and education…‖ It became possible to complete a course of studies online and to receive a degree as a result. Oblinger (2001) predicted a major growth in e-learning and the emergence of global consortia leading to the creation of one or more global virtual universities. An International Virtual Medical School (IVIMEDS), with an education programme embodying a hybrid model of a blended curriculum of innovative elearning approaches and the best of traditional face-to-face teaching, was proposed as a response to these challenges (Harden and Hart 2002). While predictions in the early 2000s of the rapid growth and perhaps domination of elearning may have been too optimistic, what is certain today is that each new cohort of students is being educated in a context where an increasing amount of their time is spent online in a virtual learning environment (VLE). In this development the distinction between online learning and face-to-face learning has become blurred, with education programmes combining or ‗blending‘ face-to-face with online experiences. There is a common misunderstanding, as pointed out by McKendree (2006), that the adoption of a VLE implies that the course is one where the learner is at a location geographically distant from the tutors and does not meet with them face-to-face. VLEs are in fact much more commonly used as one aspect of a course in which students meet regularly with tutors and other students, sometimes in an otherwise relatively traditional course.
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THE CONCEPT OF A LEARNING ENVIRONMENT The learning environment in a traditional educational setting is made up of physical features such as the lecture theatre, tutorial rooms, libraries and audiovisual facilities, together with the channels of communication between the teachers, students and administrators. Students‘ experience and perceptions of this learning environment affect their achievements, their satisfaction and their success (Genn 2001). The characteristics of a learning environment and its measurement have attracted attention in recent years (Roff and McAleer 2001). Is the learning environment competitive or does it encourage collaboration and team work? Is the atmosphere in classes relaxed or is it in various ways stressful, perhaps even intimidating? The learning environment in an e-learning setting is of no less importance. A VLE is essential to provide for a student, a setting in which they can share in a useful learning experience. The VLE provides the framework or infrastructure where learning resource materials can be located and where student activities can take place. It provides the student with the content and resources required to make the activities successful. The term ‗managed learning environment‘ has been used where a greater emphasis is placed on management issues such as enrolment, student records and course option management. The concepts of a ‗VLE‘ and a ‗managed learning environment‘, however, have moved closer together and for practical purposes can be regarded as similar facilities. Initially the VLE was seen as emulating the attributes of a traditional classroom, and was designed to provide the student with the learning resources appropriate for their course. ‗Content is key‘ characterised the philosophy. The VLE supported the students‘ learning without changing the basic approach to teaching. As VLEs evolved the emphasis moved from
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
The Virtual Learning Enviroment in Medical Education
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the provision of content towards guiding and managing the students‘ learning and providing the student with study guides and assessment tools. Today a further significant change in the learning environment can be seen with greater emphasis on a more student-centred and community-centred approach with an emphasis on networking and collaborative learning. Some VLE applications such as Blackboard and Angel, are commercial platforms. Others, such as Moodle, are open source and have been designed to support a social networking framework for education. Some universities, particularly in the field of medicine, have developed their own VLE. Available learning environments vary greatly in their size and what they can offer. Experience has shown that schools look for different things in a VLE and use a VLE in different ways depending on their own needs. International standards organisations such as Medbiquitous (www.medbiquitous.org) have been concerned with the development and promotion of standards for learning content and virtual learning environments in order to promote the exchange of learning resources between different learning environments.
ACTIVITIES WITHIN A VLE
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A VLE can facilitate and manage a range of student activities and content creation. Some of the key functions are described below. Management/administration An early element incorporated into a VLE application was support for the administration and management of student activities. This included the enrolment of students, the allocation of students to groups, the provision of a course syllabus, the provision of a timetable of activities, tracking students‘ progress and the provision of examination results. Online student support The VLE can serve as an important source of student support. Information can be provided about a student‘s tutor or mentor, the assistance offered by the mentor and how he or she can be contacted. Information can also be provided about available technical support in case the student at some time requires technical assistance. Content experts may be identified who are willing to respond to questions the student has about the subject and information is provided as to how and when they can be contacted. An important element in a VLE is an online student study guide, designed to facilitate student progress through the course and to advise them about what they should be learning at any one point in time and about how they can make best use of the learning opportunities available. Students may be advised how they can assess their own progress and achievement of the expected learning outcomes, and based on this assessment, how they can remedy any gaps in their knowledge or understanding diagnosed. Curriculum map A curriculum is a sophisticated blend of educational experiences, assessment, and the individual students‘ personal timetable and programme of work. Curriculum mapping can help both staff and students by displaying these key elements of the
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Ronald M. Harden curriculum and the relationships between them (Harden 2001). Students can identify what, when, where and how they can learn. Staff can be clear about their role in the big picture. The scope and sequence of student learning is made explicit, links with assessment are clarified and curriculum planning becomes more effective and efficient. In this way the curriculum is more transparent to all the stakeholders including the teachers, the students, the curriculum developer, the manager, the public and the researcher. It follows that a curriculum map embedded in a VLE offers many advantages. Some VLEs are more suited to this than others. While a valuable function, curriculum mapping is probably at present the least developed of VLE applications but with time this may change. Delivery of content A common feature of VLEs in the early days was the posting of PowerPoint slides or notes relating to a lecture together with prescribed reading lists. An advantage of the approach was that the resources were in colour and included animation. The resources, collected together at one site, were easily accessed by students and related to the course studied. Ease of updating resources was a further advantage. A development in content delivery was the concept of reusable learning objects small discreet self-contained chunks of learning, stored in a learning repository or bank, readily accessed by students and teacher and capable of being aggregated into larger learning programmes. Hodgins (2005) used the analogy of Lego where small pieces of instruction (Lego blocks) are assembled (stacked together) into a larger instructional structure (e.g. castle) and reused in other instructional structures (e.g. spaceships). With the application of metadata to the learning objects and the adoption of a standards approach, a learning environment was created where resources could be shared and the same objects used by different teachers in different ways in a range of learning contexts. The content available online could also be assembled as a package or course covering a small or large part of the curriculum. Such courses could include resources created by a local teacher or they could incorporate material from other academic sources using a repository such as MedEdPortal. In addition content could be accessed from commercial publishers who are increasingly providing material that can be integrated into a VLE. Such courses incorporate a built in navigation system that takes the student to the next or previous pages or to a particular section of the course as appropriate. The course pages themselves usually include all the features of a standard web page including audio and video plugs and links to other websites. Lectures may be made available online synchronously or asynchronously, or by podcasting where audio-video material is downloaded while the listener is logged onto the internet or stored for use later. E-books and journals The equivalent in the VLE of a library in a traditional medical school is the provision of access to e-books and journals made available by publishers online. This has the potential of providing students with a huge amount of information not previously accessible by them.
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
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The Virtual Learning Enviroment in Medical Education
5
Collaborative learning With students working increasingly online, concern was expressed initially about the ‗lonely learner‘ studying on their own with little or no contact with his or her colleagues and with a feeling of insecurity and isolation. It has been demonstrated, however, that students in a virtual class spend more of their time working with each other than students in a traditional classroom. Indeed the virtual learning environment offers advantages compared to the traditional environment. The VLE can seem less intimidating with students freer and less inhibited in expressing their opinion and more willing to engage in discussion and participate in group activities. Today there is a move away from thinking of the VLE simply as a means of making available to the student readily accessible content or course material. A greater emphasis is being placed on the social dimension and social networking made possible by online learning. The creation of the sense of community makes possible a powerful means of academic interaction with online communities of learners providing each other with support and sharing their experience and learning. The use of email allows one-to-one messages between individual students and between a student and a course tutor. Asynchronous threaded discussion forums have proved increasing popular online. These allow students and teachers to log in at any time, read contributions by others and make their own response. The forums may be monitored and facilitated by tutors, and may be linked to a particular part of the course. Synchronous communication or chat allows real time communication between course participants. E-portfolios E-portfolios are being used increasingly in medicine as a learning and assessment tool (Driessen 2009). Portfolios encourage students to document and reflect on their learning and to achieve higher level outcomes. Experience has demonstrated the benefits of students keeping online portfolios (e-portfolios) and their use is expanding rapidly both for teaching and assessment purposes. Assessment Online learning and VLEs have important implications for assessment. VLEs can help to blend assessment and teaching to create a rich learning experience. Pedro Paulo Popovic, Secretary for Education at a Distance in Brazil, is reported as stating ―Investing in e-learning while retaining existing assessment frameworks, is like expecting mangoes from a banana tree‖. Assessment can be embedded in the VLE and may be formative or summative (Dennick et al 2009). Approaches to assessment will vary with the online learning architecture adopted. In a directive learning approach, as found in many online courses, multiple choice or constructed response questions are embedded in the instruction and can also be used as a pre- or post-test. In problem-based learning, the assessment is related to the virtual patients presented. In an exploratory or discovery learning model using a curriculum map, assessment may be related to nodes on the map. In work-based learning, opportunities are provided for ‗just-in-time‘ assessment. A collaborative learning architecture may include peer assessment.
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Ronald M. Harden
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THE EDUCATIONAL IMPLICATIONS Much of the discussion and work related to VLEs has been concerned with the technology and the educational issues have been relatively neglected. The improvement of student learning, however, has more to do with the pedagogical assumptions than with the technology. Rosenberg (2001) warned that ―Ignoring the tenets of instructional and information design amidst fervor over technology usually results in lots of Web wizardry that often doesn‘t teach anything of value. This can be a costly lesson.‖ The use of VLEs poses important educational issues for universities, argued Stiles (2000). ―Without addressing the issues of effective learning, their use (VLEs) can compound the mistakes of the past and leave the learner with a passive, unengaging experience leading to surface learning. Educators need to recognise that learning is a social process and that providing an effective learning environment which facilitates the active acquisition of subject-specific and general expertise, and addresses the need to adopt a specific subject or professional culture, requires more than electronically delivered course notes and email discussion. Quality of course design, use of appropriate tools and the context in which learning takes place are prime factors affecting success in the era of mass higher education and lifelong learning‖. A VLE is often equated with an e-learning platform and the related software applications. Less emphasis has been given to the concept of a powerful learning environment where the emphasis is on the student learning according to educational psychology and theory. One reason why large investments in technology-based initiatives in education have had, in the past, disappointing results has been an over-emphasis on the technology or computer aspects of the development at the expense of the educational issues. In the evaluation of the UK Teaching and Learning Technology Programme (TLTP) it was noted that ―where we saw inspirational materials, we found that they had often emerged from a synthesis of computing, subject discipline and educational expertise. The presence of these three elements seemed to be a precondition for the production of materials that we could recognise as excellent‖ (Coopers & Lybrand, 1996). It is important that the technology is seen as a means of achieving the educational goals rather than being an end in itself. Fortunately we are now seeing a congruence of the technology and education approaches, moving the learning environment to a rich, multimedia collaborative and individualised learning experience for the student. Within such learning environments specific instructional design measures can be taken to foster learning (de Jong 2005). Educational strategies that should be incorporated into a learning environment include Activity There is a need to engage the learners with the programme and to encourage them to reflect and build on their prior knowledge. It is important that activity is meaningful activity, not just concerned with the mechanical dimensions of the programme and with the navigation from one section or frame to another. Relevance Learning should be authentic learning and situated in a practice context. Individualised Learning Learning should be personalised or customised to the needs of the individual student.
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The Virtual Learning Enviroment in Medical Education
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Feedback Feedback should be provided to the students as they progress and master the learning outcomes. Collaborative Learning Opportunities should be provided to learn with and through their peers.
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THE FUTURE It is always difficult to make predictions about the future, and looking to the future of learning technologies and virtual learning environments is no exception. History has shown that short-term predictions are usually over-optimistic while longer term prophesies are in general too pessimistic. What we can predict with some certainty is that increasing use will be made of virtual learning environments supported by increasingly more powerful technology. According to Moore‘s Law, every eighteen months the processing power of computers doubles while costs remain constant. Kurzweil‘s Law goes further and states that the rate of change is actually accelerating instead of doubling at a constant rate. Kurzweil concluded that because of the explosive power of exponential growth, the 21st century will be equivalent to 20,000 years of progress at today‘s rate of progress, which is a thousand times greater than the 20th century. In medicine, e-learning can enhance the curriculum and help to address problems and challenges currently facing medical educators. It has to be questioned however whether the future development of VLEs will be simply to allow us to do better and more cost effectively what we are already doing or whether we recognise that online learning makes possible an expanded vision of education in the 21st century (Harden 2008). It is to be hoped that we do not see e-learning as simply applying new technologies to supporting existing approaches to teaching and that we are more ambitious and, with a new mind set, create a VLE that makes possible a new paradigm for the training of healthcare professionals. A future VLE is likely to support: An adaptive curriculum In our current approach to teaching, students must adapt to the curriculum that is offered. This process should be reversed so that it is the system that conforms to the learner rather than the learner to the system. We can move forward to achieve the goal of an adaptive curriculum by harnessing the potential of e-learning and the creation of diverse learning environments individualised to the needs of each student with learner focused forms of assessment and feedback integrated within the learning opportunities. Related to this idea of an adaptive curriculum is the concept of ‗just in time‘ learning with the learning opportunities available to the student at a time when they are required. The future is likely to see learning environments in which each learner has a personalised learning system that responds to their individual needs in terms of their prior knowledge, learning ability, learning styles and aspirations. Collaborative learning We have introduced earlier the move to collaborative learning. Without doubt this trend will develop further and will be integral to the education process facilitated
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Ronald M. Harden within a VLE. A community of learners will be an essential core element of the educational experience in medicine. Transnational education The VLE of the future will reflect the opportunity to learn in a global context with a transnational approach in which internationalisation is integrated and embedded with the curriculum. This will involve collaboration between a number of schools in different countries, with the study of medicine exemplified in the global context rather than the context of a single country. Immersive learning and Second Life Richly visual, immersive three dimension simulations offer valuable learning experiences (Cobb and Fraser 2005) and will in the future contribute significantly to students‘ learning (Brown 2008). The use of immersive virtual worlds such as Second Life for educational purposes will almost certainly be a reality in the not so distant future. Applications such as Second Life, offering access to a threedimensional virtual environment for learning, provides the possibility for movements in 3D space, role-playing and alternative means of online interaction. Such an immersive environment allows students to experience scenarios from another person‘s perspective. In the UC Davis virtual hallucinations Second Life programme, for example, visitors experience virtually hallucinations that patients suffering from schizophrenia might experience.
CONCLUSION
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While many uncertainties about the role of e-learning and virtual learning environments remain, we can draw a number of conclusions. 1. Online learning will play an increasing role in helping medical education to meet the daunting challenges faced in the years ahead - challenges from changes in medicine and healthcare delivery, changes in the role of the doctor and changes in patient demands and expectations. 2. In both traditional and innovative schools, a blended learning environment will be the norm with students working in a virtual learning environment and in an environment with a physical presence. 3. Virtual learning environments will continue to offer a range of functionality and activities. While student management and content provision will remain as key features, there will be a shift of emphasis to more student-centred collaborative learning approaches. The VLE will help to integrate more closely teaching and assessment. 4. If we are sufficiently adventurous, the future will see a paradigm shift in medical education facilitated by a learning environment that supports personalised adaptive learning, ‗on-the-job‘ virtual learning and immersive learning in environments such as Second Life, peer-assisted and collaborative learning, and a transnational or global approach to medical education.
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Finally, thinking about virtual learning environments and the future should not be for medical educators a spectator sport. As Hodgins (2005) argues, ―This future is ours for the choosing if we can muster the courage to ignite the transformation from vision to reality by simply imagining that this bright future is now possible and begin shaping its design and implementation. The trick is that it will take all of us to imagine, design and build it. If you can imagine this previously impossible dream now, you are already part of the solution.‖
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REFERENCES Adkins, SS. Learning in the Bright Air: The Learning Technology Trends of 2015, in Masie E, Editor. Learning Rants, Raves and Reflections. San Francisco. Pfeiffer 2003; p209. Brown, JS. Creating a Culture of Learning, in Opening Up Education, The Collective Advancement of Education through Open Technology, Open Content, and Open Knowledge. Cambridge: The MIT Press; 2008. Cobb, S. Fraser, DS. Multimedia Learning in Virtual Reality. In Mayer, RE. Editor. The Cambridge Handbook of Multimedia Learning. Cambridge; Cambridge Press 2005; 525. Coopers & Lybrand, Institute of Education and the Tavistock Institute (1996) Evaluation of the Teaching & Learning Technology Programme. De Jong, T. Engaging in learning: Designing learning environments that are really used. In: Verschaffel L. de Corte, E. Kanselarr, G. Valcke, M. editors. Powerful environments for promoting deep conceptual and strategic learning. Leuven: Leuven University Press; 2005. Dennick et Al (2009) Medical Teacher. In press. Driessen, E. (2009) Portfolio Critics: do they have a point? Medical Teacher, In Press. Genn, JM. (2001) AMEE Medical Education Guide No.23 (Part 1): Curriculum, environment, climate, quality and change in medical education – a unifying perspective. Medical Teacher 23 (4) 337-344. Harden, RM. (2001) AMEE Guide No.21: Curriculum mapping: a tool for transparent and authentic teaching and learning. Medical Teacher 23 (2) 123-137. Harden, RM. (2008) E-learning – Caged bird or soaring eagle? Medical Teacher 30(1) 1-4. Harden, RM. Hart, IR. (2002) An international virtual medical school (IVIMEDS): the future for medical education? Medical Teacher 24(3) 261-267. Hodgins, W. Into the Future of me Learning: Every*One*Learning… Imagine if the impossible Isn‘t! In: Masie E, Editor. Learning Rants, Raves and Reflections. San Francisco; Pfeiffer 2003; p243. Horton, W. (2001) Leading e-Learning. Alexandria, VA, ASTD, pp.1. McKendree, J. (2006). eLearning. Edinburgh: Association for the Study of Medical Education Oblinger, D. (2001) Will e-business shape the future of open and distance learning ? Open Learning, 16(1), p2-11. Roff, S. and McAleer, S. (2001) What is educational climate? Medical Teacher 23 (4) 333334. Rosenberg, MJ. (2001) E-Learning: Strategies for Delivering Knowledge in the Digital Age. New York: McGraw-Hill.
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Simons, RJ. De Laat, M. E-pedagogies for Network Learning. In: Verschaffel, L. Dochy, F. Boekaerts, M. Vosniadou, S, editors. Institutional Psychology: Past. Present, and Future Trends: Sixteen Essays in Honour of Erik de Corte. Amsterdam: Elsevier; 2006. Stiles, MJ. (2000) Effective Learning and the Virtual Learning Environment.
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In: Medical Education: The State of the Art Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 11-17
ISBN: 978-1-60876-194-4 © 2010 Nova Science Publishers, Inc.
Chapter 2
THEORY IN MEDICAL EDUCATION David Kaufman ABSTRACT
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This chapter asserts that ―there is nothing more practical than a good theory‖ and as professional practice is better understood, theory will both inform practice and to be informed by it. Already, a body of theory has accumulated which can inform practice, and the author shows this by reviewing conclusions drawn from his earlier monograph on the application of eight educational theories to medical education. This is followed by a discussion of three different theories: cognitive apprenticeship, multiple intelligences, and conditions of learning. A brief overview is provided of each of these theories followed by a discussion of their implications for educational practice, including a specific example for each drawn from medical education.
INTRODUCTION Can educational theory inform our practice? Fortunately, the field of education and medical education in particular, has come a long way in recent years. A body of theory has accumulated which can inform practice [1, 2] However, there has been an unfortunate gap between academics and practitioners, which has led to a perception of theory as ‗ivory tower‘ and not relevant to practice. Yet the old adage that ―there is nothing more practical than a good theory‖ still rings true today, and as professional practice is better understood, theory will both inform practice and to be informed by it. My purpose in this exposition is to outline several selected educational theories, and to explore their implications for the practice of medical education. For the purposes of this paper, I use the term ―theory‖ in a general sense, that is, as a set of assumptions and ideas that help to explain some phenomenon. Knowles addressed this topic more than 25 years ago, proposing a definition of a theory as, ―a comprehensive, coherent, and internally consistent system of ideas about a set of phenomena.‖ Each of the theoretical approaches that I describe here is consistent with Knowles‘ definition. Extensive research shows that we learn best
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through a combination of theory and practice [3]. Theory is inert until it is applied to a realistic situation, and practice is shallow without the influence of theory. A clear example is how modern surgeons are trained. Though learning the theory by attending lectures and reading books are necessary, this is not sufficient training for a surgeon. There is an obvious need for practical experience. In medical education, learners learn best by applying theory and techniques to realistic cases in either simulated environments where they can make mistakes without the serious consequences of failure, or in authentic settings where they can receive expert support. In an earlier monograph, my colleague and I discussed eight theories: adult learning principles, social cognitive theory, reflective practice, transformative learning, self-directed learning, experiential learning, situated learning, and communities of practice [1]. In that publication, we outlined the following consistent messages that can be drawn from all of them to inform teaching and learning.
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All theoretical frameworks view the learner as an active contributor in the learning process. The entire context of learning is more important than any one variable alone. Learning is integrally related to the solution and understanding of real-life problems. Individuals‘ past experience and knowledge are critical in learning, in actions, and in acquiring new knowledge. Learners‘ values, attitudes and beliefs influence their learning and actions, and building learners‘ self awareness in this area is important for their development. Individuals as learners are capable of self-regulation, i.e., of setting goals, planning strategies, and evaluating their progress. The ability to reflect on one‘s practice (performance) is critical to lifelong, selfdirected learning. In another paper [2], I outlined five theories and their application to practice: andragogy, self-directed learning, self-efficacy, constructivism, and reflective practice. I refer the reader who is interested in theory to that article, as this chapter will address three different theories: cognitive apprenticeship, multiple intelligences, and conditions of learning. I will provide a brief overview of each of these theories and will discuss the implications for educational practice, including a specific example for each drawn from medical education.
COGNITIVE APPRENTICESHIP Cognitive Apprenticeship is a theory that outlines a method aimed primarily at teaching the processes that experts use to manage complex tasks. [4] The focus of this learning, through a guided experience method, is on cognitive and metacognitive skills rather than on the physical skills or processes of traditional apprenticeships. In traditional apprenticeship training, experts make their processes of performing and learning visible to the apprentice (e.g., a master carpenter or a skilled surgeon). The goal of cognitive apprenticeship is to make the thinking processes of a learning activity visible to both the learners and the teacher. The
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teacher is then able to employ the methods of traditional apprenticeship, i.e., modeling, coaching, scaffolding, and fading to effectively guide learners. [5] In a classroom or clinical setting, the teacher models his/her thinking process, e.g., clinical reasoning, by talking out loud while working through a situation or problem, before turning the task over to learners. The teacher then coaches and scaffolds learners' efforts, gradually fading as the learners become more proficient. Cognitive apprenticeship should result in learners' greater understanding of the material and avoids "inert knowledge," helping them to apply their knowledge and skills to real-life situations. By observing the processes by which an expert listener or reader thinks and practices these skills, learners can learn on their own more skillfully. A full cognitive apprenticeship approach would require the teacher to use the following steps in applying the method. However, based on the context and learners‘ educational stage, only selected steps may be used.
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Modeling -- the expert carries out a task so that the learner can observe and build a conceptual model of the processes that are required to accomplish the task. Coaching – the expert observes learners while they carry out a task and offering hints, feedback, modeling, and reminders. Articulation – the expert encourages learners to use various methods of articulating their knowledge, reasoning, or problem-solving processes. Reflection - learners compare their own problem-solving processes with those of the expert or another learner. Exploration - involves pushing learners into a mode of problem-solving on their own. Asking them to do exploration is critical, if they are to learn how to frame questions or problems that are interesting and that they can solve. [5]
EXAMPLE This method is commonly used in clinical settings, especially at the bedside to discuss patient cases. It also is employed by some surgeons with their clinical clerks, interns and/or residents. However, its application in clinical PBL or especially in lectures could enhance the effectiveness of these methods.
MULTIPLE INTELLIGENCES This theory of human intelligence, developed by psychologist Howard Gardner [6, 7], suggests that there are at least seven ways that people have of perceiving and understanding the world. Gardner labels each of these as a distinct ―intelligence‖–in other words, a set of skills allowing individuals to learn, perform and solve problems that they face. While Gardner recognizes that his list of intelligences may not be exhaustive, he identifies the following seven [6, 7]: Verbal-Linguistic– ability to use words and language
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David Kaufman Logical-Mathematical–capacity for inductive and deductive thinking and reasoning, as well as the use of numbers and the recognition of abstract patterns Visual-Spatial–ability to visualize objects and spatial dimensions, and create internal images and pictures Body-Kinesthetic–wisdom of the body and the ability to control physical motion Musical-Rhythmic–ability to recognize tonal patterns and sounds, as well as sensitivity to rhythms and beats Interpersonal–capacity for person-to-person communications and relationships Intrapersonal–spiritual, inner states of being, self-reflection, and awareness
IMPLICATIONS FOR MEDICAL EDUCATION Traditional medical education heavily favors the verbal and logical-intelligences. According to Gardner's theory, a more balanced curriculum that incorporates the arts, selfawareness, communication, and physical activity would produce a better professional. Gardner advocates instructional methods that appeal to all the intelligences, such as role playing, musical performance, cooperative learning, reflection, visualization, and story telling. This theory calls for assessment methods that take into account the diversity of intelligences, as well as self-assessment tools that help learners understand their intelligences.
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EXAMPLE The domain of communication skills training provides a good example of the use of multiple intelligences. The principles of effective communication are first learned through lectures, readings, and demonstrations. This is followed by role-playing with peers, progressing to simulated patients, and finally real patients (with supervision). Some specialized areas of human relations such as setting personal boundaries have been taught through the use of drawing on large sheets of paper placed on the floor, and, using coloured markers. [8] Music can also be used as a device to assist with memorization of bodies of facts such as learners need to do in their anatomy course.
CONDITIONS OF LEARNING This theory stipulates that there are several different types or levels of learning. The significance of these classifications is that each different type requires different types of instruction. Gagne [9, 10] identifies five major categories of learning: verbal information, intellectual skills, cognitive strategies, motor skills and attitudes. Different internal and external conditions are necessary for each type of learning. For example, for cognitive strategies to be learned, there must be a chance to practice developing new solutions to problems; to learn attitudes, the learner must be exposed to a credible role model or persuasive arguments.
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Gagne advocates that learning tasks for intellectual skills can be organized in a hierarchy according to complexity: stimulus recognition, response generation, procedure following, use of terminology, discriminations, concept formation, rule application, and problem solving. The primary significance of the hierarchy is to identify prerequisites that should be completed to facilitate learning at each level. Prerequisites are identified by doing a task analysis of a learning/training task. Learning hierarchies provide a basis for the sequencing of instruction. In addition, the theory outlines nine instructional events and corresponding cognitive processes, called the events of instruction [11]: (1) (2) (3) (4) (5) (6) (7) (8) (9)
gaining attention (reception) informing learners of the objective (expectancy) stimulating recall of prior learning (retrieval) presenting the stimulus (selective perception) providing learning guidance (semantic encoding) eliciting performance (responding) providing feedback (reinforcement) assessing performance (retrieval) enhancing retention and transfer (generalization).
These events should satisfy or provide the necessary conditions for learning and serve as the basis for designing instruction and selecting appropriate media [11].
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Implications for Medical Education Although Gagne‘s theory is dated, it is based on many years of research and writing by one of psychology‘s most brilliant contributors and still can offer valuable insights and guidance to medical education practioners. His contributions are much too enormous to discuss here, so I am focusing on his events of instruction as these provide concrete steps for teaching. By following these steps, medical teachers can greatly improve their lectures, demonstrations, and one-on-one instruction in the clinical setting.
Example The following example illustrates a teaching sequence for a first year medical student corresponding to the nine instructional events for the specific objective. Objective: Recognize a hairline fracture of the fibula in an x-ray 1. 2. 3. 4. 5. 6.
Gain attention - show a variety of x-rays of normal and fractured fibulas Identify objective - clarify objective: "What is a fibula? What is a hairline fracture? Recall prior learning - review key points about the fibula and hairline fractures Present stimulus – show a few x-rays of various hairline fractures in a fibula Guide learning- explain what to look for in the x-rays Elicit performance - ask learners to identify a hairline fracture in the fibula in various rays, some having no fracture
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David Kaufman 7. Provide feedback – provide feedback re correct/incorrect responses and explain incorrect responses 8. Assess performance- provide scores or qualitative assessment, and remediation if needed 9. Enhance retention and transfer - show x-rays of different kinds of fibula fractures, including unusual hairline fractures, and discuss differences and similarities with learners
CONCLUSION Although most educational theories have not been subjected to the rigours of randomized clinical (or educational) trials, they are based on logic, experience and best practices. Rather than debating the legitimacy of educational theory, I am urging medical educators to use theory as a guide to their practice and also as a validation of the excellent practices already carried out by exemplary teachers. There is also a debate among educators about whether these are actually theories, and there is some support for this view. However, whether we call these theories, models, or conceptual frameworks, I have argued here and elsewhere that they can provide excellent guidance for medical educators and also can evolve through being informed by effective practice. For the interested reader, the earlier monograph [1] and earlier paper [2] by this author, combined with this chapter, outline 16 educational theories that can be helpful to medical educators in their medical education practices.
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REFERENCES [1]
[2] [3] [4] [5]
[6] [7] [8]
Kaufman, DM & Mann, KV. Teaching and learning in medical education: How theory can inform practice (2nd ed.) London, England: Association for the Study of Medical Education (ASME); 2007. Kaufman DM. Applying educational theory in practice. ABC of learning and teaching in medicine. British Medical Journal. 2003; 326: 213-16. Knowles MS, Associates. Andragogy in action: Applying modern principles of adult learning. San Francisco (CA): Jossey-Bass; 1984. Collins, A, Brown, JS, & Holum A. Cognitive apprenticeship: Making thinking visible. American Educator. 1991; 6 (11): 38-46. Aziz Ghefaili. Cognitive apprenticeship, technology, and the contextualization of learning environments. Journal of educational computing design & online learning. 2003; 4(Fall). Gardner, H. Frames of Mind: The theory of multiple intelligences. New York: Basic Books; 1993. Gardner, H. Intelligence Reframed. Multiple intelligences for the 21st century. New York: Basic Books; 1999. Laidlaw T (2000) Setting Personal Boundaries. Workshops presented at Dalhousie University. Halifax, NS; 2000.
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Theory in Medical Education
Gagne, RM. The Conditions of Learning (4th ed.). New York: Holt, Rinehart & Winston; 1985. [10] Gagne RM & Driscoll M, (1988). Essentials of learning for instruction. New Jersey: Prentice-Hall; 1988. [11] Gagne RM, Briggs LJ, Wager WW. Principles of Instructional Design, 4th ed. Fort Worth, TX: Harcourt Brace Jovanovich College Publishers; 1992.
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[9]
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Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
Copyright © 2009. Nova Science Publishers, Incorporated. All rights reserved. Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
In: Medical Education: The State of the Art Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 19-30
ISBN: 978-1-60876-194-4 © 2010 Nova Science Publishers, Inc.
Chapter 3
ENTRY AND SELECTION TO MEDICAL SCHOOL – DO WE KNOW WHAT WE SHOULD MEASURE AND HOW WE SHOULD MEASURE IT? Siún O’Flynn
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ABSTRACT Internationally, entry and selection criteria to medical schools are expected to be fair, transparent, evidence-based and legally defensible and yet there is tremendous variability. The demand for places in medical schools far exceeds the supply and the demand rises in times of financial insecurity or recession. Traditionally there has been a reliance on the assessment of cognitive traits of applicants by either offering a place based on the highest prior academic achievement or using this to determine a threshold for further evaluation of non-cognitive traits or to inform access to a lottery system. Medical schools admit applicants with second and third level academic qualifications and subject such applicants to a variety of other assessments to determine their suitability. In tandem with emerging consensus regarding the outcomes to be achieved by medical graduates and the traits which characterise a good doctor there has been an evolution in entry and selection criteria with an increasing emphasis on the non-cognitive traits of applicants. This chapter reviews the entry and selection mechanisms adopted internationally, exploring the evidence-base underpinning these while asking the fundamental question – is there a relationships between what is measured on admission and the quality of doctor produced?
―…the function of selection is to provide a means of estimating candidates‟ aptitude so that the most suitable applicants are identified…‖
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INTRODUCTION
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There is a wonderful Irish expression: ―Tús maith leath na hoibre‖- i.e. a good start is half the work and to many engaged in entry and selection to medical schools this translates into selecting the right students for their courses. Annually, medical schools are charged with selecting a limited number of students either directly from second level or third level education from a large pool of apparently suitable applicants in a fair, transparent, legally defensible and efficient fashion. This must be done with due recognition of the complexity of medical practice and an acknowledgment of the diversity and evolving nature of the working environment the medical graduate will subsequently encounter. Attrition rates in medical schools are low in comparison to other courses, with some jurisdictional variance, and consequently, the process of selection to medical school assumes even more significance as it effectively selects tomorrow‘s doctors. A variety of approaches are adopted to assess applicants including analysis of previous academic achievement, personal statements, references, aptitude tests, interviews and more unusually personality and learning styles assessment although these are often only analysed for research purposes. As is often the case in medicine this heterogeneous approach reflects absence of evidence to justify an ideal selection mechanism and many medical educators and health legislators express disquiet that the approaches used are not always fair, transparent or valid. This chapter will firstly summarise the approaches used internationally examining United Kingdom systems as a model illustrating the changes also experienced elsewhere and then outline data supporting reliability or reproducibility of results and their predictive validity i.e. the degree to which the selection measure used predicts the applicant‘s performance during or after undergraduate medical training.
AN OVERVIEW OF ENTRY AND SELECTION INTERNATIONALLY In the United States and Canada, where access to medical programmes is predominantly postgraduate, each medical school retains autonomy in selecting prospective students and consequently admissions criteria vary from school to school but almost all include minimum academic levels indicated by undergraduate grade point averages (GPAs), performance in the medical college admissions test (MCAT), and an interview which then aims to identify or further evaluate of a range of non-academic characteristics. Many also require supporting personal statements or even portfolios and a Dean‘s letter of recommendation or other references. In Australia entry to medical schools is both directly from high school and as a postgraduate with use of GPAs, a variety of aptitude tests most commonly the Undergraduate Medicine and Health Sciences Admission Test (UMAT) and Graduate Medical School Admission test (GAMSAT) and interview. In Europe entry has traditionally predominantly focused on the school leaver although there is a steady increase in the numbers of places allocated to graduate entrants. A lottery system operates in the Netherlands with other countries predominantly relying on second
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level or school GPAs or results in state or university administered second level exit examinations to rank candidates. The situation in the UK had been captured in detail by the work of Parry et al in 2006 [1] concluding that most schools shortlist for interview based on A-level academic performance and scores obtained from the Universities and Colleges Admissions Service (UCAS) form which requires personal details, qualifications, employment history, personal statement and references. There was variability in the evaluation of A level data with some schools deeming resit A level applicants, i.e., applicants who passed exams at the required grade on a second or subsequent attempt, as less acceptable than first attempts and other schools considering resit applicants without prejudice often inferring that the decision to re-sit was evidence of a commitment to study medicine. In Ireland, until 2009, academic achievement was the only consideration in ranking applicants for entry to medical school direct from second level and neither the central stateoperated application system nor medical schools discriminated against those who repeated the national leaving certificate examination. This lead to a steady climb in the numbers of repeat leaving certificate student gaining access to medical courses and a growth in the ―grind school‖ industry or private schools created specifically to cater for repeat leaving certificate students intending to study medicine and other high demand courses. The UK situation is particularly interesting and warrants further discussion as a model for what has happened elsewhere. Since 2006 there has been an increasing use of aptitude tests in the admissions process. This mirrors a trend internationally and Ireland now requires all prospective school leavers who intend to study medicine to sit the Health Professions Admission test – or HPAT Ireland. Some of the momentum behind the introduction of aptitude tests stemmed from the concern regarding social exclusion. The British Medical Association noted that the majority of applicants (59%) to medical school came from the highest social groups and that the proportion of accepted applicants was even higher (64% in 2003) and although it was felt that there was no evidence to support discrimination, it was concluded that candidates from nonprofessional backgrounds experience ―a degree of disadvantage‖ during the application process. [2] Other reports further suggested that aptitude tests were less sensitive to socioeconomic background than measures of pure academic achievement and some groups for example the Sutton Trust lobbied for their introduction. [3] [4] There was also an acknowledgement of the difficulties medical schools were presented with when trying to differentiate between students increasingly achieving academic excellence compounded by the sense that the selection process should screen for desirable non-cognitive traits for example interpersonal skills empathy and decision making abilities in tomorrow‘s doctors. Internationally these are also the forces which have led to the introduction of aptitude tests.
PRIOR ACADEMIC ACHIEVEMENT –COGNITIVE TRAITS All agree that a medical course is academically challenging and that past academic success is the best indicator of future academic success. Attaining academic excellence e.g. high GPAs, excellent A levels, top high school scores, optimal leaving certificate results also
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requires personality traits such as conscientiousness and motivation which are also beneficial at medical school and for lifelong learning as a doctor. There is evidence that such measures of prior academic achievement have strong predictive validity in determining success in medical school and thereafter. The Higher Education Funding Council for England HEFCE has unequivocally demonstrated that there is a clear correlation between A levels and university grades. Specific analysis of medical student performance suggests that prior academic performance has a high predictive effect. [5][6]Specific data also exists to support the use of GPAs. [5] [7][8]McManus et al argue that cognitive ability alone cannot be the main basis of the predictive ability of A levels noting that measures of intelligence and intellectual aptitude alone are poor predictors of performance at university reinforcing the argument that prior academic achievement also measures some desirable non-cognitive traits and that tests of prior academic achievement “predict university achievement mainly because they measure the knowledge and ideas that provide the conceptual scaffolding necessary for building the more advanced study of medicine. As with building a house, the scaffolding will later be taken down and its existence forgotten, but it will nevertheless have played a key part in construction” [9] The evidence is clear that prior academic achievement not only predicts undergraduate success in medicine but also postgraduate success although here the effect is smaller. [10] Thus the widespread practice of using measures of academic achievement as a threshold for further assessment or as the main criterion for ranking medical school applicants for admission is justified and should continue. It is important to note that the predictive validity of measures of prior academic attainments are highest for, and strongly predict success in, the early years of a medical course and wane thereafter. The lottery system weighted against academic attainment adopted in the Netherlands was essentially a reaction to the absence of an evidence base to support any alternative selection mechanisms apart from those assessing prior academic achievement. The morality and lack of objectiveness of this process is now questioned and all schools in the Netherlands, previously advocates of a lottery system, are actively reviewing entry and selection processes. [11] [12] Currently 50% of medical school places are reserved for those candidates with the highest GPA scores i.e. those who demonstrate excellent prior academic attainment – and such candidates are given unrestricted access to medical school with the remaining 50% of places granted on the basis of local university selection processes. Thus the open lottery system has been abandoned.
THE CONTEXT FOR APTITUDE TESTS Since the 1990s a number of international organisations responsible for medical education have focussed attention on the definition of outcomes of undergraduate medical education –the World Federation of Medical Education 1998, 2003 has developed global standards, the AAMC American association of Medical Colleges (AAMC) (2000) identified six core competencies and with the licensing committees linked these to undergraduate outcomes, the General Medical Council in the UK created the Tomorrows Doctors documents. [13][14][15]
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Concomitantly other groups have identified desirable non-cognitive traits which include a capacity for independent learning, interpersonal communication, empathy, decision-making, teamwork and self-awareness, as well as the ‗‗attributes of a stable adult‘‘, motivation, and integrity. Albanese et al have documented about 80 such desirable traits in the literature. [16] Traditional cognitive tests like A levels and GPAs do not measure these traits or the specific capacity of applicants to attain specific medical programme outcomes and hence there is a vacuum which aptitude tests seek to fill. Few would argue that a doctor needs to be capable of critical thinking but whom and what defines this? The literature doesn‘t provide answers to this question.
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APTITUDE TESTS Aptitude has many meanings, and a commonly used definition suggests that aptitude tests are ―designed to measure intellectual capabilities for thinking and reasoning, particularly logical and analytical reasoning abilities.‖ Let us examine 2 such tests in some detail before reviewing the evidence regarding the use of aptitude tests in general. The MCAT or Medical College Admission Test, used by most American and Canadian schools is worthy of some discussion. It evolved from the Scholastic Aptitude Test for Medical Students developed in the 1920s in response to the high drop-out rates in US medical schools. The exam has undergone many iterations under the auspices of the American Association of Medical Colleges and is now a 4.5-5 hours computer based exam with 4 sections; Physical Sciences, Verbal Reasoning, Writing Sample and Biological Sciences. The Verbal Reasoning, Physical Sciences, and Biological Sciences sections are in multiple-choice format. The Writing sample consists of two short essays that are typed into a computer. The Physical Sciences section assesses problem-solving ability in general chemistry and physics while the Biological Sciences section evaluates these abilities in the areas of biology and organic chemistry. The Verbal Reasoning section evaluates the ability to understand, evaluate, and apply information and arguments presented in prose style. The Biological Sciences section most directly correlates to success in medical school and the medical board licensing exams especially the USMLE Step 1 exam, with declining correlations for Physical Sciences and for Verbal Reasoning. There is little evidence of any predictive validity of the writing sample test. The MCAT is therefore a test which contains elements of an aptitude test but whose predictive validity and ability to predict success in medical school is to some extent governed by curriculum based elements of physical sciences and biological sciences more akin to those assessed elsewhere in more traditional cognitive tests like A levels and GPAs. Many argue therefore that the usefulness of the MCAT lies not in its role as an aptitude test per se but rather in its ability to independently and objectively test academic ability in the basic sciences. MCAT exams have been and continue to be rigorously evaluated and MCAT scores not only predict medical school success but also predict US and Canadian licensing and postgraduate exam success. [8] [17] At the core of aptitude test construction is the desire to measure ability rather than attainment and to be free of the biases often attributed to more traditional academic tests.
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Even the MCAT, arguably one of the most refined aptitude tests in use, has its detractors in this regard with some reports suggesting concerns in relation to the performances of minority students and even female applicants. [5] The Graduate Medical School Admissions Test GAMSAT, developed by the Australian Council for Educational Research (ACER) an independent company, is also worthy of mention as it also enjoys wide usage in Australia since 1996 and in the UK. This extended to Ireland, as of 2008 where controversially it is often the only other selection mechanism used to assess graduate entry to medical school once a threshold of an upper second class honours degree in any area has been achieved. The secure test takes 5.5 hours to complete and consists of three sections: Reasoning in Humanities and Social Sciences; Written Communication, and Reasoning in Biological and Physical Sciences which is to an extent a curriculum based section. The reasoning sections consist of questions in multiple-choice format, whereas the written communication section involves two 30-minute writing tasks. Predictive validity is established for early phase medical courses in Australia but it remains to be seen whether this is sustained in later phases of medical training and reproduced elsewhere. Unlike MCAT there is little data available comparing the scores in individual sections of the test and their relationship with subsequent medical school success but as with MCAT there is a suspicion that the predictive validity and power of the test may rest predominantly with the biological and physical sciences element [18]Others evaluating this test acknowledge that GAMSAT is highly reliable but that its predictive validity correlates and overlaps with that of GPAs and consequently question its role or added value. GAMSAT is perhaps more reliable than GPAs which are derived from multiple courses marked by a wide range of individuals in different universities whereas the GAMSAT is standardized and for many this is its main appeal. [19] The strengths of MCAT, GAMSAT and arguably other aptitude tests rests in their overlap with, and inclusion of, knowledge based and academic elements which are already assessed in all medical school applicants but they tests may have a role in systems where national second level exit examinations do not exist and perhaps to correct for GPA variations between university courses and schools. This is a useful role but is not the true function of an ―aptitude test‖ and must lead one to question their role or usefulness in systems where national or independently administered exams do exist. The introduction of aptitude tests has led to a thriving industry of commercial courses purporting to prepare students and there is some evidence that coaching may be of benefit especially in the non-curriculum elements. [20] [21] This then defeats the purpose and intent of including aptitude tests to select of medical students and exacerbates the issue of social exclusion as not all are in a position to attend expensive preparatory courses The data to support other aptitude tests is scarce and, although such data may emerge, it does not exist at present despite their wide usage. [5] Outline descriptions of other commonly used aptitude tests are included in Figure 1. Developers and purveyors of these tests can demonstrate reliability and reproducibility of results but predictive validity, which is the real currency of any test used to select students for entry to medical school, is lacking. The introduction of the UK Clinical Aptitude Test, (UKCAT) by most UK schools in 2006 was not without its difficulties although admittedly some of these were operational but students have been vehement in their protests against it calling on the British Medical Association to wield its influence to abolish it![23]Many academics joined their protests.
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Entry and Selection to Medical School Test / Organisation MCAT Medical College Admission Test
Brief description 4.5-5 hours computer based exam with 4 sections; Physical Sciences (MCQ in general chemistry and physics), Verbal Reasoning (MCQ), Writing Sample (2 short essays) and Biological Sciences (MCQ in biology and organic chemistry). 5.5 hours; consists of three sections: Reasoning in Humanities and Social Sciences (MCQ), Written Communication (two 30 minute writing tasks), and Reasoning in Biological and Physical Sciences (MCQ) curriculum based section.
Application Widespread use in United states and Canada to screen graduate entrants to medical school.
Two hour MCQ test with 5 sections;1.Verbal reasoning 2. Quantitative reasoning - ability to solve numerical problems. 3. Abstract reasoning –4.Decision Analysis -. 5. Non-cognitive Analysis – attempts to identify aspects of each candidate's personality and character in order to determine their suitability for a career in medicine or dentistry. No curriculum based element
Currently 26 UK schools employ this test and it is used to screen school leavers and in a few cases graduate entrants. Many schools have restricted its impact on final selection results until more data is available.
UMAT Undergraduate Medicine and Health Sciences Admission Test Developed and administered by Australian Council for Educational Research (ACER) a private company.
2.5 hours MCQ test with 3 sections; logical reasoning and problem solving, understanding people and non verbal reasoning. No curriculum based element.
Widespread use in Australia to evaluate school leaver applicants to medical school and other healthcare courses.
BMAT Biomedical Admissions Test owned and administered by Cambridge Assessment a private company.
2 hour test; combination of MCQ short answer and essay questions in three sections 1. Attitude and skills, 2. Scientific knowledge and applications – school curriculum based and 3. writing task
Developed and administered by American Association of Medical Colleges (AAMC) in use since 1920 GAMSAT Graduate Medical School Admissions Test in use since late 1990s Developed and administered by Australian Council for Educational Research (ACER) UKCAT UK Clinical Aptitude Test, (UKCAT) introduced in 2006
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Developed by a consortium of UK universities in association with Pearson VUE (a UK media and electronic testing company)
Widespread use in Australia UK and Ireland to screen graduate entrants to medical school.
Modifications of this test e.g. HPAT now introduced in Ireland and being considered elsewhere. Currently used by 4 UK medical schools
Figure 1.
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INTERVIEWS In the UK the vast majority of schools interview candidates in order to assess noncognitive traits – many attempting to evaluate several pre-specified traits however the configuration of the panel (gender, lay members, number on panel), level of training of panel members and nature of the interview is highly variable. [1] Interviews are also commonplace in Australia, Canada and the United States with equally heterogeneous practices and yet there is little evidence of any predictive validity of interviews. [5] [23] [24] There is also data that the types of questions posed can be gender specific and hence the reliability of interviews is also questioned. [25] A number of models of innovation and good practice in harnessing the interview techniques and refining it exist such as the multi mini interview MMI which is akin to an interview OSCE however there were no significant correlations between the scores obtained in these resource intensive simulated tutorials on admission and those obtained at subsequent clinical examinations. [26] The multi mini interview has high appeal as it eliminates the flaws and inconsistent approach inherent in more traditional approaches to admission interviews. Consequently this format has been adopted in a number of institutions and data may yet emerge to support its widespread adoption. Should this be the case the issue of feasibility and cost will then be the focus of scrutiny. Elsewhere, others have developed assessment centres where stations and interactions are designed to assess attributes such as empathy initiative & resilience, communication skills, organisation/problem-solving, team-working, insight & integrity, effective learning style and academic ability. The face validity of such approaches is obvious but, in the absence of robust predictive validity data, many are loath to invest the time and resource these initiatives require. Despite the flaws suggested applicants seem to like and may even favour interviews! [28] On review of the evidence many schools are now removing interviews from their entry and selection processes. [19]
PERSONALITY, PERSONAL STATEMENTS LEARNING STYLES AND REFERENCES In the UK it is clear that the evaluation of personal statements and references, required by most schools, varies. [1] and there is little to suggest that there is a uniform approach elsewhere. Provision of personal statements with a lot of information which may relate to motivation correlates well with assessment performance as does the detection of ―conscientiousness‖ and ―agreeableness‖ from personal statements and references. A high ―conscientiousness‖ factor suggests a methodical, organized person motivated by achievement while ―agreeableness‖ suggests an ability to cooperate and trust. [28] These are findings from committed researchers but the practical application of these findings is questionable. There is little evidence that high scores in these categories derived from personal statements reliably predict medical school performance. Scientifically analysing and scoring them requires considerable investment of time and expertise.
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Systematic review of the literature suggests that there is insufficient evidence to make any conclusive recommendations about personal statements and the general conclusion is that references are of no predictive value. [5] Despite this they are still widely used in admission and selection to medical school! Learning style describes the motivations for learning and processes by which the student learns. Various validated questionnaire tools exist to categorise learners by their dominant learning style There is some evidence of a positive association between strategic learning (tripartite model) and convergers (Kolb) who use deductive reasoning and medical school success and clearly enthusiasts are intrigued by such associations but whether this will ever reliably inform medical school selection is doubtful. [5]
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CONCLUSION Consideration of non-academic characteristics, such as empathy, conscientiousness, team working, and so forth, have face validity, and the idea is appealing to many, not least the public, that future doctors are selected on the basis of the presence or absence of these traits. There is however no absolute consensus regarding the characteristics medical schools should be seeking among future doctors nor the optimal mechanism to be employed to do this. The diverse nature of the potential practice of any medical graduate requires diverse characteristics and it is entirely likely that it is only at the point of specialty postgraduate training, where the outcomes required become more sophisticated and defined that such traits or characteristics should be carefully assessed. In selection for medical school the emphasis should then perhaps be the avoidance of extremes or candidates with absolute absences of desirable traits and researchers must focus on reliable, feasible and cost effective methods of identifying these. Academic characteristics do however predict medical school and postgraduate success and hence should predominate in any entry and selection procedure. The role of aptitude tests with some exceptions is uncertain and, where predictive validity is established, it often aligns with the academic or knowledge component of the test as opposed to an ―aptitude‖ component. Where the terminal academic test at the end of second or third level education course is not independent or nationally administered there may be some justifiable role for the inclusion of aptitude tests to eliminate bias but the actual added contribution of non-knowledge based elements to the predictive validity of such tests must be more rigorously evaluated. In an era of evidence-based practice the inclusion of tests to inform such high stakes decisions as admission to medical school should be based on evidence of predictive validity and perhaps until such data is available any new mechanisms should be used for research purposes only or have a minimal, moderated effect on the final decision reached by admitting boards. Entry and selection methods are increasingly the subject of scrutiny with the Admissions to Higher Education Steering Group in the UK who warn against the use of selection methods without evidence of their reliability and validity. [4] An authoritative review of the literature concluded that long-term prospective cohort studies are still needed to examine predictors of
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success after qualification as predictive data often extend into the early undergraduate phase only with fewer studies analysing cohorts in the postgraduate phase of their careers. [5] The only rational reasons to make rapid changes to entry and selection mechanisms are high attrition rates, as seems to may be the case in Denmark where radical revision is underway [29], but this is not a widespread problem and ninety six percent of medical students complete studies if tracked over 10 years in the US and low attrition rates are the norm elsewhere. [30] There is debate as to whether any of the aptitude tests and other newer mechanisms eliminates socioeconomic bias or ethnic bias in medical school selection. [5] [31] Predictive data must look beyond the undergraduate course and, with the exception of various measures of prior academic achievement and MCAT data, this evidence is lacking for selection mechanisms. In the ASME review Patterson et al rightly suggest that “Undergraduate and specialty postgraduate „selection‟ may have different goals undergraduate courses selecting primarily on academic ability, with a focus on passing the course and postgraduate selection focuses more on job-fit…it cannot necessarily be assumed that those with high academic ability alone can be turned into potentially good doctors via medical training - other skills and qualities may need to be present from the start.” [32] Perhaps, as Benbassat and Baumal suggest, some of our attention should shift to disseminating information on the requirements for medical training in general to help prospective applicants in making an informed decision, based on a realistic self-appraisal as to whether or not to apply to medical school. [33] Uninformed medical school application is certainly felt to account for high attrition rates in Denmark. All who deal with medical students on a daily basis can attest to the experience of dealing with academically excellent young people who are poorly informed and have not given sufficient consideration to the likely demands of a medical course or career. [29] The author has often found herself in this position and the distress of the students involved is significant. Career guidance teachers and students also describe the misery incurred by failure to gain access to a much desired course. Application processes should seek to ensure that students are well informed but there will always be a small group of applicants who are unduly influenced in their decision to apply to medical school by the perceived financial security offered by the profession or parental and societal pressure. Some of these influences may increase in the current difficult financial climate. Entry and selection to medical school will be the subject of ever increasing scrutiny by prospective applicants, the public and legislators. More data is needed to decisively clarify what we should measure in this process and how we should measure it.
REFERENCES [1]
[2] [3]
Parry, J., Mathers, J., Stevens, A., Parsons, A., Lilford, R., Spurgeon, P., & Thomas, H. (2006). Admission processes for five medical courses at English schools: review. British Medical Journal, 332, 1005–1009. BMA June 2004, The demography of medical schools; A discussion paper pp 2-7. Bekhradnia B, Thompson J. (2002) Who does best at university? London: Higher Education Funding Council England.
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
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[11] [12] [13]
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[14] [15] [16]
[17]
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Admissions to Higher Education Steering Group. Fair admissions to higher education: recommendations for good practice. Nottingham: Department for Education and Skills Publications, 2004. Ferguson, E., James, D., & Madeley, L. (2002). Factors associated with success in medical school: systematic review of the literature. British Medical Journal, 324, 952– 957. Commission on the Points System Final Report and Recommendations (1999) Kulatunga-Moruzi, C., & Norman, G. R. (2002b). Validity of admissions measures in predicting performance outcomes: The contribution of cognitive and non-cognitive dimensions. Teaching and Learning in Medicine, 14, 34–42. Julian, E. R Kreiter, C. D., Yin, P., Solow, C., & Brennan,. (2005). Validity of the Medical College Admission Test for predicting medical school performance. Academic Medicine, 80, 910–917. McManus, I. C., Powis, D. A., Wakeford, R., Ferguson, E., James, D., Richards, P. (2005b). Intellectual aptitude tests and A levels for selecting UK school leaver entrants for medical school. British Medical Journal, 331, 555–559. McManus, I. C., Smithers, E., Partrige, P., Keeling, A., & Fleming, P. R. (2003). A levels and aptitude as predictors of medical careers in UK doctors: a 20 year prospective study. British Medical Journal, 327,139–142. ten Cate, O., & Smal, K. (2002). Educational assessment center techniques for entrance selection in medical school. Academic Medicine, 77, 737. Urlings-Strop LC, Stijnen T, Themmen AP, Splinter TA (2009) Selection of medical students: a controlled experiment. Medical Education.Feb;43(2):175-83. Executive council, World Federation for Medical Education(1998) International standards in medical education: assessment and accreditation of medical schools‘ educational programs. A WFME position paper, Medical Education, 32, pp. 549–558. Accreditation Council for Graduate Medical Education (ACGME) (2000) Outcome Project: General Competencies.[Online]. General Medical Council (1993) (2003) Tomorrow‟s Doctors: Recommendations on Undergraduate Medical Education. [Online]. Albanese, M. A., Snow, M. H., Skochelak, S. E., Huggett, K. N., & Farrell, P. M. (2003) Assessing personal qualities in medical school admissions. Academic Medicine, 78, 313–321. Donnon, T., Paolucci, E. O., & Violato, C. (2007). The predictive validity of the MCAT for medical school performance and Medical board licensing examinations: A meta-analysis of published research. Academic Medicine, 82, 100–106. Coates, H. (2008) Establishing the criterion validity of the Graduate Medical School Admissions Test (GAMSAT) Medical Education, 42, 999–1006. Wilkinson, D., Zhang, J., Byrne, G.J., Luke, H., Ozolins, I.Z., Parker, M.H., Peterson, R.F. (2008) Medical school selection criteria and the prediction of academic performance. Medical Journal Australia. 2008 Mar 17;188(6):349-54. Griffin, B., Harding, D.W., Wilson, I.G .,Yeomans ,D.,(2008) Does practice make perfect? The effect of coaching and retesting on selection tests used for admission to an Australian medical school. Medical Journal Australia 189, 270-273.
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[21] McGaghie, W.C., Downing, S.M., Kubilius, R., (2004) What is the impact of commercial test preparation courses on medical examination performance? Teach Learn Med 2004; 16: 202-211. [22] Cassidy, J. (2008) UKCAT among the pigeons Student BMJ 16 146-147. [23] Smith, S. R. (1991). Medical school and residency performances of students admitted with and without an admission interview. Academic Medicine, 66, 474–476. [24] Basco, W. T., Gilbert, G. E., Chessman, A. W., Blue, A. V., & Basco, W. T. (2000) The ability of a medical school admission process to predict clinical performance and patients‘ satisfaction. Academy of Medicine, 75, 743–747. [25] Marquart, J. A., & Franco, K. N., & Carroll, B. T. (1990). The influence of applicants‘ gender on medical school interviews. Academic Medicine, 65, 410–411. [26] Eva, K. W., Rosenfeld, J., Reiter, H. I., & Norman, G. R. (2004). An admissions OSCE: the multiple mini interview. Medical Education, 38, 314–326. [27] Mc Manus I., C., Richards, P., Winder, B,. (1999) Do UK Medical School Applicants Prefer Interviewing to Non-Interviewing Schools? Advances in Health Sciences Education 4: 155–165. [28] Ferguson, E., James, D., O‘Hehir, F., Sanders, A., & McManus, I. C. (2003). Pilot study of the roles of personality, references, and personal statements in relation to performance over the five years of a medical degree. British Medical Journal, 326, 429–431. [29] O'Neill, L., D., Korsholm, L., Wallstedt, B., Eika, B., Hartvigsen, J., (2009) Generalisability of a composite student selection programme. Medical Education, Jan;43(1):58-65. [30] Analysis in brief, (2007) Association of American Medical Colleges, April Volume 2 [31] Story M, Mercer A. (2005) Selection of medical students: an Australian perspective. Intern Med J 2005; 35: 647-649. [32] Patterson, F., Ferguson, E., (2007) Selecting for Medical Education and Training. Association for the Study of Medical Education (ASME), Edinburgh. [33] Benbassat, J., Baumal, R., (2007) Uncertainties in the selection of applicants for medical school Adv in Health Sci Educ 12:509–521.
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In: Medical Education: The State of the Art Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 31-45
ISBN: 978-1-60876-194-4 © 2010 Nova Science Publishers, Inc.
Chapter 4
LEARNING AND TEACHING IN DIFFERENT CLINICAL ENVIRONMENTS John Spencer ABSTRACT
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This chapter discusses the strengths and challenges of clinical education, explores some relevant educational theory and its implications, focuses on a number of specific clinical learning environments, reflects on the benefits of early clinical contact and the role of the patient, and draws some conclusions about the current state and future developments in clinical education.
INTRODUCTION Few would disagree that the clinical environment is potentially the most powerful setting for learning medicine. This has long been recognised, indeed the traditional apprenticeship approach, opportunistic, unpredictable and subject to the vagaries of patronage though it might have been, was the mainstay until the evolution of university-based medical education in the 13th and 14th centuries [1]. However, formal clinical education – that is, teaching and learning focused on, and usually directly involving patients, their problems and their care [2] – only emerged in the 18th century. It has weathered well, ‗surviving‘ many challenges, including the partition of medical curricula into pre-clinical and clinical phases, changes in health care organisation, increasing student numbers and, most recently, the increasing use of simulation in the context of concerns about patient safety. Teachers go to great lengths to maximize opportunities for clinical experience, students can‘t get enough of it, and, reassuringly, most patients seem only to willing to be involved [3, 4]. Yet teaching and learning in clinical environments poses many challenges and despite its superiority as an educational setting, research has identified many problems, well documented in an extensive literature. To quote the author of one review, it is ―a conceptually sound
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model, flawed by problems of implementation” [5]. However, even the most hectic ward round, outpatient clinic, general practice surgery or operating theatre session can be transformed into a valuable learning experience.
STRENGTHS AND CHALLENGES One of the main strengths of clinical education is that it takes place ‗in context‘ in the workplace. This enhances integration, recall and application of skills and knowledge. Relevance is immediately apparent to the learner, since attention is focused on real patients with real problems, and this in turn increases motivation, confidence and enjoyment. It is the ideal, perhaps the only location in which the vast array of technical and non–technical skills that constitute ‗doctoring‘ – communication, examination, data interpretation, clinical reasoning, decision-making and problem-solving, appraising risk and managing uncertainty, record keeping, working in a team, leadership, and so on – can be modeled by teachers (consciously or unconsciously!) and learnt as an integrated whole. At the same time, the challenges are many and varied, and have been well documented [2]. They can be divided into factors to do with the environment, the patients, the students, and the teachers themselves, and are shown in Box 1. Some of these challenges are simply ‗part of the territory‘; indeed how the teacher handles of them, skillfully or otherwise, may stimulate powerful learning as part of the ‗hidden curriculum‘ [6]. Meanwhile, many of the other challenges can be tackled or at least ameliorated with planning and forethought.
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SOME RELEVANT THEORIES AND THEIR IMPLICATIONS Clinical teachers tend to be highly pragmatic (a useful attribute when having to juggle commitments in the hurly burly of clinical practice) with little time for musings on educational theory. Further, theories abound (a Google search on the term ‗educational theory‘ received over 420,000 hits), are complex and may seem rather esoteric and jargonbound. However, if theory has any use it must be able to explain or illuminate phenomena and to predict what will happen in particular situations and to guide actions. In the oft-quoted words of Kurt Lewin, the founder of social psychology, ‗There is nothing more practical than a good theory‘ [7]. This section briefly describes several theories and models that are relevant to clinical education, namely: constructivism; experiential learning; reflective practice; situated learning; cognitive apprenticeship; and experience-based learning. Constructivist theories argue that learners create knowledge through interaction between new information and their ‗prior knowledge‘ [8]. Through this process of elaboration and restructuring they build new knowledge, integrate it into previously existing concepts; in turn, it becomes better organised and more easily accessible. Constructivism shifts the focus of education from the teacher and the subject to the learner, recognising that they are not a blank slate but an active participant in the learning process. Knowledge is best recalled and applied in the context in which it was learned which has implications for ensuring that as much learning about ‗the job‘ takes place in the setting in which the job is actually done. The teacher‘s role is to help learners ‗activate‘ their prior knowledge, create opportunities for
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elaboration, and challenge misconceptions, rather than to act simply as a transmitter of information. Experiential learning extends the constructivist model, and is usually attributed to Kolb [9]. It proposes that learning includes both concrete experience (‗doing‘) and abstract conceptualisation (‗thinking‘) which are transformed (and new knowledge created) through reflection and active experimentation. Learning is represented as a cyclical process, and is most effective when learners compete the cycle, i.e. use all four components (Figure 1). Experiential learning helps learners connect their previous knowledge, skills and beliefs with current experience and promotes new learning. Given the complexity of most learning situations, learners are usually simultaneously engaged in several cycles of varying amplitude, some completed within a short time (e.g. a single learning session), others of longer timeline. Kolb also applied the model to learning styles, recognising that both teachers and learners have different styles which emphasise different elements of the cycle (e.g. ‗activist‘ or ‗reflector‘). An important issue is that someone‘s teaching style usually reflects their own learning style, and thus may not suit all the learners in their charge.
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Box 1. Challenges of teaching and learning in the clinical environment Environment Physical environment not ‗teaching friendly‘ Requirements of infection control Lack of space Patients Unpredictable Unavailable (e.g. in physiotherapy or Xray) Unusable (e.g. too ill, ‗wrong‘ diseases) Unwilling Short hospital stays Ensuring fully informed consent Maintaining confidentiality Students Multiple levels of learners Increased numbers Unprepared for clinical learning (particularly in early years) Teachers Lack of training in teaching and not understanding how people learn Not knowing about the curriculum Not knowing the learners Lack of incentives and rewards Conflicts with clinical and other responsibilities Time pressures
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Concrete experience
Active experimentation
Reflection
Abstract conceptualization
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Figure 1. Experiential learning cycle (after Kolb).
Reflection, ―.....a generic term for those activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations‖ is an important component of learning, and the development of ‗the reflective practitioner‘ a key aim of curricula, whether undergraduate or postgraduate. It is a process which involves the learner ‗returning‘ to experience, examining it from both a cognitive and affective perspective, and re-evaluating it with a view to future experience [8]. There is an extensive literature on reflection but it is probably the work of Schön that has had most influence in the context of professional education. He defined two types of reflection: ‗reflection-in-action‘ which takes place during the activity, and ‗reflection-on-action‘ which takes place later. Reflection is seen as an iterative process and appears to promote deep learning and the skills of self-regulation. Reflective ability can be developed, but reflection probably needs to be formally built into the teaching and learning process. Social learning theories argue that people create knowledge and meaning collaboratively. Learning occurs within social relationships as a result of a dynamic interaction between the learner and the environment. ‗Situated learning‘ posits that learning is a function of the context in which it takes place, and occurs through participation in a ‗community of practice‘. Learners enter the community (i.e. the clinical environment) as ‗legitimate peripheral participants‘, involved but performing less important tasks. Then, through increasing participation, they take on more responsibility, moving gradually towards the centre and gradual absorption into the community. Much of this learning is informal, unstructured and opportunistic as they learn from role models the ‗talk‘ of the community, including the values, shared knowledge and practices thereby promoting professional socialization. [10, 11] ‗Cognitive apprenticeship‘ lies at the heart of situated learning and combines a constructivist approach with the concept of professional modeling. The teacher provides the learner with a ‗scaffold‘ for their further learning. The emphasis is as much on meta-cognitive aspects as on cognitive and psychomotor skills – the ―why‖ as well as the ―what‖ and the ―how‖. This requires the teacher to articulate what is usually implicit, i.e. their expertise. This happens through modeling (the teacher carries out a task so the student can observe and build a conceptual model of what is required to accomplish the task); coaching (observing learners
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as they carry out a task and offering guidance and feedback); articulation (helping students to think aloud); reflection; and exploration (forcing students into a mode of problem solving on their own) [12]. Finally, experience-based learning (ExBL) is a model that links the context, processes and outcomes of clinical learning [13] (Figure 2) Students learn best by participating in activities in (and of) the workplace involving real patients, but only so long as they are appropriately supported and challenged, so-called ‗supported participation‘. Their level of participation lies on a spectrum ranging from passive observer (i.e. fly on the wall) to active participant actually doing the job (e.g. clerking a patient when on emergency take). The ExBL model defines three kinds of support for participation: ‗affective‘, dependent upon establishing a conducive learning environment; ‗pedagogic‘, which involves, for example, the teacher understanding the curriculum; and ‗organisational‘ involving maximising opportunities for participation. Research into the attributes of the best clinical teachers generally supports this model [14]. Learning leads to two kinds of outcome, ‗practical‘ (e.g. transfer of skills to the workplace, integrating and applying knowledge) and ‗emotional‘ (such as developing a sense of professional identity and building confidence), which are mutually reinforcing.
(Image courtesy of Professor Tim Dornan, University of Manchester) Figure 2. The Experience-based learning model.
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DIFFERENT ENVIRONMENTS Anywhere that health professionals interact with patients, directly or indirectly, in the course of caring for them falls within our definition of clinical education [2]. Historically the main locations for clinical learning were the wards, operating theatres and casualty departments of the teaching hospital. Over the past 40 years, however, changes in both curricula and health care organisation have seen it relocate to new settings, including the community, particularly in general practice. This section will focus on the following environments: the bedside, the ambulatory care setting (including general practice), and the operating theatre .
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AT THE BEDSIDE Learning at the bedside, at its best, ticks all the boxes for effective and powerful experiential learning, providing, as it does, ―an opportunity for the multi-disciplinary team to listen to the patient's narrative and jointly interpret his concerns. From this unfolds diagnosis, management plans, prognosis formation and the opportunity to explore social, psychological, rehabilitation and placement issues.‖ [15]; there are also opportunities to learn about issues such as note-taking, which may have been neglected in the past [15]. At worst, however, bedside teaching can be ‗....chaotic and frustrating.....as students of varying levels of sophistication and interest fight off (or surrender to) interruptions and urges to go to sleep, while the attending physician holds forth on unanticipated topics, and about patients who may not be available.‟ [16]. There are a number of possible formats: the ward round, whether organised specifically for teaching purposes or a ‗business‘ round, with or without pre and post-round meetings; dedicated teaching sessions with selected patients; and students clerking patients, carrying out procedures, and so on, both supervised and unsupervised. The teaching may move between the bedside and classroom (or the corridor). Despite the undoubted potential, there are several problems with teaching and learning at the bedside. It is generally a very busy environment, the teacher often balancing clinical care with teaching responsibilities, and patient turnover is high. Patients are often sick and the presence of students may compromise their welfare and safety, contemporary concerns focusing on infection control. There is also potential for exploitation of patients and abuse of their goodwill if they are not given the opportunity to give fully informed consent. Learners, particularly on the traditional ward round, may be of mixed ability and experience, and some (usually the most junior) may feel they are a burden, indeed may feel positively unwelcome. Less experienced teachers may fear being shown up in front of the patient. The traditional ward round format may be intimidating, even demeaning for patients as their problems are discussed in front of the whole ward. Patients may be unwilling, unavailable, or unsuitable (e.g. the ‗wrong disease‘) and teachers have to be ready to exploit unexpected ‗teaching moments‘, although ‗far more reliable and effective are those opportunities created through systematic planning and preparation‟ [17]. One of the challenges, particularly on the ‗business‘ type of ward round, is keeping learners actively involved as problems are assessed and decisions made, usually at a fast pace. Nonetheless, as Stanley suggested, learning opportunities are increased when time for discussion is built into
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the ward round format, for example ‗3 minute round ups‘ after the round, when learners can raise any issues; in her studies these were usually conducted away from the bedside. [17] Cox, an Australian surgeon, proposed a model for bedside teaching (although it could be applied in many settings) which links two processes in a double loop of learning, the actual clinical experience, and an explanation of the experience. [18] Preparation and briefing before the patient encounters are followed by direct experience and debriefing. Students then reflect on the experience, explicitly relate experience to theory and evidence, and close the loop by preparing for the next encounter. Organisation and structure are the key to adopting such an approach, which begs the need for planning and evaluation. However, in Cox‘s words, the instructions to teachers are simple ―Work out what you want to do before you do it, and stop and think after you‟ve done it.‘ [18] Learners can also prepare for ward rounds so as to be more effective learners. [19] Many studies of the attributes of effective teachers have taken place at the bedside. Irby studied a group of teachers thought, by both their peers and their students, to be ‗exemplary‘ and identified their key attributes. These teachers were well prepared and organised, understood how students learn, provided a collaborative learning environment, actively involved the students, briefed both the students and their patients, gave constructive feedback, taught general rules and modeled professional behavior [14]. Students recognise these good teachers, identify them as positive role models, and ultimately learn more from them.
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THE AMBULATORY CARE SETTING Ambulatory care settings, which include hospital outpatient clinics, emergency rooms, clinical investigation units and primary care and community clinics, have emerged as some of the most important locations for clinical education in recent years. Advantages include the fact that patients are usually less sick than in hospital and may be known to the healthcare team (notably in general practice), enabling a more holistic understanding of their problems. The different contexts offer a range of learning opportunities, for example as Sprake, et al suggested: ―In hospital outpatients....learners can attend specialist clinics and learn about diagnosis and management of specific diseases. In primary care learners can see early presentation of disease or observe long term impact of disease on patients and families. Ambulatory investigation centres allow learners to observe diagnostic procedures, understand the underlying rationale, and appreciate patients‟ perspectives.” [20]. Challenges shared by all ambulatory locations include the fact that clinicians are usually providing active care at the same time as teaching, often to more than one patient at a time, and must address their needs before they leave the clinic. Teaching inevitably tends to be opportunistic and unpredictable, particularly in the light of the rapid patient throughput characteristic of such clinics. There is thus a need for educational strategies that allow exploitation of these situations. McGee and Irby described several principles to make such teaching ‗effective, gratifying and fun.‘ [21]. These include: before the session, preparing by explicitly defining the student‘s tasks, identifying their learning needs and priming them before the patient encounter; during the session, teaching to the learners‘ needs, asking questions and focusing on only a few (1 or 2?) teaching points or general rules; modeling appropriate thinking and behavior; seeing the learner‘s patients after they have seen them; and providing feedback.
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More formal teaching and debriefing can take place after the clinic. [21, 22] Useful teaching methods for such time-limited situations include the ‗one minute preceptor‘, SNAPPS and ‗Aunt Minnie‘ models [22]. Arguing that the rich potential of ambulatory settings is often lost through lack of foresight, Sprake et al offer the following planning strategies: orient the learners; organise patient consent; manage time to ensure effective teaching; and encourage learners to take responsibility for their own learning [20]. One possible solution to the problems is the dedicated teaching clinic. Dent has described the ‗ambulatory care teaching centre‘, essentially a teaching outpatient clinic with longer appointment times for pre-selected patients [23]. A similar approach is often used in general practice, as is the dedicated teaching session when patients, for example those with particular diseases, are brought in specifically for the teaching (i.e. are not receiving active care). Learners can take on a number of roles in ambulatory settings, ranging from simply being an observer (anecdotally, an all too common ‗default‘ situation and somewhat passive) to seeing their ‗own‘ patients in parallel with the main clinic. The latter obviously is more demanding of the clinical teacher but provides a powerful experience. Box 2. Models for teaching in ambulatory care settings [20]
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One-to-one teaching Simple observation: it is important to make sure the learner is actively engaged by allocating specific tasks such as writing down thoughts about differential diagnosis, noting communication skills used, etc „Hot-seating‟: the learner takes the lead in the consultation, with discussion and feedback with the tutor taking place during or after the encounter Learner sees the patient alone: then feeds back to the teacher (who also usually has to provide care for the patient); note that the chance to observe and give feedback is lost Larger groups of learners Grandstand: several learners sit in with one clinician; there is thus limited opportunity for patient interaction; as with ‗simple observation‘ above, learners need to be given specific tasks Report-back: learners see patients independently or in pairs and report back; this is time consuming for the patient but gives learners opportunities to practice case presentation and receive feedback Shuttle: clinical teachers consult simultaneously and pass learners between them as interesting cases present; this requires all involved (both patients and teachers) to be comfortable with the format, as it can be difficult to organize and manage. It can also create an environment where clinical information, e.g. clinical signs, may be seen as more important than patient welfare It is vital to clarify intended learning outcomes. Flip-flop: here learners spend a designated time with each clinician; this has the advantage of not tiring teachers and allowing protected time both for teaching and clinical commitments
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A variety of organisational models for teaching in ambulatory settings have been described, depending on the number of teachers, students, and the location. They range from the ‗grandstand‘ model, with multiple observers, to the ‗report back‘ model, where learners see patients on their own, then report back [20, 23]. ( Box 2) Formal postgraduate training in general practice (family medicine) has been established for over 40 years, and ‗set the bar‘ in many areas of clinical education including curriculum development, quality control, teacher training, and methods of assessment. Undergraduate teaching and learning in general practice has also come of age in the last couple of decades, with many medical schools offering extensive exposure in this setting, sometimes in every year of the course. Concerns about whether general practice could ‗deliver‘, for example about quality of teaching, impact on service, and effects on the doctor-patient relationship [24], have not been borne out in practice. Virtually anything, other than what one author referred to as ‗fire engine medicine‘, can be taught in general practice, the real question being ‗what is best taught where, and by whom?‘ [25]. However there are certain areas that may be best taught or can only be taught in this setting. These include: presentation and management of undifferentiated problems; the skills of triage; early presentation of disease and evolution of problems over time; aspects of population medicine; conditions which, though rarely seen in hospital, are common in the community; and health, illness and disease in its social context [25]. In this era of increasing specialization and sub-specialization it is one of the few settings in which learners can experience a generalist approach [26], and it is also an ideal setting for early patient contact. On the whole, general practice placements receive excellent ratings from learners. In some innovative undergraduate programmes students spend major periods of their clinical training in the community, mainly in rural settings; evaluations of these schemes are generally very favourable [27].
THE OPERATING THEATRE The operating theatre (OT) is one of the most complex and challenging settings in which clinical education takes place. Student involvement might involve anything from working with the anaesthetic team to scrubbing up and assisting with the operation. The potential for learning is huge. As Patricia Lyon of Sydney University put it ‗The operating theatre provides a sensory perceptual experience enabling students to construct a „clinical memory‟; by integrating tactile sensations of live pathology with visual images and verbal learning. It presents an opportunity to observe real clinical problems and their surgical management, to begin to appreciate what surgery means to patients both physically and emotionally, and gain insights into the work of the surgeon as a member of a multi-professional team.‟ [28]. When it works, the experience is valuable and enjoyable, even exciting. Unfortunately, for many students, the environment is alien and hostile, they find themselves competing with other learners whose needs are more pressing (eg the surgical trainee), learning is passive, and the potential is not realised. In fairness, unlike most other educational situations, the needs of the patient are critical and immediate, there may be considerable tension due to the demands of the surgery, and the student is not only a hindrance to the surgical team, they are potentially a hazard. At worst, the hapless medical student stands at the periphery of the action, with no real idea what is going on and who the various players are, is hardly spoken to except when
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curtly told not to stand there or do that, and when finally allowed a peek into the operating area is berated in thunderous tones by the surgeon for not knowing any anatomy. A caricature, perhaps, but one that will resonate with many readers. As Lyon wrote ‗The operating theatre can be a confronting, unpredictable and disorienting place for the medical student as a learner...‟ [29]. Despite being a routine component of surgical placements, teaching and learning in the OT is a relatively under-researched area. However, Lyon has recently described a model of learning in OT which proposes that students have to successfully negotiate three ‗domains‘ if they are to benefit from the experience (see Box 3). Firstly, they must ‗navigate‘ the physical environment, orientate to and learn about the culture, protocols and norms of the OT, and cope with the emotional impact of both the surgery itself, and the demands it places on the surgical team. Students usually have to work all this out ‗on the run‘ against a background of anxiety about doing something wrong or being made to look a fool. Secondly, they often have to monitor and manage the learning experience themselves, including defining objectives and goals, using time efficiently, and making judgments about the relevance and usefulness and thus the opportunity costs of attending theatre, or not. Thirdly, they must negotiate the social relations and dynamics of the OT, and find a legitimate role that enables them to participate and make a useful contribution. Lyon again: ‗Establishing credibility, negotiating a role to play, participating in the team, and having that participation supported and acknowledged as legitimate, is crucial to student learning in theatres.‟ [28]. Later work elucidated this particular domain and suggested that students ‗size up‘ the situation and in particular the willingness and interest of the surgeon in teaching, at the same time as the surgical teacher judges the student‘s motivation; thus they effectively co-create a learning environment which is conducive (or not) to teaching and learning [29]. The educational implications are clear. Although ultimately a culture change may be required to make the OT more teaching-friendly, there are many practical steps that can be taken. These include investing in preparation of the students with briefing information, orientation sessions with theatre staff, exercises in group interaction, and provision of a template for guiding learning (for example, in developing ‗noticing skills‘), and so on [28]. Thomas, writing from a student‘s perspective argued, in addition, the case for the use of a simulated OT in preparing students and trainees for the experience [30]. The stereotype of the hostile environment has, encouragingly, been challenged by recent work in a UK operating theatre [31] Box 3. Domains of learning in the operating theatre [28] 1. The demands of the working environment and the emotional impact of surgery as work 2. Learning and the social relations of work in the operating theatre 3. The educational tasks, determining the learning objectives and relevance
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EARLY CLINICAL EXPERIENCE There has been a trend for some time towards introducing medical students to the clinical environment at an early stage, and this is now considered one of the features of a modern curriculum. A wide range of formats have been reported: clinical placements in both hospital and general practice; community-based projects (e.g. student attached to a woman expecting a baby, following them up over time); placement with a community agency; and involvement in public health campaigns. A considerable literature has also accumulated about the benefits, problems and potential outcomes. A recent systematic review showed that early experience, here defined as ―authentic (real as opposed to simulated) human contact in a social or clinical context that enhances learning of health, illness and/or disease, and the role of the health professional‖ occurring in the first two years of a pre-registration course, had a variety of aims and was most commonly provided in primary care and community settings. Early experience seemed to increase popularity of primary care residencies, helped foster self-awareness and empathic attitudes, motivated students and boosted their confidence and satisfaction, especially when they contributed to the care of patients, helped them learn interpersonal skills and influenced development of a professional identity and sense of social responsibility. Significantly, early experience appeared to make transition to the clinical environment less stressful. It also helped students learn about the health needs of populations, and the link between theory and practice. [32]. A recent survey of activity in UK medical schools, showed wide variation in amount of contact (ranging from 4 to 65 days in the first two years), and three basic patterns: traditional pre-clinical/clinical split, with limited early contact providing an introduction to social aspects of health and illness; significant contact designed to help integrate knowledge and develop skills, often starting as early as the first week of medical school; and an intermediate model. Between one third and a half of such contact was provided by general practice. Early clinical contact is generally very well received by learners [33]. One would predict that for early contact experiences to be most effective, beginning learners need clear guidance and structure, i.e. ‗supported participation‘ [13].
THE PATIENT’S ROLE Sir William Osler‘s dictum that ‗For the junior student in medicine and surgery it is a safe rule to have no teaching without a patient for a text, and the best teaching is that taught by the patient himself‘.‘ [34] reminds us of the central role of the patient in clinical education. Yet historically patients have been more or less passive players, often little more than interesting teaching ‗material‘ with which the teacher performs their ‗magic‘ [35]. A significant literature has accumulated about the benefits, the challenges and the potential of involving patients in more active roles [3, 4, 35]. Levels of involvement vary. Clearly a critically ill patient around whom students might learn is unavoidably passive! However, there is great potential for more active involvement of less sick patients. At the most basic level, a clinical teacher can brief the patient about the students, their background and level of learning and, in particular, the aims of the teaching encounter, what the patient might expect and what the teacher would like them to do. Research has shown that many patients have an
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astute notion of what they can contribute [35]. For example, they recognise they can ‗show and tell‘ what it is like to experience a particular condition, and understand the role they play in helping facilitate the development of professional skills and attitudes. Increasing numbers of initiatives have been introduced in which patients with particular conditions, usually chronic, for example musculoskeletal problems, and who are often not under active care, act as both the patient and the teacher and run a teaching session. Evaluations of such patient educator or ‗expert patient‘ schemes are invariably very positive [35]. Advantages of involving patients who not are actively receiving care in the clinical setting include reduced likelihood of causing harm, less chance of exploiting their goodwill, and possibly better motivated and willing participants. Patient educators may also help overcome challenges involving intimate examinations, for example pelvic and breast examination. Indeed some of the earliest literature about patient educators described, in the 1960s, the role of ‗Gynaecology Teaching Associates‘ [36]. Patient educators may ease pressure on already overstretched clinical teaching staff since, once they are trained, they can perfectly well run sessions themselves. Finally, suitably trained patients can be used in clinical assessments, at the least giving contributing a global mark, at most, as is commonplace in North America, being involved in an OSCE with no other examiner present. Most patients appear to benefit from involvement in teaching and training, generally reporting high levels of satisfaction. Altruism and a wish to pay the system back for the care they have received are powerful motivators. They feel better informed about their condition, are pleased to be able to contribute to the training of ‗tomorrow‘s doctors‘, and may feel they are given a better service all round. There is little published work on any long-term benefits of involvement. A proportion of patients may prefer not to have student contact, for example a student ‗sitting in‘ a clinic or taking a history at the bedside. This may depend on the nature of the problem(s); patients with more intimate and embarrassing conditions, or those in ‗high stakes‘ situations (e.g. childbirth) are less likely to wish to see a student, and/or are less satisfied with encounters in which they do. Learner gender or cultural factors may influence patients‘ willingness, as may previous experience, or when group size is large. In the long term some patients may feel worse after involvement in teaching, and a proportion may have feelings of ill-health reinforced, particularly through repeated contact. A number of challenges arise in relation to patient involvement, both organisational and ethical. Practical problems include recruitment, provision of appropriate training, remuneration (whether to and at what level), and monitoring to ensure patients are not harmed or abused. The main ethical issues, and patients‘ concerns, relate to consent and confidentiality. It was assumed in the past that it was part of the ‗quid pro quo‘ for receiving care in a teaching hospital that a patient must expect to see students and trainees. With informed consent now embedded in policy and practice, and in the context of the drive towards greater patient-centredness, this is no longer tenable. It should be the norm to inform patients, ideally through information sent in advance if they are ambulant, that students or trainees may be involved in their care, and that they have the right, without prejudice, to refuse. Patients may also be concerned about confidentiality, particularly when large numbers of professionals are involved in their care and are sharing information whether for clinical or educational reasons. There may also be concerns about learners having access to the patient‘s records. Patients need sufficient information to make informed choices about involvement. There are some practical steps that can be taken, such as avoiding discussion of personal or
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embarrassing issues at the bedside (curtains around a bed are not soundproof!), briefing learners about confidentiality matters, and finding a more intimate space (as well as time) to discuss distressing issues. Recent recommendations in the UK on promoting more active involvement of patients suggested appointed of a dedicated lead, greater exposure of learners (both undergraduate and postgraduate) to patients with long-term conditions and from more diverse background, extending the role of patients into areas such as assessment and curriculum development, and provisions of clear guidance on consent and confidentiality for all involved [3].
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CONCLUSION There is no doubt that clinical education is under pressure and that this is unlikely to diminish. Significant factors include changes in demography, continuing organisational change, greater external control (e.g. managed care in the US), changing patterns of health care and an increasingly complex work environment, and new working practices (for example the European Working Time Directive). ‗On the shop floor‘ clinical educators are also challenged. Those in non-academic positions (who comprise the majority of clinical teachers, at both undergraduate and postgraduate levels) may feel ill-prepared for the job, poorly supported and under-resourced, and not part of a broader educational system. They perceive that their efforts go unrecognised and unrewarded. Clinical academics have the additional burden of reconciling the demands of academia, in which setting, whatever the rhetoric, research activity has traditionally been valued over involvement in teaching, in addition to problems of recruitment and retention and a lack of a career track [37]. Tackling these problems in order to maximise the potential of learning in the workplace will require flexible and innovative solutions. A decade ago an international group of experienced clinical educators recommended four strategies for enhancing the learning environment: ensuring teachers understand the purpose and process of learning; equipping learners with ‗survival skills‘; making best use of available resources; and judicious use of information technology [38]. These remain pertinent today.
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Jolly B. Historical and theoretical background. Ch 7.1 in: Jolly B, Rees L (eds). Medical education in the millennium. Oxford: Oxford University Press, 1998. Publications. Spencer J. Learning and teaching in the clinical environment. British Medical Journal 2003; 326: 591-594. BMA. The role of the patient in medical education. London: BMA, 2008 Jha V, Quinton ND, Bekker HL, Roberts TE. Strategies and interventions for the involvement of real patients in medical education: a systematic review. Medical Education 2009; 43: 10-20. Irby D. Teaching and learning in ambulatory settings. A thematic review of the literature. Academic Medicine 1995; 70(10): 898-931.
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John Spencer Lempp H, Seale C. The hidden curriculum in undergraduate medical education: qualitative study of medical students‘ perceptions of teaching. BMJ 2004; 329: 770773. Lewin, K. Field theory in social science; selected theoretical papers. Cartwright D (ed.). New York: Harper & Row, 1951. Mann K. Learning and teaching in professional character development, pp145-183. In: Kenny N, Shelton W (eds), Lost Virtue: Professional Character Development in Medical Education: Advances in Bioethics 10. Oxford: Elsevier Ltd, 2006. Kolb DA. Experiential learning. Eaglewood Cliffs NJ: Prentice Hall, 1984. Lave J, Wenger E. Situated learning. Legitimate peripheral participation. Cambridge: Cambridge University Press, 1991. Kaufman D, Mann K. Teaching and learning in medical education: how theory can inform practice. Understanding Medical Education booklet. Edinburgh: ASME, 2007. Collins, Brown, Newman, 1989, 481-482. Dornan T, Boshuizen H, King N, Scherpbier A. Experience-based learning: a model linking the processes and outcomes of medical students‘ workplace learning. Medical Education 2007; 41: 84-91. Irby D. How attending physicians make instructional decisions when conducting teaching rounds. Academic Medicine 1992; 67: 630-638. O‘Hare JA. Anatomy of the ward round. Eur J Intern Medicine 2008; 19(5): 309-313. Ramani S, Leinster S. Teaching in the clinical environment. AMEE Guide no 34. Medical Teacher 2008; 30: 347-364. Stanley P. Structuring ward rounds for learning: can opportunities be created? Medical Education 1998; 32: 239-243. Cox K. Planning bedside teaching: 1. Overview. Medical Journal of Australia 1993; 158: 280-281. http://student.bmj.com/issues/04/02/careers/63a.php (accessed March 2009). Sprake C, Cantillon P, Metcalf J, Spencer J. Teaching in an ambulatory care setting. British Medical Journal 2008; 337 doi:10.1136/bmj.a1156 McGee SR, Irby DM. Teaching in the outpatient clinic. Practical tips. Journal of General Internal Medicine 1997; 12: s34-40. Irby DM, Wilkerson L. Teaching when time is limited. British Medical Journal 2008; 336: 384-7. Dent J. AMEE Guide No 26. Clinical teaching in ambulatory care setting: making the most of learning opportunities with outpatients. Medical Teacher 2005; 27(4): 302315. Murray E, Modell M. Community-based teaching: the challenges. British Journal of General Practice 1999; 49: 395-398. Spencer J. What can undergraduate education offer general practice? Ch 4 In: Harrison J, van Zwanenberg T (Eds). GP tomorrow (2nd edition). Oxford: Radcliffe Medical Press, 2002. Spencer J. Generalism is dead. Long live generalism! In: Welfare M (ed). Monograph on the Foundation Programme. Edinburgh: ASME, 2007. Worley P, Prideaux D, Strasser R, Magarey A, March R. Empirical evidence for symbiosis medical education: a comparative analysis of community and tertiary-based programs. Medical Education 2006; 40:109-116.
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[28] Lyon PMA. Making the most of learning in the operating theatre: student strategies and curricular initiatives. Medical Education 2003; 37: 680-688. [29] Lyon P. A model of teaching and learning in the operating theatre. Medical Education 2004‘ 38: 1278-1287. [30] Thomas P. A junior medical student meets the operating theatre. The Clinical Teacher 2006; 3: 202-205. [31] Nagraj S, Wall D, Jones E. Can STEEM be used to measure the educational environment within the operating theatre for undergraduate medical students? Medical Teacher 2006; 28: 642-7. [32] Littlewood S, Ypinazar V, Margolis SA, Scherpbier A, Spencer J, Dornan T. Early practical experience and the social responsiveness of clinical education: systematic review. British Medical Journal 2005; 331: 387-391. [33] Hopayian K, Howe A, Dagley V. A survey of UK medical schools‘ arrangements for early patient contact. Medical Teacher 2007; 29: 806-813. [34] Osler W. The hospital as a college. Chapter XVI. In: Aequanimatus, and Other Addresses. London: HK Lewis; 1905. [35] Spencer J, Blackmore D, Heard S, McCrorie P, McHaffie D, Scherpbier A, Sen Gupta T, Singh K, Southgate L. Patient-oriented learning: a review of the role of patients in the education of medical students. Medical Education 2000; 34: 851-857. [36] Towle A et al. Active patient involvement in the education of health professionals. Medical Education (in press) [37] Spencer J. The clinical teaching context: a cause for concern. Medical Education 2003; 37: 182-183. [38] Gordon J, Hazlett C, Ten Cate O, Mann K, Kilminster S, Snell L et al. Strategic planning in medical education: enhancing the learning environment for students in clinical settings. Medical Education 2000; 34:841-50.
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In: Medical Education: The State of the Art Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 47-55
ISBN: 978-1-60876-194-4 © 2010 Nova Science Publishers, Inc.
Chapter 5
INTERPROFESSIONAL EDUCATION Marilyn Hammick
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ABSTRACT Internationally, policy makers and practitioners in education, health and social care, view effective collaborative practice as a mean towards improved outcomes for health and social care service users. Concomitantly, evidence indicates that effective interprofessional education prepares staff for collaborative practice. This applies to the future workforce, i.e. students on initial education programmes and also those who participate in postgraduate education, continuing professional development and service enhancement work. This chapter discusses how systematic review evidence and the principles of good education practice, can be applied to the development and delivery of interprofessional education to enhance its effectiveness. It outlines the distinctive challenges of planning and facilitating interprofessional education. These include the need for learning to be meaningfully related to the learner‘s practice, cognisant of adult learning principles and mindful of the individual context of the education initiative. There is comment on the importance of preparing staff for their role in interprofessional education and evaluating its impact on learners and the services they deliver.
INTRODUCTION ‗Interprofessional education occurs when students from two or more professions learn about, from and with each other to enable effective collaboration and improve health outcomes.‘ [1] This chapter opens by looking at the reasons for the recent worldwide interest in interprofessional education. The characteristics of interprofessional education across the world are outlined. There is comment on why learning to be interprofessional and thus to be part of a ‗collaborative practice ready‘ workforce [1] is important for all practitioners responsible for delivering human services. Developing and delivering effective interprofessional education is then discussed. This discussion draws on the definition of
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interprofessional education that opened this chapter, four key practice-related lessons from a 2008 systematic review of international interprofessional education (Box 1) and some general principles of sound education practice. Learning about being interprofessional in a context that reflects the students‘ current or future practice is important for effective learning. IPE curriculum developers need to recognise the adult learning needs of the participants and structure teaching with this in mind. Teachers need to be aware that learner reaction to IPE is related to multiple factors. Staff development in the facilitation of IPE is essential to its effectiveness. .
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REASONS FOR INTERPROFESSIONAL EDUCATION Evidence indicates that interprofessional education can lead to improved collaboration between health and human services practitioners. [1, 2, 3, 4] Pollard et al. [5] reported that ‗IPE can impact positively on interprofessional working in practice, and on care delivery itself‘. Interprofessional collaborative practice has been shown to enhance health outcomes, improve patient safety and have a positive impact on staff morale. [6, 7, 8] The implementation of effective interprofessional education is growing. Canada, Sweden and the United Kingdom now have examples that have been maintained over a number of years and have demonstrated its feasibility and value; see, for example, a 2008 report from two Scottish universities. [9] There are reports of interprofessional education in Iran, Mexico, Poland, and South Africa. Worldwide initiatives involve students from a broad range of professions, including allied health practitioners, midwives, nurses, pharmacists, physicians, and social workers. [1, 10] Implementation of interprofessional education often arises from the recognition that better collaboration amongst all practitioners delivering human services can contribute to more effective heath and social care systems. The 2008 World Health Organisation Framework for Action on Interprofessional Education and Collaborative Practice calls for global action on interprofessional education as a way to mediate concerns about achieving the health outcomes in the Millennium Development Goals. [1] In the United Kingdom interprofessional education has been developed (in part) as a response to poor collaboration being identified as a key factor in critical service delivery errors in some high profile cases. [11, 12]. Box 1. Some Key Lessons for Practice [2] Learning about being interprofessional in a context that reflects the students‘ current or future practice is important for effective learning. IPE curriculum developers need to recognise the adult learning needs of the participants and structure teaching with this in mind. Teachers need to be aware that learner reaction to IPE is related to multiple factors. Staff development in the facilitation of IPE is essential to its effectiveness.
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The development and delivery of interprofessional education does not only happen in reaction to a potential crisis or fatal incident. The measured and thoughtful response by educators and practice managers to the needs of many patients and clients, often driven by policy imperatives, has also prompted its implementation. For example, it is seen as one way to enhance services to the increasing number of people with complex and enduring health and social care needs and the growing population of older people in North America and Europe, and to under-served rural populations in Australia and Canada (see, for example [13]). Interprofessional education is also a mechanism to enhance the development of practice and improvement of services in the context of quality improvement initiatives. [2] In many situations, ‗interprofessional working is now seen as an integral part of service delivery.‘ [10] Significantly, many practitioners now consider that being able to collaborate effectively with their colleagues is part of their professional practice. In other words, being professional means being interprofessional. [14] Given these imperatives it is up to educators and their colleagues in related practice settings to implement effective interprofessional education.
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EFFECTIVE INTERPROFESSIONAL EDUCATION Effective interprofessional education means that students learn the knowledge, skills and attitudes essential for collaborative practice. More than this, they need to know how to transfer collaborative behaviours into diverse practice settings; in their present situations and, as their career develops, in the future. Importantly, it also means understanding that the width of twenty first century professional practice spans independent practice, consulting with colleagues and collaborative practice. Learners on interprofessional courses include those on initial registration programmes, post registration or continued professional education courses and continuous quality improvement initiatives. How interprofessional education happens varies. It depends on who the learner is, where learning takes place, and why interprofessional learning has been selected as the outcome to be achieved. The relationship between education and practice also varies. Campus based interprofessional education may have a more distant relationship to the workplace, bringing practice into the learning through case based material. Many preregistration students experience interprofessional learning on their clinical placements, [15, 16] and almost all interprofessional quality improvement learning is done within the practice setting. [17, 18] As Freeth (2007) reminds us ‗interprofessional education … is just a special case of professional education‘. [19] It is special because it sets out to create learning situations where students from two or more professional groups can learn about, from and with each other. Special also because this learning has a specific purpose: to improve collaboration and thus outcomes for the patient/client. Interprofessional education can occur in all practice settings and types of health and social care services. This means that sometimes the learning outcomes focus on specific services, for example, cardiovascular or palliative care services, management of falls for the older person, and sometimes they are more general, for example, aimed at key principles of good practice in topics such as patient safety. In all these different interprofessional learning situations the principles of good education practice and effective interprofessional education practice underpin the development and
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delivery of the curriculum. It is impossible in this chapter to elaborate on all aspects of good education practice but one that does deserve attention is the need for learning outcomes that align with how the learning is delivered and assessed. For effective interprofessional learning, the content of learning outcomes must be strongly related to the knowledge, skills and attitudes needed to be an interprofessional practitioner and work effectively in collaboration with colleagues from other professions. [1] These are often then aligned to an individual institution‘s interprofessional competency or capability framework. They will differ according to educational level and intent and, as Clark reminded us, should be aimed at enabling health care practitioners to collaborate in a patientcentred practice. [20] In general, interprofessional learning outcomes for students on initial professional education programmes tend to focus on:
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knowing more about other‘s scopes of practice and basic team working, for example, the stages that teams pass through during their lifetime; the skills of being a team member, for example, communicating well, and being able to identify where collaborative practice is necessary for effective patient/client care; the attitudes that enable these skills to be applied in the right way, for example, having respect for the knowledge and views of colleagues. For qualified staff the expectation is (amongst other outcomes) that they will have a greater understanding of the context and challenges to collaborative work, be skilful negotiators, know when to be a leader and when not to be and have a positive attitude to relinquishing responsibility. Learning outcomes also need to be tailored to the patient/client or service setting of the learning situation. For more details of interprofessional learning outcomes see. [1, 17 , 21] As Box 1 shows using principles of adult learning in interprofessional education is important. Interprofessional education needs to be delivered in ways that recognises that the learners bring their prior educational experiences into the classroom and, for some, their experience of practice; and they have individual levels of self esteem and self-efficacy. They may also bring unhelpful stereotypical images of their peers, memories of friction in the workplace, apprehension rooted in earlier unsatisfactory experiences, and hidden agendas relating to traditional power structures in healthcare. [20] These learner characteristics give interprofessional education its unique nature. They create challenges for staff introducing interprofessional education and, as discussed below, demand attention to some distinctive aspects of its development and delivery.
The Unique Nature of Interprofessional Education Partnership working by staff from different faculties, often from different higher education institutions and from relevant practice settings, is needed to develop and implement a curriculum that is acceptable for all interprofessional learners. This is especially so when compulsory interprofessional education is introduced into several undergraduate programmes. [9] It is also important for the team planning interprofessional in-service study days.
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Attracting participants from across professional groups depend on delivering a course that suits all needs and working patterns. Often this is a tall order. Staff involved in developing interprofessional education themselves learn the challenges of learning about, from and with each other before their students do. The uniqueness of interprofessional education determines the content of a curriculum or course plan, i.e. what is in the syllabus, the reading lists and the key texts and policy documents cited in the rationale for the initiative. The processes involved in realising the aims and objectives of the education being planned, for example, the teaching and learning methods, are also shaped by the distinctive nature of interprofessional education. Learning has to be arranged so that students can initially learn about each other, then from each other and then move onto learning with each other. With adult learning principles in mind this needs to be both active and interactive learning. Problem and enquiry based learning provide ways of achieving this; small group work using case study materials do the same. Simulated learning in Clinical Skills Laboratories offers potential opportunities that mirror the real world of practice and prepare students for interprofessional working. [22] Potential because these learning experiences need to be well designed and delivered by staff prepared for their role as interprofessional learning facilitators using simulated situations. Similarly, the training ward at the Karolinska Institutet, Sweden provides a safe and real interprofessional learning environment. [23] The use of patient narratives as described by Blickem and Priyadharshini (2007). Blickem et al [24] offer material to initiate discussions related to the real world of professional practice. All these learning experiences put the patient or client or the service to be delivered at their centre. In this way, they achieve authentic interprofessional learning –a key determinant of effective interprofessional education. Interprofessional education almost always involves some face to face to contact between learners, in small groups facilitated by staff who have had some training to prepare them for this role (there is more about staff training for interprofessional education later). For students on their initial education course e-learning often provides the way to meet the challenge of enabling students from different programmes to continue to learn together. On line interprofessional learning initiatives are not confined to these students and can be used effectively blended with face to face events. They can provide qualified practitioners with opportunities to learn about their colleagues‘ practice [25] and enable service users to be included in the learning. [26] Your approach to developing and delivering interprofessional education will depend on the purpose for its implementation, the nature of the student cohort and the context in which the planning, teaching and learning will take place. However, as Box 1 shows, a key factor for effective interprofessional education is authentic, sometimes also called customised, learning.
The Challenge of Providing Active and Authentic Interprofessional Learning The importance of learning about collaborative practice with material, or in a context, relevant to students‘ practice has already been highlighted and teaching methods that achieve this discussed. The clinical skills laboratory and training ward are not available for all. Many education developers face considerable challenges organising active and authentic interprofessional learning. The reasons for this are outlined briefly below.
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Universities plan interprofessional learning for students registered on the programmes delivered in their medical, health science and social science faculties. In most cases this also involves the practice settings responsible for the clinical education of students. Interprofessional modules, study days or practice related initiatives for full time students are shaped according to the students‘ uniprofessional programmes with all their diverse curricula and regulations for professional education. It is rare to have the luxury of the ideal mix and numbers of students or (at least initially) to have facilities and learning spaces suitable for large numbers of students to work in small groups together. The availability and use of information and communication technologies to enable students to learn together varies, especially off campus access to e-learning materials and communication tools such as wikis and blogs. The practical challenges all need to be worked out in a collaborative way. The aim is that everyone involved sees the introduction of interprofessional education as a welcome and sustainable addition for their students rather than an unnecessary and thus potentially short term intrusion.
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STAFF DEVELOPMENT FOR INTERPROFESSIONAL EDUCATION Staff engaged in any aspect of interprofessional education develop need to be prepared for this work: this applies to on-campus and clinical teachers. This need for training and support about interprofessionalism extends to the staff students will meet on their placements. [5, 27] In this way staff are good role models for students and equipped to facilitate and support learners preparing to be part of the collaborative practice ready workforce. [1] Once again, the distinctive nature of interprofessional learning is the reason why attention is needed to the preparation of staff for their roles in developing, delivering and supporting interprofessional learning. Participants in interprofessional education bring unique values about themselves and others into any learning initiative. Their age, gender, previous work and personal experiences and perception of professional stereotypes interact in complex ways during the process of learning about, from and with each other. For students on initial education programmes the timing of the interprofessional element of their programme may ill suit their uniprofessional studies. They may be surprised at the inclusion of interprofessional learning. Although not recommended, interprofessional education is still sometimes voluntary; sometimes it is voluntary for some students and compulsory for their peers! Assessment of interprofessional learning remains developmental and many initiatives do not have dedicated assessment for all participating learners. All this leads to the potential for a challenging student group for the interprofessional teacher. Facilitating qualified staff who are learning interprofessionally also has challenges. Health care carries a history of a traditional hierarchy which can make it difficult for some participants to be confident that their views will be respected. Improvement in health outcomes in the twenty first century requires an enlightened approach to who should be learning and working together. Often this needs to be inter-agency as well as interprofessional, for example, to improve child protection service many staff from health and social care agencies need to learn and work together. These staff will bring their diverse professional values, models and ways of working into the learning situation. A trained
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facilitator is better able to recognise the problems that this mélange gives rise to and to support learners through the potential stormy phases of their team learning processes.
CONCLUSION Interprofessional education is an increasingly important part of professional education for all health and social care practitioners. It is frequently the preferred way of learning for qualified staff on post-graduate and continued professional development courses and those involved in quality improvement work. There is no-one model for interprofessional education. Rather, as discussed above, there are principles of good practice to apply to the individual context of the planned learning experience. These principles need to be applied by teaching staff who have undertaken some training and development in interprofessional education. Clinical learning facilitators also need to learn about interprofessional education to support students on placements. In this way, interprofessional education becomes an effective means towards effective collaborative practice.
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World Health Organization (2008) Framework for Action on Interprofessional Education and Collaborative Practice, Geneva: World Health Organization. Hammick, M; Freeth, D; Koppel, I; Reeves, S. & Barr, H. (2007) A Best Evidence Systematic Review of Interprofessional Education BEME Guide No. 9, Medical Teacher 29, 8, 735-51. Reeves, S; Zwarenstein, M; Goldman, J; Barr, H; Freeth, D; Hammick, M & Koppel, I. (2008) Interprofessional education: Effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews, Issue 1. Barr, H; Koppel I; Reeves, S; Hammick, M & Freeth, D. (2005) Effective Interprofessional Education: Argument, Assumption and Evidence, Oxford: Blackwell Publishing. Pollard, K; Rickaby, C & Miers, M (2008) Evaluating student learning in an interprofessional curriculum: the relevance of pre-qualifying inter-professional education for future professional practice, London: Health Sciences and Practice Subject Centre of the Higher Education Academy. Mickan, SM; (2005) Evaluating the effectiveness of health care teams, Australian Health Review, 29(2):211-217. West, M. A; Guthrie, J. P; Dawson, J. F; Borrill, C. S & Carter, M. R. (2006) Reducing patient mortality in hospitals: The role of human resource management, Journal of Organizational Behavior, 27, 983-1002. Reeves, S. (2001) A systematic review of the effects of interprofessional education on staff involved in the care of adults with mental health problems, Journal of Psychiatric Mental Health Nursing, 2001 8, 6:533-542. The University of Aberdeen and Robert Gordon University, Aberdeen (2008) The Aberdeen Interprofessional Health and Social Care Education Initiative - Final Report
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Marilyn Hammick to the Scottish Government Aberdeen: The University of Aberdeen and The Robert Gordon University, Aberdeen. Lakhani, N & Anderson, EA (2008) Interprofessional Education: preparing future pharmacists for 2020 The Pharmaceutical Journal 280, 571-2. Kennedy, I; Howard, R; Jarman, B & Maclean, M (2001) Learning from Bristol: the report of the public inquiry into children‘s heart surgery at the Bristol Royal Infirmary 1984-1995. Command Paper CM 5207 and available from www.bristolinquiry.org.uk/index.htm Laming, Lord (2003) Report of the Victoria Climbié Inquiry Presented to the Secretary of State for Health and the Secretary for the Home Department. McNair, R; Stone, N; Sims, J & Curtis C (2005) Australian evidence for interprofessional education contributing to effective teamwork preparation and interest in rural practice, Journal of Interprofessional Care 19, 6 579-594. Hammick, M; Freeth, D; Copperman, J & Goodsman, D. (in press) Being Interprofessional, Cambridge: Polity Press. Metcalfe, J (2008) Embedding patient safety teaching in clinical placements for undergraduate healthcare students CAIPE Bulletin London: Centre for the Advancement of Interprofessional Education. Crutcher, R; Then K; Edwards, A; Taylor, K & Norton, P. (2004), Multi-professional education in diabetes, Medical Teacher, 26, 5, 435-443. Horbar, JD; Rogowski, J; Plsek, PE; Delmore, P; Edwards, WH; Hocker, J; Kantak, A D; Lewallen, P; Lewis, W; Lewit, E; McCarroll, CJ; Mujsce, D; Payne, N R; Shiono, P; Soll, RF; Leahy, K & Carpenter, J H. (2001) Collaborative quality improvement for neonatal intensive care. NIC/Q Project Investigators of the Vermont Oxford Network, Pediatrics, 107, 1, 14-22. Ketola, E; Sipila, R; Makela, M; & Klockars, M. (2000) Quality improvement programme for cardiovascular disease risk factor recording in primary care, Quality in Health Care, 9, 3, 175-180. Freeth D. (2007) Interprofessional Education: Understanding Medical Education, Edinburgh: Association for the Study of Medical Education. Clark, P G (2006) What would a theory of interprofessional education look like, Some suggestions for developing a theoretical framework for teamwork. Journal of Interprofessional Care 20 6 577-589. Freeth, D; Hammick, M; Reeves, S; Koppel, I & Barr, H. (2005) Effective Interprofessional Education: Development, Delivery and Evaluation, Oxford: Blackwell Publishing. http://www.qub.ac.uk/ceipe/index.htm (accessed 19/09/08) Lidskog, M; Lofmark, A & Ahlstrom G (2007) Interprofessional education on a training ward for older people; students‘ conceptions of nurses, occupational therapists and social workers, Journal of Interprofessional Care 21, 4 387-399. Blickem, C & Priyadharshini E (2007) Patient narratives: The potential for ‗patientcentred‘ interprofessional learning, Journal of Interprofessional Care 21 6 619-632. Walsh, K (2007) Interprofessional education online: The BMJ Learning experience, Journal of Interprofessional Care 21 6 691-693.
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[26] Posel, N: Fleiszer, D; Wiseman, J; Birlean, C; Margison, J; Faremo, S; Clauson, C & Bateman, D (2008) Using electronic cases to teach healthcare professionals and students about interprofessionalism, Journal of Interprofessional Care 22 1 111-114. [27] Hylin, U; Nyholm, H; Mattiasson, A & Ponzer, S (2007) Interprofessional training in clinical practice on a training ward for healthcare students; a two year follow up, Journal of Interprofessional Care 21 3 277-288.
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In: Medical Education: The State of the Art Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 57-68
ISBN: 978-1-60876-194-4 © 2010 Nova Science Publishers, Inc.
Chapter 6
DEVELOPING CLINICAL TEACHERS Peter Cantillon
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ABSTRACT Clinical education is the most important formative period during undergraduate and postgraduate medical education. The clinical learning environment has been described as chaotic, unplanned and at times, intimidating. The most important determinant of the quality of the clinical learning environment is the clinical teacher, yet most clinical educators have not been trained to teach. It has always been assumed that expert clinical knowledge is the only requirement for teaching clinical medicine. However, it has become increasingly clear that the haphazard nature of the clinical learning environment and the variable quality of clinical education is no longer acceptable and needs to be addressed. The most obvious development is help clinical educators to become better and more consistent teachers, mentors and supervisors. This is the essential focus of this chapter. However, if clinical teacher development is to work there also needs to be concomitant adjustments to the organisational structures of clinical settings that facilitate better education without jeopardising clinical care. Despite the fact that most clinical educators have not been trained to teach, they often process considerable tacit knowledge of pedagogy. This knowledge is likely to have been derived from their experiences as learners and teachers during a so called ―apprenticeship of observation‖. It is vital that teacher developers take cognisance of clinical teacher‘s prior pedagogical knowledge and beliefs because they exert huge influence on what they are capable of learning from teacher training workshops and courses. When planning teacher training it is also important to consider the nature of the clinical contexts where teachers work. The quality of the clinical environment is a key determinant of the ability of teachers to transfer new knowledge and skills to their workplaces. The first part of this chapter will review how teachers are developed from different theoretical perspectives. The second part of the chapter will describe and critique current teacher development approaches. Readers should emerge with a clearer understanding of what developing teachers is all about and be able to select appropriate teaching methodologies to suit their educational goals and purposes
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INTRODUCTION Clinical teaching is at the core of medical education. It represents the most important formative educational experience for both undergraduate and postgraduate learners (Parsell and Bligh 2001). Yet all too often students‘ experience of learning in a clinical environment is unsatisfactory, (Spencer, 2003). The clinical learning environment has been described as being chaotic, unplanned, haphazard and at times intimidating (Irby, 1994, Spencer, 2003). The primacy of service over teaching and factors such as a lack of space, time or teaching resources all play their part in making the clinical learning environment a very difficult place for high quality learning. However, despite the challenges of working in a setting dedicated to patient care it is the clinical teachers who are the most important determinants of the quality of the clinical learning environment, (Hesketh, 2001). It therefore follows that the variability manifest in the quality of clinical education is attributable in large part to the ability (and willingness) of clinical teachers to create safe and effective clinical learning environments despite the many obstacles. Whilst clinical teachers may be a critical determinant of the quality of learning they are often untrained for what they do, (Purcell & Lloyd-Jones, 2003). Much of clinical teachers‘ knowledge about teaching and learning is derived from their own experiences as learners and teachers during their lifelong ‗apprenticeship of observation‘ (Lortie, 1975 and Whitcomb, 2003). Teachers‘ apprenticeship of observation allows them to develop their own personal (or implicit) theories about teaching and learning that informs their teaching practice. Clinical teachers develop commonsense models of how students learn that influence their interpretation of the learning environment and inform their choices of action, (Munby, 2001). The extent of medical educators‘ implicit theories about pedagogy was nicely demonstrated in a study by McLeod et al in 2004. They found in an MCQ test of pedagogical knowledge that untrained clinical teachers often had considerable pedagogical knowledge that could be mapped to existing educational theory. However, other studies have found a lack of congruence between untrained teachers‘ knowledge of pedagogy and their teaching actions. In other words it appears as if experienced but untrained clinical teachers‘ can identify pedagogical principles correctly in an MCQ, but this knowledge does not necessarily convert into learner centred teaching that would be congruent with those same pedagogical principles. We know from studies of teachers in primary and secondary education that teachers who share the same domain expertise (e.g. mathematics) can differ markedly in terms of their representation of the subject matter, their knowledge of pedagogy and learners, (Mapolelo 1999 , Carter 1990). Why might this be so? One interesting explanation is the notion of conceptions of teaching (CoTs). Teachers‘ CoTs are specific meanings that teachers attach to phenomena in the learning environment, that then mediate how teachers interpret what they perceive and how they choose to act, (Devlin, 2006). Pratt (1992) described teachers as looking at the world through the lens of their CoTs. CoTs are derived from the teachers‘ apprenticeship of observation and act like blinkers to limit what they perceive and interpret. One of the commonest CoT descriptions is that of teaching orientation, (Devlin, 2006). Teachers are described as being either teacher or learner oriented. Teachers who are teacher oriented focus on transmitting knowledge and their own performance. Learner oriented teachers focus more on facilitating learner understanding. Thus, variance between clinical teachers may not only be a product of their lack of training or the pressures of the clinical
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work environment but it may be also due to the very different states of their knowledge and beliefs about learners and teaching. Interestingly, teacher‘s prior knowledge and beliefs about learning not only affect what and how they choose to teach, but it also limits their ability to acquire new pedagogical knowledge as in teacher training programmes (Ennis, 1997). In practice this means that teachers‘ prior knowledge and beliefs about pedagogy can make it difficult for them to acquire new knowledge about teaching.
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WHAT IS A GOOD TEACHER? People often say ―I don‘t know what a good teacher is but I know one when I see one‖. Another common aphorism about teachers is that good teachers are born not made. There is no doubt that personal attributes such as ability to listen, ability to explain, excellent memory are likely to support superior teaching. However teachers are also profoundly influenced by their own learning and teaching experiences. Thus, good teachers are both born and made. The purpose of this chapter is to examine the different approaches that might be used to develop clinical teachers bearing in mind that they come with the ‗baggage‘ of their prior knowledge and beliefs and that they do work in difficult educational environments which may be very difficult to influence. There have been several studies that attempt to describe from what a good clinical teacher is. One of the most recent systematic reviews of the literature was carried out by Sutkim et al (2008). They categorised the characteristics of a good clinical teacher in terms of three essential categories i.e. those of a) physician, b) teacher and c) human/personal characteristics. The characteristics of good teachers are outlined in box 1 below. The important finding from Sutkin‘s extensive review was that many of the features of good clinical teachers were non-cognitive. Whilst traditional faculty development workshops tend to focus on cognitive attributes such as curriculum design and assessment there is a clear need to include faculty development designs that promote attributes such as role modelling, inspiring learners and being able to communicate well. Box 1. characteristics of good clinical teachers Physician characteristics Possession of excellent clinical knowledge Demonstration of professional competence, Excellent professional role modelling. Teacher characteristics establishing a positive learning environment and An ability to inspire curiosity and interest in students. Human or personal characteristics An ability to communicate or explain well and a Personal characteristic of integrity and/or humility.
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DEVELOPING TEACHERS The development of teachers has been an object of study for nearly 100 years. It is important to examine some of the main theoretical paradigms that informed research on teacher development because they explain the different approaches currently used in teacher development.
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THE BEHAVIOURIST APPROACH Behaviourism is an approach to human development founded in the positivist scientific tradition, (Brophy & Good 1986). In the context of teacher development behaviourism focused on the relationship between teaching behaviours and student learning achievements, (Whitcomb, 2003). Behaviourism did not concern itself with the workings of memory or thinking because these were constructs that could not (apparently) be empirically measured, (Watson, 1930). The behaviourist approach to teacher development led to the establishment of a compendium of evidence based teaching approaches all of which had been shown to lead to more effective learning amongst students, (Carter, 1990). Teacher development was about giving teachers pedagogical skills and approaches that they could reassemble in the context of the classroom or lecture theatre. The problem with this approach was the marked discrepancy between how teachers were taught in for example in teacher education colleges and how they actually subsequently behave in classrooms, (Whitcomb, 2003). The behaviourist approach, by ignoring teachers‘ cognition and the importance of context, could not predict how teachers might behave when presented with complex and often unpredictable challenges of the classroom. It is as if teachers were making up solutions to teaching problems ―on the hoof‖ rather than following prescribed evidence based approaches. A growing dissatisfaction with behaviourisms ability to inform and explain teachers‘ behaviour led to a growing interest in how teachers acquire knowledge and how they think.
COGNITIVE PERSPECTIVE The advent in the 1950s of cognitive research in education shifted the object of interest from the link between teachers‘ behaviours and what students learn, to the relationship between how teachers think and how they act. Cognitivism is concerned with memory and how information is perceived, interpreted, stored and reproduced, (Regehr and Norman 1996). In the context of teacher development the cognitive perspective looks at the nature of teachers‘ knowledge and how it is acquired. It is also interested in how teachers make sense of new information (about teaching and learning), how they construct meaning and how they solve problems. One of the dominant approaches to studying teachers from a cognitive perspective was to study differences in the states of knowledge and the problem solving behaviours of expert and novice teachers. This research showed that as teachers become more expert their knowledge becomes more organised and elaborate. As knowledge becomes more elaborate it becomes easier to solve educational problems and to learn from experience. Thus expert teachers are
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better than novices at recognising the regularities (or salient issues) within educational problems. In practice this means that experts are not only better than novices at solving educational problems but they also learn better from their experiences of dealing with problems, (Carter, 1990). Differences between novices and experts were manifest in their approaches to teaching Novice teachers‘ knowledge about teaching and about the subject matter lacks the breadth and depth of expert knowledge. Novices are not aware for instance of the multiple examples, analogies and strategies that experts possess to make subject matter comprehensible for learners. Novices lack knowledge of learner misconceptions. They are more likely to present prototypical or text book descriptions when teaching rather than highlighting deeper structures and relationships within phenomena. Novice teachers tend to focus almost entirely on their own performance rather than student learning. Expert teachers on the other hand are much more concerned with what is happening in students‘ heads and what they can do to manipulate the environment to help students to learn. Understanding the differences between novice and expert teachers is helpful when considering how we might develop teachers. Should we, for example, help novice teachers to become more aware of the state of their own knowledge and how they might address deficiencies? Does self awareness lead to better teaching? The focus of this chapter so far has been on what teachers know about teaching and learners. However another important factor that determines the quality of teaching is what teachers know about the subject matter. Lee Shulman (1986) highlighted the different states of teachers‘ subject matter knowledge as important source of variance in education. Shulman described how teachers have to reformulate their own subject matter in order to make it comprehensible for learners. He coined the term ―pedagogical content knowledge‖, (PCK) to describe the ways that a teacher uses to represent subject matter to make it easier to learn for students. The key elements in teachers‘ PCK are: 1. The teachers‘ knowledge and beliefs about the subject matter 2. The teachers‘ knowledge and beliefs about the learners and the teaching context 3. The teachers‘ knowledge and beliefs about pedagogy and instructional strategy. These three elements combine in the moment of teaching to inform how the teacher represents and formulates the subject so that it is accessible for students. The PCK concept was translated by Irby, (1994) into the context of medical education. He described how expert clinical teachers develop ―teaching scripts‖ to inform their teaching about particular patients in clinical settings. An expert‘s teaching script is made of the teachers‘ knowledge of the patient, the subject matter (medicine), the students and his/her knowledge about teaching. These different sources of knowledge are brought together and enacted in the moment of teaching. Irby argued that teaching scripts are often tacit and that teachers tend to develop scripts for all of their common teaching tasks. The challenge for teacher developers is how to make the development of teaching scripts more explicit. Cognitive research has been hugely influential in helping us to understand the nature of teachers‘ knowledge but it still does not explain why teachers behave so unexpectedly in classrooms. These observations led researchers to explore what happens to teachers‘ knowledge in a teaching context. The relationship between knowledge and context is territory of situated cognition.
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THE SITUATED COGNITION PERSPECTIVE Situated cognition is a development of cognitive research based on the premise that teacher knowledge is not abstract and immutable. Rather, teachers‘ knowledge is strongly influenced by the context in which the knowledge is acquired and used, (Brown, 1989). In other words teachers‘ knowledge is shaped and changed by context. Researchers describe teachers‘ knowledge as ―contextually situated‖. In practice this means that the ―knowing‖ of teaching needs to be integrated with the ―doing‖ of teaching. Thus, when developing teachers we need to ensure that we understand their work contexts and that the learning is as authentic (realistic) as possible. There are several developments that emerged from situated cognition research on teachers. For example situated cognition includes the concept of reflective practice in which teachers are asked to reflect on their experiences, interpret events in the light of theory or principles and decide on new and better teaching approaches. Another situated cognition perspective is that of a so called ―cognitive apprenticeship‖ (Collins, 1991). It is an approach in which tacit or cognitive aspects of practice are made explicit whilst teachers are coached in educational approaches and techniques. The cognitive apprenticeship approach is fundamental to the role modelling and mentorship approaches to teacher development.
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SUMMARY So far we have established that clinical educators have not been trained to teach and yet they often process considerable tacit knowledge of pedagogy. This knowledge is likely to have been informed by their experience as learners, teachers and directs their teaching behaviours. We know from studies of teacher development that it is important to take account of teachers‘ prior knowledge and beliefs about learners, the subject matter and pedagogy. It is also important to consider the nature of the teaching and learning context as this profoundly affects both how teachers know, think and choose to act. The teacher development approaches that are outlined in the remainder of this chapter will take cognisance of these important factors.
DEVELOPING TEACHERS The remainder of this chapter will explore the different approaches to developing teachers (and in particular clinical teachers). It might be helpful to start with examining whether there is a defined set of teaching competencies or standards that clinical educators need to achieve however sadly no such commonly agreed set of standards exist. In table 1 you will find a brief list of clinical teaching competencies that have been derived from some recent comprehensive reviews, (Sutkin, 2008, Yeates, 2008). These are very common themes in teacher development courses, but how many workshops or faculty development approaches pay attention to teachers‘ prior knowledge and how many build learning transfer (i.e. transfer to the clinical teaching context) into their educational designs?
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Teaching competencies 1. 2. 3. 4. 5. 6. 7. 8.
Establishment of a positive learning environment for learning Setting of clear learning goals Provision of timely, specific and appropriate feedback Effective use of questioning Effective use of explanations Acting as an excellent role model Assessing learners Ability evaluate teaching and reflect on experience
Faculty development should not simply be about helping teachers to attain mastery of teaching routines. It should also encourage teachers to ask worthwhile questions of their own teaching, and to continue to learn from their own practice. Furthermore, faculty developers need to bear in mind that teachers are frequently returning to work environments that are toxic for educational innovation! Thus whatever faculty developments methods we choose to endorse they should encourage teachers to reflect on their own teaching and they should include some elements that prepare teachers for the work environments that they are returning to.
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APPROACHES TO DEVELOPING CLINICAL EDUCATORS The various approaches to developing clinical educators can be divided into formal and informal approaches (Steinert 2009). Formal approaches include workshops, seminars, short courses as well as fellowship degree programs and peer coaching. Informal approaches include work based learning, communities of practice, mentorship, role modelling and organisational changes that support effective teaching.
WORKSHOPS Workshops are perhaps the most common approach to developing teachers including clinical teachers. They are based on the behaviourist idea of giving teachers evidence based teaching knowledge and skills. Workshops offer many different potential educational approaches including mini-lectures, collaborative learning, role play, micro-teaching and so on. They represent an effective means of promoting teaching skills as well as knowledge acquisition. Workshops usually focus on particular competencies such as feedback or asking questions, they often include some theoretical explanation and some opportunities to practice the new techniques for skills within ‗authentic‘ settings. However workshops occur in places that are apart from the place of work or teaching. The so-called authentic experiences are rarely like the challenges that face clinical educators as they work. There is some evidence that workshop based educational approaches can lead to changes in thinking and subsequent behaviour however there are few if any studies that show that workshop based interventions lead to sustained changes in teaching behaviour.
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LONGITUDINAL PROGRAMS, FELLOWSHIPS, TEACHING SCHOLARS PROGRAMS ETC. For those clinical educators who express a strong wish to develop a deeper knowledge of teaching and learning the idea of taking a longitudinal program such as a post-graduate course in medical education or a fellowship is very attractive. Such programs usually include modules on learning theory, assessment, curriculum planning etc. There is no doubt that developing a deeper and more integrated knowledge of how students learn, helps clinical educators to become more versatile in their teaching approaches and much better at establishing effective learning environments. Fellowships and longitudinal programs are limited in a few important ways. First of all they are attractive and indeed feasible only for a few clinical educators. Many longitudinal courses are quite academic and course content does not always transfer well into the teaching workplace. Better courses and programmes include teaching practice elements and observations of teachers‘ teaching. Longitudinal programmes are a good way to develop educational leaders within professional domains; however the idea of spending a year or more studying and taking time out from clinical work to do a more indepth study of clinical education or education in general is impractical for most clinicians. Thus other models of faculty development are necessary.
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TEACHING PORTFOLIOS The situated cognition perspective on teacher development has argued very persuasively for the importance of encouraging reflection on teaching experiences and contexts to stimulate change and learning amongst teachers. There is good evidence to show that if teachers process their own experiences they develop deeper understandings of what teaching and learning are all about and are more likely to develop into better and more effective educators. Portfolios are commonly used for capturing such reflections. Portfolios are collections of reflections, samples of work, feedback from learners and colleagues and items of relevant literature that provide evidence of reflection on practice and progress as a teacher. Portfolios are used not only in longitudinal degree courses but are also used within universities and other settings as a means of developing teachers and recording progress in academic development. There is good evidence to show that portfolios do lead to better reflection and have demonstratible effects on the nature of teachers‘ development. However, portfolios are not feasible for everybody; portfolios require external mentors or supervisors to ensure that reflections are appropriate and that lessons are being learned. They can also be unwieldy and difficult to assess.
INFORMAL APPROACHES TO DEVELOPING CLINICAL EDUCATORS One of the major criticisms of formal approaches to developing clinical educators is their lack of authenticity compared to work based faculty development approaches. Formal (or classroom based) faculty development methods find it difficult to incorporate the critical
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influence of the clinical service/learning environment on the ability of clinical educators to develop new or different approaches to teaching. Informal approaches work based approaches on the other hand score well on authenticity but are more difficult to organise and may undermined by the demands of clinical service.
PEER COACHING Peer coaching is an approach to staff development that has been well described in educational literature. The key elements of a peer coaching approach include the identification of individual learning goals, observation of teaching by colleagues and the provision of feedback in written or verbal format. The peer coach does not have to be expert but does need to work to agreed standards that allow him or her to assess and evaluate the quality of the teaching that he or she witnesses. Peer coaching requires a good deal of organisation, clearly the peer coach needs to be freed up from his/her responsibilities in order to be able to observe another person teaching. Peer coaching is often operated as a reciprocal arrangement. However reciprocity with colleagues can lead to collusion and the lack of a critical approach to the examination of each other‘s teaching. One method of enhancing peer coaching is to use video examples of teaching for peer review by groups of colleagues; this requires courage and often requires patient and learner consent. Video recordings of teaching can serve not only as substrate for discussion with peers but can also serve as a record of change and progression for developing teachers.
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COMMUNITIES OF PRACTICE The working environment in clinical settings is usually dedicated to providing a clinical service. Thus everything, i.e. the rooms, the furniture, the schedule, the clinical team structure are all designed to support clinical care. The design of clinical care environments and the organisations that support them can undermine the potential for good clinical education. Faculty developers need to think carefully about the contexts in which teachers work and the nature of the groups with whom they work and teach. Behavioural change in clinical educators is often hindered by organisational and group based obstacles. From a situated cognition perspective clinical educators who work together can represent a ―community of practice‖. A community of practice is a group of people who share common goals and interests and who work in relative close proximity. Clinicians who share the same clinical space or who form members of a clinical team could constitute a community of practice. Communities of practice are important because they define norms and values that can profoundly affect clinical teaching. Whilst communities of practice are usually described as a positive entity they can of course exert a negative influence on individuals. For example if the teaching standards within a clinical unit are problematic new teachers joining that unit are going to experience great difficulties in bringing about change or indeed in acting in a manner in which they think is conducive to good education. This means that one of the most important developments in thinking about developing clinical teachers is to consider what is the nature of the community of practice that applies where the teacher works. What can be
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done to influence that community of practice so that it becomes a positive environment for change and development? The idea of communities of practice in terms of being a development medium for clinical educators is still very much in its early phases however it is an approach that offers great promise for the future.
ROLE MODELLING Role modelling has great potential as a means of developing clinical educators. However role modelling is usually an unconscious or tacit process. Role models are not usually aware that they are influencing anybody else yet many descriptions of how good teachers develop mention the importance of role models as distinct influences on teacher development (Irby, 1994, MacDougall & Drummond 2005). Role modelling of clinical teaching can be made more deliberate and explicit. Using a cognitive apprenticeship approach expert teachers can explain their thinking as they solve educational problems and make choices in clinical teaching contexts. Novice educators can be assigned to work with established teachers to learn professional approaches to clinical education as well as some of the tricks of the trade. Role modelling is likely to be much more powerful than workshop based teaching because it occurs in the clinical setting with all of its complexities and challenges
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CONCLUSION This chapter has sought to review what is known about the development of clinical educators. It is clear that clinical teachers are a critical source of variance in terms of the quality of clinical education. The growing vogue for the professionalisation of clinical educators is pressuring faculty development units into providing more and more opportunities for clinical educators to acquire new knowledge and skills. However there is still a tendency to rely on the tried and trusted approaches such as workshop and longitudinal courses to develop clinical educators. Whilst these approaches provide teachers with good theoretical understanding of what teaching and learning are about they are usually offered at some distance from the realities of the clinical teaching environment. Newer faculty development approaches acknowledge the importance of situating learning in authentic contexts and are more likely to be based in or around the clinical education context. A key purpose of this chapter is to encourage teacher developers to consider the prior knowledge and beliefs of each teacher when planning and delivering faculty development. Faculty developers should also pay heed to the organisation or environment in which each educator works. Many teacher development ideas come to nought because of the clinical organisational and environmental barriers to implementing new educational practices. This chapter ends with a recommendation that faculty developers should always seek to customise what they do to suit the realities of participants‘ clinical work contexts. It is highly likely that the next frontier in faculty development will be the organisational change processes required to create the better clinical learning environments of the future.
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ACKNOWLEDGMENT I would like to thank Dr. Yvonne Steinert of McGill University, Canada for sharing early drafts of the forthcoming ASME guide ―Developing Medical Educators: A Journey, Not a Destination‖. This guide provided the structure for categorising faculty development approaches used in this chapter.
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REFERENCES Brophy, J. E. & T. L. Good. 1986. Teacher Behavior and Student Achievement. In Handbook of research on teaching, ed. M. C. Wittrock, 328-375. New York: Macmillan. Brown J, Collins A and Duguid S (1989) Situated cognition and the culture of learning. Educational Researcher. 18(1): 32-42. Carter, K. 1990. Teachers' knowledge and learning to teach. In Handbook of research on teacher education. Collins A Brown J and Holum A (1991) Cognitive apprenticeship: making thinking visible. American Educator. 15: 6-11,38-46. Devlin M. (2006) Challenging accepted wisdom about the place of conceptions of teaching in university teaching improvement. International journal of teaching and learning in higher education, 18, 112-119. Ennis, C.D., Cothran, D.J., & Loftus, S.J., (1997). The influence of teachers‘ educational beliefs on their knowledge organization. Journal of Research and Development in Education,30 (2),73-86. Hesketh E, Bagnall G, Buckley E, Friedman M, Goodall E, Harden R, Laidlaw J, Leighton-Beck L, McKinlay P, Newton R and Oughton R. (2001) A framework for developing excellence as a clinical educator. Medical Education. 35(6): 55564. Irby D (1994) What clinical teachers in medicine need to know. Academic Medicine. 69(5): 333-42. Lortie, D. C.(1975). School-teacher. A sociological study. The University of Chicago Press. Mapolelo DC. (1999) Do pre-service primary teachers who excel in mathematics become good mathematics teachers? Teaching and Teacher Education 15: pp 715-725 McLeod, P., T. Meagher, Y. Steinert, L. Schuwirth & A. McLeod (2004) Clinical teachers' tacit knowledge of basic pedagogic principles. Med Teach, 26, 23-7. MacDougall, J., & Drummond, M. J. (2005). The development of medical teachers: An enquiry into the learning histories of 10 experienced medical teachers. Medical Education, 39, 1213-1220. Munby, H., T. Russell & A. Martin. 2001. Teachers' knowledge and how it develops. In Handbook of research on Teaching (4th edition).(2001), 877 - 904. Parsell G. Bligh J. (2001). Recent Perspectives on Clinical Teaching. Medical Education, 35, 409-414
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Pratt, D. D. (1992). Conceptions of teaching. Adult Education Quarterly, 42(4), 203220. Purcell N and Lloyd-Jones G (2003) Standards for medical educators. Medical Education. 37(2): 149 –54 Regehr G, Norman GR. (1996). Current Issues in cognitive psychology: Implications for professional education. Academic Medicine,71, 988-1001. Sutkin GS, Wagner E,, Harris I.,Schiffer R., (2008) What Makes a Good Clinical Teacher in Medicine? A Review of the Literature Academic Medicine 83:452– 466. Schön D (1983) The Reflective Practitioner: How Professionals Think in Action. Basic Books, New York. Shulman, L. S. 1986. Paradigms and research programs in the study of teaching: a contemporary perspective. In Handbook of research on teaching, ed. M. C. Mattock, 3-36. New York: Macmillan. Spencer, J. (2003). The clinical teaching context: a cause for concern. Medical Education, 37, 182-3. Steinert Y, (2009) Developing Medical Educators: A Journey, Not a Destination ASME Guide (in press) Association for the Study of Medical education, Edinburgh Watson, J. 1930. Behaviourism. New York: Norton. Whitcomb, J.A. (2003). Learning and pedagogy in initial teacher preparation. In W.M. Reynolds & G.E. Miller, (Eds.) & I.B. Weiner (Editor in chief) Handbook of Psychology, Volume 7: Educational Psychology, (pp. 533-556). New York: John Wiley & Sons, Inc. Yeates P.J.A., Stewart J., & Barton, J. (2008). What can we expect of clinical teachers? Establishing consensus on applicable skills, attitudes and practices. Medical Education, 42, 134-142.
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In: Medical Education: The State of the Art Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 69-80
ISBN: 978-1-60876-194-4 © 2010 Nova Science Publishers, Inc.
Chapter 7
TEACHING CLINICAL AND COMMUNICATION SKILLS AND GIVING EFFECTIVE FEEDBACK Simon Edgar and Iain Lamb
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ABSTRACT This chapter will explore the stages learners go through as they learn how to perform clinical skills. This helps teachers understand how they can help learners perform skills to a safe and competent level. A four stage model is offered as a way of teaching a clinical skill. Communication is a skill that can also be learnt and one way of doing this is also discussed. In particular students or trainees can develop a patient centred approach that remains clinically effective. There are many models of the consultation and one is considered that will help them work effectively with patients. Models offer clarity about how doctors should communicate and encourage constructive alignment for assessment of consultation skills. An example of assessment is discussed. Finally methods of giving effective feedback are identified. Without the ability to give good feedback a teacher will struggle to develop a learner‘s skills successfully.
INTRODUCTION Although it may appear to be an unnecessary comment, we feel it is important to stress that a teacher should be competent in the skills they are teaching. This is not just in order to make the teaching effective but also as part of being a good role model. [1] Any teaching can be enhanced if the teacher and the working environment are seen to be encouraging and effective. The teacher should understand how to teach effectively and this will be covered in some detail. We deal with learners with a range of learning styles, level of inherent skill and degree of motivation. The more we know about the learner the better. If as often happens learners are
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with us for a short period of time we have to be flexible to needs and provide a number of ways of supporting them. So don‘t always do things the same old way but discover how much the learner knows already, about this or related skills, and ensure they understand why the skill is relevant and important to them. Consider a range of ways of providing reminders or support to the learner. These, for example, may be written articles or guidelines, diagrammatic, interactive web sites or activities in a skills lab. Ultimately we are ensuring they have a knowledge base upon which to build skills, have had the opportunity to show us how competent they have become before eventually being considered safe to actually do the skill with patients.
TEACHING CLINICAL SKILLS The process of gaining knowledge and skills can be likened to a journey with several stages to pass through on the way from being unskilled to skilled. [2]
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Theoretical models 1. Awareness First there is the awareness of the existence of a knowledge or skill – this awareness may be raised by self-recognition of a gap in knowledge or through interaction with others. A teacher should be able to help a learner recognise their needs and identify how these should be met. This would often follow the experiential learning cycle. 2) Acquisition The acquisition of new knowledge or skills can be done in a number of ways and this should suit the learning style of the learner whilst always remembering that patient care comes first. Thus for example learning could be achieved informally through colleagues, during tutorial time, in discussion in small groups, through elearning or by a formal teaching course. 3) Development The trainee then develops their knowledge and ability to perform the skill. This requires 4 R words which help develop a cycle of learning. Reflection, Rehearsal, Repetition and Review. The teacher can support this by encouraging the learner to reflect upon what they are doing, providing the opportunities for rehearsal and repetition and regularly reviewing progress. But remember that Practice does not make perfect – makes permanent. Only perfect practice makes perfect performance. One description of this calls this Deliberate practice. This is activity that's explicitly intended to improve performance that reaches for objectives just beyond one's level of competence, provides feedback on results and involves high levels of repetition. (from work over the past 15 yrs by Dr K Anders Ericsson and colleagues)
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4. Mastery Eventually the teacher‘s review concludes that the learner has mastered the skill and is able to do this independently. They should also have reached a stage where they can teach others. It should be remembered that once a skill is learnt it will become rusty and potentially dangerous if there is not ongoing practice and repetition. 5. Adaptability Once we have learnt one skill it then becomes possible to adapt it to other skills. For example once we can take a blood sample it becomes easier to learn how to gain intravenous access for a drip.
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A second but parallel model of the journey from novice to expert is depicted in The Conscious-competence framework which consists of four stages. [2] 1) UI - The person is unaware of the existence of the skill and therefore of its relevance to the role they are performing. This typically is true of new learners but there is a danger that established doctors remain unaware of changes in practice whilst thinking they are competent. 2) CI - The person becomes aware of the existence of the skill and how it could be used to enhance their knowledge and improve their working practice. They then aim to acquire that skill. 3) CC - The person acquires the skill and reaches a level where they are comfortable performing the skill and can perform it consistently to a reasonable standard. Because it requires concentration of thought this can lead to a rather robotic performance or loss of focus if other things happen. At times this means that there can be a temporary loss of competence when working under pressure or having to multitask. 4) UC - The person has acquired a level of performance that enables them to perform the skill with little mental effort, it has become second nature and often intuitive. The person who has reached this stage is not necessarily the best teacher of a skill as they no longer need to think about the actions they are performing and therefore may have difficulty in articulating all the aspects of the skill to a novice. Diagram 1 shows the movement of this journey as the learner follows the red arrows. The green arrow identifies the need of the teacher to reflect back to be able to teach at the right stage for the learner. The most effective teacher should be in the zone of the learner and once awareness has been raised this would typically be in CI in early learners and CC in those who are more established. The teacher should think through the processes involved in performing the skill and articulate this comprehensively and accurately to a trainee. UI may be the domain of the poor performer in that their skills are lacking but they may not be aware of this. CI may be the domain of the trainee in that they know they need to acquire skills in certain areas and are actively pursuing this. CC may be the domain of most interaction between the learner and teacher as the former seeks mastery.
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Competence
Conscious
Unconscious
Incompetence
CC: the person achieves CI: the person becomes 'conscious competence' in a aware of the existence skill when they can and relevance of the perform it reliably at will skill and aims to acquire it
UC: the skill becomes so UI: the person is not practiced that it enters the aware that they have a unconscious parts of the particular brain - it becomes 'second deficiency in the area nature' concerned
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Diagram 1.
Diagram 2. Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
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The ability to reflect back is an important skill and has been explained with the term reflective competence [2a] - a step beyond unconscious competence and looking at how the teacher‘s unconscious competence developed and understanding the theories and models and beliefs that informed and maintained that competence. The problem for many teachers is doing this effectively. In actual fact the journey for a learner is much more fluid and follows the cyclical or spiral pattern that is so typical of effective adult learning. [2b] Diagram 2 details this and identifies the above journey and how it links into reflective competence and around the outside the influences that take the learner towards mature practice. The role of the teacher in this journey will include tutelage but will also be to raise awareness, encourage, support, challenge and mentor for example.
Practical Application
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This provides some background to the theory of learning a skill and I will now detail a learning exercise where skills teaching can be demonstrated using the 4 step approach. If this is being done on a course I would ask participants to bring a non medical skill – like tying a knot, fitting a camera battery or making a paper napkin for example – which they can teach in less than 2 minutes. I would usually tie this in with a session looking at feedback skills so that participants can work in trios with all playing the part of teacher, learner who then gives feedback to the teacher and observer who gives feedback on the feedback. The 4 step approach [3] 1) 2) 3) 4)
Trainer demonstrates – no commentary Trainer demonstrates – with commentary Trainer demonstrates – trainee commentates Trainee demonstrates – trainee commentates
At the start it is worth checking what experience the learner already has of the skill or similar skills. Allow time for questions and check how the learner is getting on throughout. Get the learner positioned so they can see easily and from the correct angle. (For example side by side rather than facing one another) Allow time at the end to summarise and decide what the learner should do next. Demonstrating with no commentary allows a learner to concentrate fully on observing the task and this will be particularly important to visual learners. Many teachers find it difficult to remember this stage. Teachers who teach with Unconscious Competence sometimes run through this very quickly and make it appear very easy which can put a learner off. Also when they move to Stage 2 they can find it difficult to articulate what they are doing. However adding a commentary breaks down the process for the learner and letting them commentate acts as repetition before they move on to the task of both doing and commenting on what they are doing. This allows 4 stages of repetition and the first stage towards the learner reaching mastery.
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TEACHING COMMUNICATION SKILLS Much of what has been said about the teaching of clinical skills is applicable to communication skills. Several publications [4-8] cover this topic, and in this short section we do not plan to go into particular theoretical detail but it is important to note that
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Communication skills can be taught It helps if there is clear guidance as to what these skills are Rehearsal of good practice is essential whether it be by role play or in consultations that are observed either directly or by video. Therefore we offer a method of teaching a group of learners about communication that is evidence based and concentrates on the key episode of communication that all doctors have with patients – the consultation. There are many models of the consultation that guide learners and one is chosen as an example. Assessment of the consultation should be aligned with good medical practice and a guide to this is given using the example of assessment for the Royal College of General Practitioners (UK) exam. Stage 1; On a course ask a series of questions about the consultation and the skills that might make for good consulting. An example using evidence would be ―How long does it take the average doctor to interrupt a patient at the start of a consultation?‖ The learners discuss and debate this, offer an answer and then are given a fact from one study – 18 seconds – before further discussion looks at the importance of the start of the consultation and how the learners might develop skills for this. Other more general questions might ask about rapport, how a patient knows you are listening or the use of non verbal communication. Stage 2; Offer some models and an example would be the Disease Illness Model. [9] This acknowledges that the traditional approach of clinically effective disease management by the doctor and the need to understand the patient‘s perspective are equally important in developing a proper management plan that both doctor and patient are happy with. The consultation should weave back and forth between the two perspectives as outlined in diagram 3. Stage 3; Observe some Video consultations using the model and discuss how a mixture of good clinical effective disease management should be balanced with an understanding of the individual and their illness to meet a shared agreement with the patient. Stage 4; Identify how the assessment of consultation skills will be done and how it measures those skills identified in the models. An example would be the Consultation Observation Tool that is used to assess GP trainees. The marking looks for I (insufficient evidence), N (Needs further development), C (Competent) and E (Excellent). There are specific guidelines as to what each means and what should be achieved. Diagram 5 RCGP COT headings 1. 2. 3. 4. 5. 6.
Encourages the patient‘s contribution Responds to cues Places complaint in appropriate psychosocial contexts Explores patient‘s health understanding Includes or excludes likely relevant significant condition Appropriate physical or mental state examination
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Makes an appropriate working diagnosis Explains the problem in appropriate language Seeks to confirm patient‘s understanding Appropriate management plan Patient is given the opportunity to be involved in significant management decisions Makes effective use of resources Conditions and interval for follow up are specified
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Stage 5; Perform further Video analysis whilst assessing the competency of the doctor on the video using this grid for guidance. Stage 6; Use role play either with actors or teachers to practice scenarios. This allows the learners to show how competent they are in a safe environment. It allows for ideas to be tried out based on constructive feedback. Stage 7; Teachers who have been trained in Video or Observational analysis develop and/or assess the skills of the learners as they consult with patients. This looks at how well the learner is actually performing.
Diagram 3. The Disease Illness model of the consultation.
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FEEDBACK SKILLS Feedback is the breakfast of champions Ken Blanchard Feedback is one of the most challenging skills to do well and it is important that it is done correctly. Whether it is informal feedback delivered during day to day work or formally during an appraisal, performance review or management of poor performance, feedback can have seismic effects on the recipient. At its best, feedback gives learners an opportunity to find out how they are performing and offers suggestions for change. It should include positive reinforcement, increase and encourage reflection and personal development. At its worst it is negative, personal and tempts learners to hide future issues from their teachers. When giving feedback the teacher should ensure that it is relevant and tailored to the individual concerned. It should be factual and the right amount of feedback given at the right time (often immediate) and in an appropriate setting. (For example it is not always appropriate to give feedback on performance in front of others) Therein lies the challenge! At all times the learner should be treated with respect and the aim should be to help them realise their own potential through support and challenge.
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Principles for Constructive Feedback Constructive feedback does not mean only giving positive feedback. Negative feedback, given skilfully, can be very important and useful. Destructive feedback means that which is given in an unskilled way which leaves the participant simply feeling bad gives nothing on which to build and no options for using the learning. 1. Start with the positive Most people need encouragement, to be told when they are doing something well. When offering feedback it can really help the receiver to hear first what you like about them or what they have done. Our culture tends to emphasise the negative therefore the focus is likely to be on mistakes more often than strengths. In a rush to criticise we may overlook the things we liked. If the positive is registered first, any negative is more likely to be listened to and acted upon. 2. Be specific Try to avoid general comments which are not useful when it comes to developing skills. Rather than saying something was good or bad it is better to specify what was done. For example ―The way you asked that question just at that moment was really helpful‖ or ―By responding that way you seemed to be imposing your views‖. Specific statements give a learner something to develop and the teacher something that can be used to develop teaching plans. 3. Refer to behaviour that can be changed If the size of a student group is too large but the teacher can‘t do anything about it then giving this feedback is unhelpful. On the other hand, to be told that ―It may
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5.
6.
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help to think of ways of breaking the size of the group down‖ can give a person something on which to work. Offer alternatives If you do offer negative feedback then do not simply criticise but suggest what the person could have done differently. Turn negative feedback into a positive suggestion or even better discuss a range of choices that give the learner the opportunity to choose the one that suits them and their situation best. Own the feedback You should be giving factual information which has informed your opinion – So use statements that start with ―I think‖ or ―I feel that‖. Identify that good performance is based on relevant outcomes, criteria and standards. Leaving the recipient with a choice Feedback which demands change or is imposed heavily on the other person may invite resistance, and is not consistent with a belief in each of us being personally autonomous. It does not involve telling someone how they must be to suit us. Skilled feedback offers people choices and they can choose how they act. It can help to examine the consequences of any decision to change or not to change, but does not involve prescribing change. However as much of teaching also involves assessing it is important at times to provide more directive feedback to the learner so that they can prepare properly for other formal assessments like exams. Be descriptive rather than evaluative Tell the person what you saw or heard and the effect it had on for example a consultation. You asked this question after 15 seconds of the consultation – how do you think this affected the patient‘s story. How (like what, where and when) is an Awareness Raising Questions that allows the learner to be challenged but in a constructive way. If you‘d asked an evaluative question like ―Why did you interrupt the patient‖ it is likely you would receive an excuse or less open discussion. As identified in the Johari Window we can increase the size of the open learning box with good feedback that challenges the unknown self. Of equal importance is creating an open and honest relationship and learning culture that allows the learner to open up the façade of things that had previously been hidden from you.
Johari Window [10]
Known to self
Unknown to self
Known to others
Open
Unknown to others
Façade Explored by disclosure
Blind spot Explored by feedback Unknown Reveal by joint exploration
Finally, as with the consultation, many learners find it helpful to have some models of feedback to fall back on. 3 models are offered. 1)
The feedback sandwich [11] is useful for immediate day to day feedback, particularly to students. Give some positive feedback first.
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2)
Then make a suggestion for change. Be specific and describe what you have seen that could improve and offer choices for change. Then give another positive message. Pendleton‟s rules (5b) offer a useful structure to ensure we give feedback in a safe way. It allows the learner to comment on things first and if they have insight often this leaves less active feedback is needed by the teacher. Get matters of fact. Learner to comment on what went well. Teacher to comment on what went well. Learner to note areas for improvement. Teacher to comment on areas for improvement and offer suggestions for change.
Some Difficulties with Pendleton's Rules
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People may find it hard to separate strengths and weaknesses in the formulaic manner prescribed. Insisting upon this formula can interrupt thought processes and perhaps cause the loss of important points. Though it sets out to protect the learner, it is artificial. Feedback on areas of need is held back until part way through the session, although learners' may be anxious and wanting to explore these as a priority. This may reduce the effectiveness of feedback on strengths. Holding four separate conversations covering the same performance can be time consuming and inefficient. It can prevent more in-depth consideration of priorities. 3) In order to address some of these difficulties the Cambridge-Calgary [12] team (who have done a lot of work on communication and the importance of teachers giving feedback on the consultation) ask learners to identify what outcome they wish and set an agenda of what will be looked at with the teacher. They describe Agenda Led Outcome Based Approach (ALOBA) and the SET GO method of giving feedback. What I Saw What Else did you see? What do you Think? The facilitator and learner discuss and problem solve together by; Clarifying what Goal should be achieved using ALOBA Offering suggestions and alternatives as to how to progress Start with the learner‘s agenda and ask what problems the learner experienced and what help they would like. Look at the outcomes the learner and patient are trying to achieve. This encourages problem solving - effectiveness in communication is dependent on what you are trying to achieve.
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Encourage self assessment and self problem solving first before helping generate ideas and suggestions.
CONCLUSION Teaching clinical and communication skills is challenging on many levels as this brief introduction has endeavored to highlight, namely: The need for the ―instructor‖ to reflect on their own accomplishment and distil from their ―unconscious competence‖, those aspects of performance that are implicit to their daily routine but demand to be made explicit to instruct others. The need to raise awareness in learners of the contextual relevance of the skill to be taught in a way that appeals to varying learning styles and perceived learning needs. The need for ―instructors‖ to revisit the zone of learning occupied by the student and ―remember‖ how challenging this skill was before it became second nature. The absolute necessity for teachers to be masters of a skill prior to instructing others especially in the domain of clinical skills. Mere psychomotor instruction is not enough when the grey areas of uncertainty and error in performance have to be addressed. Finally the skill of supportive yet challenging feedback is one that comes naturally to few and is misguided, misplaced or avoided by many. This gift from teacher to learner is priceless if delivered well and devastating if delivered badly.
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REFERENCES [1]
Cruess SR, Cruess RL, Steinert Y. Role modelling--making the most of a powerful teaching strategy. BMJ. 2008 Mar 29;336(7646):718-21. [2] The original learning stages model from ―The US Gordon Training Organization‖. [2a] Reflective competence from Nonaka in 1994 (Dynamic Theory of Organizational Knowledge Creation – Organizational Science 5: 14-370). [2b] Spiral form by Will Taylor of the Department of Homeopathic Medicine Portland Oregon in 2007. [3] Lake FR, Vickery AW. Teaching on the run tips 14: teaching in ambulatory care. Med J Aust. 2006 Aug 7;185(3):166-7. [4] Silverman, Kurtz and Draper. Skills for Communicating with Patients. Radcliffe Publishing. [5] Usherwood. Understanding the Consultation. Open University Press. [6] Peter Tate. The Doctor‟s Communication Handbook . Radcliffe Publishing. [7] Pendleton Schofield, Tate and Havelock. The Consultation (2nd edition 2003 OUP). (1984) [8] Roger Neighbour. The Inner Consultation. Radcliffe Publishing. [9] Stewart MA and Roter D 1989 (eds) Communicating with Medical Patients Sage 1989 Newbury Park.
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[10] Joseph Luft and Harry Ingham (University of California 1955) [11] Schwenk TL, Whitman N. The Physician as Teacher. Baltimore: Williams & Wilkins; 1987. [12] Silverman, Draper and Kurtz – Education for General Practice (Now Education for Primary Care) Vol 7 No 4 and Vol 8 No 1.
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In: Medical Education: The State of the Art Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 81-91
ISBN: 978-1-60876-194-4 © 2010 Nova Science Publishers, Inc.
Chapter 8
SMALL GROUP LEARNING: PROBLEM-BASED-LEARNING APPROACH Rossana Salerno-Kennedy
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ABSTRACT A variety of teaching methods for small groups has found an increasing role in medical education worldwide. Not all of the approaches that have been developed are widely used, nor are their advantages and disadvantages well documented. The Socratic dialogue of bedside teaching has always been and should remain at the core of medical education. The relatively recent introduction of the Clinical Skills Laboratory (CSL) with simulated patients has helped medical students to overcome problems related to doctor-patient‘ interaction and physical examination; it is still under development. Problem based learning (PBL) is another approach that has gained increasing credibility internationally. It is fundamentally a learner centered educational method, which has become a useful tool in higher education, particularly in undergraduate medical programmes. It has been implemented as an alternative to conventional curricula by several medical schools in the United States and elsewhere. This chapter presents an overview of the most effective methods that have been developed to date, including clinical teaching in small groups, such as bedside teaching and the Clinical Skills Laboratory. Particular emphasis is placed on PBL.
INTRODUCTION Small Group Learning (SGL) is an educational approach in which teaching and learning take place in a structured environment with a limited number of participants (typically eight to ten students). It may be defined as a group of learners demonstrating three common skills: active participation, a specific task and reflection. [1] After the lecture, this is probably the most widely used teaching/learning method in medical education.
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Various forms of SGL have been developed over recent years; these include: classical clinical teaching in the form of bed-side teaching, tutorials, seminars, free-discussion groups, brainstorming, snowballing, buzz groups, paired (also called one-to-one) discussion, simulations, plenary sessions, problem-based learning (PBL), team-based learning, role plays, games and IT approaches. [1] Not all of these approaches are widely used and a comprehensive comparison of their relative advantages and disadvantages has not yet been made. After providing an overview of SGL, we will focus in this chapter primarily on clinicallyoriented SGL, such as bedside teaching and the Clinical Skills Laboratory, and on an interactive form of SGL known as Problem-Based-Learning (PBL).
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COOPERATIVE AND COLLABORATIVE LEARNING John Dewey's view that "education is a social enterprise in which all individuals have an opportunity to contribute and to which all feel a responsibility" has influenced group learning theory which distinguishes two forms of learning: cooperative and collaborative. [2] Cooperative work is accomplished by the division of labour among participants, where each person is responsible for solving part of the problem. [2, 3] Cuseo distinguishes cooperative learning from other forms of small group learning. He defines it as: ―A learner-centered instructional process in which small intentionally selected groups of 3-5 students work interdependently on a well-defined learning task; individual students are held accountable for their own performance and the instructor serves as a facilitator/consultant in the group learning process‖. [4] Collaborative learning [3], on the other hand, is defined as a coordinated, synchronous activity that is the result of a continued attempt to construct and maintain a shared conception of a problem. Matthews et al, [2] pointed out that collaborative learning differs from cooperative learning in one key way: where the output of cooperative learning is the synthesis of work done by individuals, collaborative learning has at its centre the notion of joint learning. The participants work together on a task and are jointly responsible for the strategies employed in achieving a satisfactory outcome. In their view, this approach has a number of valuable educational by-products because the process is a shared one, where each participant has to articulate, justify and possibly defend their approach to the task. This approach also obliges each participant to explain their attitudes, values and theories of action. Collaborative learning also develops skills of negotiation, assertiveness and listening. The theory underpinning collaborative learning has developed separately from the theories supporting the development and practice of cooperative learning. Collaborative learning theory and practice derive largely from the humanities and social sciences and are founded on political and philosophical questions on the nature of knowledge as a social construction and the role of authority in the classroom. Its adherents therefore take a less structured approach to group work, on the basis that students are responsible participants who already use social skills in performing group tasks. [2]
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SMALL GROUP LEARNING AS A FORM OF COLLABORATIVE LEARNING: BEDSIDE TEACHING AND CLINICAL SKILLS LABORATORY Bedside Teaching
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The traditional signature pedagogy of medical education is bedside teaching. This is a version of SGL which is a form of collaborative learning. All students contribute to solving the same problem under the guidance of a clinical expert. Although over 300 years old, the advice of Sylvius, the 17th Century Chair of Medicine at Leiden, is still valid regarding the focus of bedside teaching. "My method ... (is to) lead my students by the hand to the practice of medicine, taking them every day to see patients in the public hospital, that they may hear the patient's symptoms and see their physical findings" .[5] Bedside teaching, which has always been and should remain at the core of medical education [6], provides an opportunity for demonstrating procedures directly, observing learners‘ skills, and giving immediate substantive feedback to them. This type of teaching experience is unmatched in other clinical teaching formats, such as the traditional lecture by a consultant physician. [7] Learning in the clinical environment has great potential but the ideal experience is seldom realized in practice because most clinical teaching takes place in the context of a busy practice. Many studies have shown that a disproportionate amount of time in teaching sessions may be spent on regurgitation of facts, with relatively little on checking, probing, and developing understanding [7]. Other common problems are [7]: passive observation rather than active participation of learners, inadequate supervision and provision of feedback, little opportunity for reflection and discussion, lack of clear objectives and expectations, focus on factual recall rather than on the development of problem-solving skills and attitudes, teaching ―by humiliation,‖ informed consent not always sought from patients, and relatively passive participation by patients. Two fundamental drawbacks of traditional bedside teaching are the lack of a standardised learning experience (different groups of students may encounter different patients and different sets of conditions) and insufficient time for each student to practise. [8]
The Clinical Skills Laboratory (CSL) The Clinical Skills Laboratory (CSL) has been developed to address these issues. The CSL is a clinical environment in which mannequins and role players simulate real patients.
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The CSL allows every student to learn basic skills in a standardised way. This approach has fundamentally changed the teaching and learning scenario in medical education. CSL provides a simulation of reality so that the reality itself can be better understood, controlled and practiced. [9] It also provides a safe, non-threatening environment which facilitates both the teaching and learning of clinical skills. It allows practical skills to be perfected under the direct supervision of a tutor, prior to attempting the chosen skill on a real patient. Furthermore, it enables students to receive immediate feedback on their performance. [10] The advantages and disadvantages of a CSL compared to traditional bedside teaching are summarized in Table 1. [10, 11]
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Table 1. Advantages and disadvantages of a CSL Advantages of CSL No interference with patient-care in traditional clinical settings. Early clinical exposure for inexperienced medical students is stressful. Teaching some diagnostic and therapeutic procedures may cause pain and discomfort to patients. Social and ethical problems can be overcome for intimate examination skills. Medical students often acquire skills on the ward in an ad hoc manner (―hit and miss‖) Difficulty in finding suitable patients. Focus on individual skills Learner-centred: learn by doing Make mistakes without emotional reaction Standardized and reproducible experiences Simulated patients are available on demand
Disadvantages of CSL Costs: equipment (capital and maintenance costs), staff, and consumables Coverage: some clinical signs are impossible to simulate Motivation: medical students prefer hospitals and real patients
VARIANTS OF SGL Several other variants of SGL have been developed over recent years. These include tutorials, free-discussion groups, brainstorming, snowballing, buzz groups, paired (also called one-to-one) discussion, simulations, seminars, plenary sessions, problem-based learning (PBL), team-based learning, role plays, games and IT approaches. [1] Not all of these methods are widely used and their relative advantages and disadvantages are not yet well detailed in the literature. Overall, the evidence to date suggests that, through the SGL approach, students develop problem solving, interpersonal, presentational and communication skills. SGL provides social
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contact with peers and teachers as a way of learning with and from each other. Small group work seems to provide a supportive environment for learning which caters for students with different learning styles. [1] Moreover, it gives students the opportunity to involve themselves in a variety of tasks that are not catered for in the more formal settings of lectures and seminars. [1, 2] They can:
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use their peers as a learning resource learn to evaluate their own and others' work (through the process of giving and receiving feedback) share expertise, study methods, ideas, concerns generate ideas (creative thinking) identify common areas of ignorance take risks in an atmosphere of trust and confidentiality develop negotiation skills learn to give and receive feedback give and receive support develop self-confidence and increase motivation work through experiences and misunderstandings produce synergy (the collective output of the group is greater than the sum of the individual contributions) learn to become less dependent on tutors and to take more control over their own learning. Research indicates that where students simply observe other group members working, or listen to others explaining and discussing things, this will not enable them to learn the material; they must be actively involved in the group process for learning to occur. [8] In order to be effective, a SGL session should involve: [1] active participation among group members; a tutor/facilitator, who facilitates rather than dominates discussion; a focus on application of knowledge on a specific task, and reflection. The potential cognitive benefits of small group learning are more likely to be realized in a social context characterized by group cohesiveness, mutual trust and emotional security. [4] Facilitatory skills are also essential as the teacher must ensure that both the task is achieved and the group functions correctly. In addition to the task itself, the functioning of the group and the learning that takes place need to be assessed and evaluated. [4] Despite its educational potential, Matthews et al, [2] have pointed out that some students do not enjoy or benefit from small group work. It may be a new learning method for which they do not feel properly prepared. If the ―institutional culture‖ is didactic, students may value group learning less highly than more traditional lecture/seminar methods. This is more likely to be the case if assessment is heavily weighted towards exams or the programme has a heavy assessment burden. In particular, if the assessment process evaluates the individual rather than the group, then group work may be seen to be at best incidental to ―real‖ learning and, at
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worst, counterproductive to the individual's own intellectual progress. There may be ―personality‖ issues within the group which obstruct progress and enjoyment. Indeed, some people may prefer to work alone so that they remain in control of both the process and the outcome of the learning. Moreover, group work should encourage dissenting opinions, yet some students may find this intimidating and feel freer sitting in a lecture. Some students (surface learners and those low in confidence) simply prefer dependency. [2]
DIRECTED AND INDUCTIVE TUTORIALS In medical education, two different forms of small group interactive teaching―directed and inductive tutorials―have grown in importance. The directed tutorial sees the tutor taking the initiative; he/she initiates and guides the discussion on a particular topic. By contrast, the inductive tutorial places the initiative on the students: they ask questions and answer them. [12] Jones et al. have found that both types of tutorials are effective but that, by adding a reflective component, the inductive method appears to facilitate deeper learning. [12]
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INDUCTIVE TUTORIAL: PROBLEM-BASED LEARNING AS A SAMPLE Problem-Based-Learning (PBL) is an educational method that is fundamentally learnercentered which uses tutorial discussion groups, supplemented by traditional teaching methods, to stimulate students‘ active learning. [13] It is an innovative and challenging approach to medical education that has gained increasing credibility internationally. It was pioneered in the North American medical schools of Case Western Reserve University in the 1950s and the Medical School at McMaster University, Ontario, in the 1960s. It started because medical teachers, concerned about curriculum overload and innapropriate teaching methods, shifted the emphasis of the undergraduate curriculum away from individual disciplines such as biochemistry, anatomy, and physiology towards an integrated approach involving students in problem solving and indipendent learning, often from the first term. [13] PBL derives from a theory initially described in 1977 [14], called the information processing approach to learning. This theory suggests that ―for effective acquisition of knowledge, learners need to be stimulated to restructure information they already know within a realistic context, to gain new knowledge, and to then elaborate on the new information they have learned, for example by teaching it to a peer or by discussing the material in a group setting”. Although it was first used in medicine, this approach can now be found in many professional teaching settings such as architecture, nursing, engineering, social work and many others. [13] PBL involves a small group of students (typically no more than eight) which comprises: [13] 1. Tutor/Facilitator/ 2. Group leader Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
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3. Recorder 4. Group members 5. Observer The starting point of the learning process is a problem which is discussed in a structured way over two sessions, following seven prescribed steps. [13] The problems chosen are derived from clear course objectives. Students work through the problem, defining what they do not know and what they need to know in order to understand (not necessarily just to solve) the problem. [14] The seven steps are:
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1. 2. 3. 4. 5. 6. 7.
Clarification of terms Definition of problem(s) Analysis of problem Structuring ideas (summarize and discuss) Formulate Learning objectives Collection of new information (self-study) Reporting and synthesis of information (second session)
PBL differs from more traditional approaches to teaching in that the participants are encouraged to use self-directed learning skills to analyze a scenario, formulate and prioritise key learning objectives within that scenario, and then to collect additional information they think they need to address those objectives. [15] The case-scenario is used in a problem simulation format, encouraging free inquiry. It is fundamentally different from the traditional case study tutorial, mainly used in Law and Business education, where cases are studied in preparation for class discussion. In the latter fields, cases organize and synthesize material to direct the application of learning. [16] Student-centered problem-based learning (PBL) has been implemented throughout the entire undergraduate curriculum by several medical schools in the United States and elsewhere. [13] Recently, attempts to integrate PBL with lecture-based curricula have created "hybrid PBL" curricula with varying amounts of the philosophical underpinnings of student-centered PBL. [17] There is a voluminous literature on the subject, but it often remains unclear just what is being done in the name of PBL. Different accounts highlight different, often contradictory, positions on the key features of the approach. In 1999, Maundsley described the ―true‖ PBL curriculum as follows: [17] A method and a philosophy that is curriculum-wide and supported by all curriculum elements; Aims at efficient acquisition and structuring of knowledge arising out of working through a progressive framework of problems providing context, relevance and motivation Builds on prior knowledge, integration, critical thinking, reflection on learning and enjoyment
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Rossana Salerno-Kennedy Achieves its goal via facilitated small-group work and independent study; and possibly Relates to problem solving only insofar as knowledge becomes more accessible and can therefore be applied more efficiently during its process.
More recently, Barrows [18] devised a taxonomy to try to identify instances of ―true‖ PBL learning in medicine. He has concluded that the term best applies to teaching that achieves the following four objectives:
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1. 2. 3. 4.
Structuring knowledge for use in a clinical scenario Development of the student‘s clinical reasoning process Development of self-directed learning skills Increasing the student‘s motivation for further learning
Similarly, despite the many claims made for the advantages of PBL, the evidentiary basis of such claims is often questionable. [16] PBL has been the subject of considerable interest and debate in undergraduate and, increasingly, postgraduate medical education in recent years. Its supporters maintain that PBL enhances learning by providing a highly motivational environment for the acquisition of knowledge, which is well received by those who take part in it. Critics argue that PBL is a time-consuming exercise, often undertaken by people with a limited appreciation of its complexities, and the lack of evidence that PBL translates into better clinical competence brings into question the relevance of such intensive learning methods in everyday practice. [16] The effectiveness of problem-based learning (PBL) was examined by conducting a metaanalysis-type review of the literature from 1972 to 1992. [19] The findings suggested that, compared with conventional instruction, PBL is more nurturing and enjoyable; PBL graduates performed as well, and sometimes better, on clinical examinations and faculty evaluations; and they were more likely to enter family medicine. Furthermore, faculty tended to enjoy teaching using PBL. However, PBL students in a few instances scored lower on basic sciences examinations and viewed themselves as less well prepared in the basic sciences than were their conventionally trained counterparts. PBL graduates tended to engage in backward reasoning rather than the forward reasoning experts engage in, and there appeared to be gaps in their cognitive knowledge base that could affect practice outcomes. The costs of PBL may slow its implementation in schools with class sizes larger than 100. While weaknesses in the criteria used to assess the outcomes of PBL and general weaknesses in the design of the studies limit the confidence one can have in conclusions drawn from the literature, the authors recommend that caution should be exercised in making comprehensive, curriculum-wide conversions to PBL until more is learned about (1) the extent to which faculty should direct students throughout medical training, (2) PBL methods that are less costly, (3) cognitive-processing weaknesses shown by PBL students, and (4) the apparent high resource utilization by PBL graduates. After ten years of experience with its implementation, the advantages and disadvantages of PBL are summarized in Table 2. [16]
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Table 2. Advantages and disadvantages of PBL Advantages of PBL Helps develop key learning skills Helps develop key interpersonal skills: Communication Prioritisation of time/resources Identification of key problems Team working and task sharing Has the potential to increase learner confidence
Disadvantages of PBL Time consuming to set up at the start Time consuming to facilitate Faculty members must be prepared to ―step back‖ from traditional teaching role Requires easy access to internet and a good quality medical library Not suited to all subject areas
More recently, it has also been proposed that the small group size in PBL may have additional benefits for integrating a diverse population of students into a new academic environment [20]; it has also been shown to have positive effects on physician competencies after graduation, especially in the social and cognitive dimensions.[21] There is still room for further research on PBL to measure its effects on other dimensions of physician competency [21] and to contribute towards a better understanding of why and how the concepts of constructive, self-directed, collaborative and contextual learning work or do not work and under what circumstances. [22]
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CONCLUSION Over the past two decades, the delivery of health care has changed considerably. There have been advances in understanding health and illness, advances in technology, team-based delivery, and theories of learning. In addition, the learning style of students choosing healthcare as a profession has changed. Arising from these developments, new approaches to medical education have become necessary. Different forms of Small Group Learning (SGL), which is an educational approach by which teaching and learning takes place among a limited number of participants (eight to ten students), have found an increasing role in medical education in the recent past. One of these forms, bedside teaching, has always been highly motivating for students and should remain at the core of medical education. Despite its strengths, this form of clinical teaching in small groups has some fundamental drawbacks from the perspective of learning. The introduction of the Clinical Skills Laboratory (CSL), in the early stages of undergraduate education, has helped medical students to overcome problems related to doctor-patient interaction, physical examination, and familiarization with clinical issues prior to encounters with real patients in a real clinical setting. Several other forms of SGL are being developed and trialed; these are finding an increasing role in medical education. The relative advantages and disadvantages are not yet detailed comprehensively in the literature. Problem based learning (PBL) is one approach that has growing credibility internationally. PBL is a learner centered educational approach, which started in the US in the 1950s and has been applied widely in higher education, particularly in undergraduate medical programmes. A fully student-centered problem-based learning (PBL) curriculum has been
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implemented as an alternative to conventional education by several medical schools in the United States and elsewhere. There is a growing literature on the effectiveness of this strategy. PBL enhances learning by providing a highly motivational environment for the acquisition of knowledge which is universally well received by those who take part in it. Critics argue that PBL is a time-consuming exercise, often undertaken by people with a limited appreciation of its complexities, and the lack of evidence that PBL translates into better clinical competence brings into question the relevance of such intensive learning methods in everyday practice. Further research on PBL should contribute towards a better understanding of why and how the concepts of constructive, self-directed, collaborative and contextual learning work or do not work and under what circumstances.
REFERENCES [1] [2] [3]
[4]
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[5] [6] [7] [8] [9] [10] [11] [12] [13] [14]
Jones RW. Learning and teaching in small groups: characteristics, benefits, problems and approaches. Anaesth Intensive Care. 2007 Aug;35(4):587-92. Matthews R.S, Cooper JL, Davidson N et al, "Building Bridges Between Cooperative and Collaborative Learning" Change. 1995, 27(4), 35. Roschelle J and Teasley S. 'The construction of shared knowledge in collaborative problem solving' in C O'Malley (ed) 1995 Computer supported collaborative learning Berlin: Springer Verlag. Cuseo J. 'Cooperative learning vs small group discussions and group projects: the critical differences' Cooperative Learning and College Teaching 1992, 2(3):5-10. Lifers EW, Neelon TA. The case for bedside rounds. NEJM, 1980; 303:1230-1233. Stam J. Clinical practice is the most important environment to acquire clinical knowledge. Ned Tijdschr Geneeskd 2007 Jul 7;151(27):1536. Spencer J. ABC of learning and teaching in medicine. BMJ 2003; 326:591-594 (15 March). Tribe D. 'An overview from higher education' in L Thorley and R Gregory R (eds) 1994 Using group-based learning in higher education London: Kogan Page. Issenberg SB & McGaghie, WC Clinical skills training – Practice makes perfect. Med. Educ. 2002 36(3):210. Dent JA Current trends and future implications in the developing role of clinical skills centres. Med. Teach. 2001, 23(5):483-489. Hao et al. The Clinical Skills Laboratory: A cost-effective venue for teaching clinical skills to third-year medical students. Academic Medicine 2002, 77(2):152. Jones VS, Holland AJ, Oldmeadow W. Inductive teaching method an alternate method for small group learning. Med Teach 2008;30(8):2246-9. Bligh J. Problem-Based-Learning in medicine: an introduction. Postgrad Med J 1995;71:323-326. Anderson RC. The notion of schemata and the educational enterprise: General discussion of the conference. In: Anderson RC, Spiro RJ, Montague WE, eds. Schooling and the acquisition of knowledge. Hillsdale, NJ: Erbaum, 1977.
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[15] Cannon R. & Newble D. (2000). A handbook for teachers in universities and colleges. London: Kogan Page. [16] Kilroy DA. Problem based learning. Emerg Med J 2004;21:411-413. [17] Maudsley G. Do we all mean the same thing by ―Problem-based-learning‖? A review of the concepts and a formulation of the ground rules. Acad Med 1999;74:178-185. [18] Barrows HS. A taxonomy of problem-based-learning methods. Med Educ. 1986;20:481-6 [19] Albanese MA, Mitchell S. Problem-based learning: a review of literature on its outcomes and implementation issues. Acad Med. 1993 Jan;68(1):52-81. [20] McLean M, Van Wyk JM, Peters-Futre Em et al, The small group in problem-basedlearning: more than a cognitive ―learning‖ experience for first-year medical students in a diverse population. Med Teach. 2006 Jun;28(4):e94-103. [21] Choon-Huat koh G, Eng Khoo H, LianWong M et al. The effects pf Problem-BasedLearning during medical school on physician competency: a systematic review. CMAJ 2008;178(1):34-41. [22] Dolmans DH, De Grave W, Wolfhagen IH et al. Problem-based learning: future challenges for educational practice and research. Med Educ. 2005 Jul;39(7):732-41.
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In: Medical Education: The State of the Art ISBN: 978-1-60876-194-4 Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 93-106 © 2010 Nova Science Publishers, Inc.
Chapter 9
ASSESSMENT STRATEGIES IN MEDICAL EDUCATION Kevin W. Eva
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ABSTRACT While there are few answers in this world as unsatisfying as ―it depends,‖ that is the right answer to the question of how one should assess the progress of learners in medical education. Over the years since medical education has evolved into a field of study in its own right the focus of assessment has expanded from determining how to assess one‘s knowledge to how to assess a broad array of competencies including professionalism and patient advocacy. The focus has similarly expanded from determining how to assess one‘s knowledge to how to assess one‘s actual practice. Undoubtedly the focus will continue to expand in unanticipated directions, but even within the current scope of educational practice it is important to recognize that there is no one right way to assess learners. General criteria defining good assessment have been identified and a variety of assessment protocols appear to provide suitable fits to those criteria, but context is critically important in five ways: (1) It determines which compromises are appropriate when quality criteria oppose one another; (2) it influences assessees‘ performance within the chosen assessment protocol; (3) it provides guidance as to which competencies should be prioritized; (4) it reminds us of the need to tailor our assessment protocols to the educational philosophy and curricular goals of the institution; and, (5) it determines the extent to which assessment protocols will be implemented in an effective manner. As a result, the goal of this chapter is to provide the reader with guidance regarding what issues should be considered when striving to adapt existing assessment protocols (or to create innovative protocols) to the specific context of their own needs. It begins by providing a brief summary of the criteria through which assessment protocols should be assessed and subsequently presents concrete examples of a variety of testing formats that emphasize various cognitive and contextual constraints on student assessment.
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INTRODUCTION There are few subjects as contentious in health professional education as are issues of assessment. And rightly so. As Abraham Flexner noted in his world famous study of medical education in the United States and Canada ―the power to evaluate is the power to destroy‖ [1]. In the health professions we are fortunate to have students who are highly motivated to succeed and they have a right to be recognized for their learning successes through honest and fair assessments of their progress. At the same time, our educators have an obligation to their institutions, to their profession, and to society that extends beyond that of most educators to ensure that only students who have met the required competencies are graduated as having met those competencies. The health and safety of patients are quite literally at stake if the assessment protocols we use are not fit for purpose, especially when those protocols are directed towards the continuing competence of those in practice. When things are going well there is little issue as assessors are generally happy and comfortable giving praise. When things go poorly, however, either because a student is struggling (and perhaps unappreciative of that fact), or because there is disagreement between individuals about the ability of the one being assessed, two reactions are too often elicited: (1) silence, an educator choosing to simply pass the student rather than taking on the arduous task of explaining and defending what he believes, or (2) passionate debate regarding the accuracy, credibility, and sufficiency of the evaluation protocols in use [2]. Debate is good, but the heat and passion in this context arises in part because the assessment strategies adopted are often based more on intuition and tradition than on empirical evidence and because the empirical evidence does not always correspond to those intuitions. This chapter will not provide a survey of the strengths and weaknesses of the countless assessment protocols for which evidence has been reported in the literature for two reasons, one logistical and one more philosophical. The logistical reason is that so many new protocols are developed every day that such a chapter would be out of date before the print on the ―State of the Art‖ portion of the book‘s cover was dry. More fundamentally, however, I have chosen to avoid that tack because it is an impossible task with attempts to do so often yielding misleadingly simplistic conclusions. The context within which an assessment protocol is to be used and the way in which the assessment protocol is implemented have such profound impacts on the appropriateness or ―success‖ of the protocol that the reader should feel justified in stating ―hogwash‖ if ever they encounter a statement along the lines of ―the {insert assessment protocol here} has excellent reliability and validity‖ full stop. What works in one context does not necessarily work in another. As a result, the scholarly educator charged with implementing an assessment protocol, be it at the undergraduate, postgraduate, or maintenance of competence levels, must see it as their role to adapt the lessons from the literature to their local environment and to perform continuous quality assurance to test whether or not that adaptation has been successful [3]. The goals of this chapter then are to provide guidance regarding the definition of quality in this context and to summarize some general principles that should be considered in one‘s adaptation efforts. In deciding upon how to assess learners and practicing professionals one might benefit from thinking of assessment strategies as rhetorical devices. Aristotle defined rhetoric as ―the art of discovering, in a particular case, the available means of persuasion.‖ Assessment protocols (or any measurement activity for that matter) are at their root strategies
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for developing persuasive arguments about the extent to which an individual has a sufficient knowledge base, is lacking in a particular clinical skill, or displays adequate professional behaviours, to name three examples. As with all rhetoric, there are some modes of persuasion that are more trustworthy than others and one must, therefore, critically analyze the strength of any claims made. This chapter is about providing a foundation on which to judge whether or not the data arising from a particular ―argument‖ should be trusted or ignored given what has been learned through the study of assessment in the health professions over the past four plus decades. To provide materials through which educators can build and defend a point of view it is necessary to first consider some fundamental issues such as the purposes to which assessment might be oriented and the basis on which to judge the fit between those purposes and the reality of the implementation. The subsequent section will focus on specific case studies of assessment protocols used in the health professions in an attempt to extract some general principles, as alluded to earlier.
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THE FUNDAMENTALS At its most basic level assessment requires observing and rating performance. The observation might take place in a simulated setting with low fidelity relative to the context in which the assessee is expected to perform (e.g., multiple-choice question (MCQ) exams) or in a real world situation as is done using a variety of direct observation techniques developed for the purpose of collecting clinically-oriented work place-based assessments [4]. Each strategy will have advantages and disadvantages and the compromises one is willing to accept should depend heavily on the purpose of conducting the observations. Is the goal formative (to help the assessee develop her knowledge/skills) or summative (to generate a formal mark of the level of knowledge/skills the assessee has achieved)? Is the purpose to have a steering effect (guiding assessees towards behaviour/activities that are considered beneficial to the assessee, the program, or the community) or is it quality assurance (evaluating the impact of an educational program with which the assessees are engaged)? These four aims are not necessarily mutually exclusive of one another, but the relative balance educators strive to achieve across these purposes should be considered dynamic, variable, and contextually driven and should be used to influence the extent to which one emphasizes one or another aspect of an assessment tool‘s utility [5].
Utility in Assessment van der Vleuten and Schuwirth define utility based on five components: Feasibility, acceptability, reliability, validity, and educational impact. Feasibility and acceptability are relatively straightforward as any measurement instrument is useful only to the extent that it can be used and to the extent that it will be used. The needs to train examiners extensively, to observe assessees for dozens of hours, and to constantly argue against pre-conceptions of a tool‘s value all limit the extent to which an assessment format can be deemed useful. The other three aspects of utility have been fodder for countless books and journal articles yet remain common sources of confusion within the health professional education community. I
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cannot do justice to the rich discussion that has taken place in this domain within the space constraints of this chapter, but it is important for the reader to at least have a conceptual overview of the issues and the most common misconceptions.
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Reliability Reliability itself is likely the most mis-used term in health professional education. It is not the same as agreement, nor is it equivalent to discrimination (i.e., demonstrating variability in performance across those being assessed) [6]. Rather, the definition of reliability incorporates both of the preceding concepts as reliability should be considered the extent to which one can consistently differentiate between the subjects of the measurement [7,8]. If every student receives a rating of 7/7 on their tutorial participation from each of two tutors, the agreement between tutors is perfect, but the reliability will be undefined as there is no variability across which assessees can be considered to deviate from one another. The observation of a normal distribution in candidate performance within tutorial similarly tells us nothing about the reliability of the scores, as without a second set of observations (from another rater, another course, or some other variable), we have no way of knowing the extent to which the variability is driven by differences in individual student performance versus the extent to which the variability is driven by random error or systematic biases. This is one of the reasons that context is so important as the exact same test will be seen to have different psychometric properties in different settings; a simple 5-item MCQ exam on the anatomy of the heart might differentiate a physician from an architect in a highly reliable manner, but it is unlikely to yield capacity to consistently differentiate between physicians. Assessment formats that yield unreliable information within the domain and the population of interest are worse than worthless as the information they provide within the context of health professional education can have profoundly misleading impacts upon the lives of the assessees, their coworkers, and the patients in their care [9].
Validity Reliability alone, however, is not sufficient to avoid that fate. It is a necessary precursor for claims of validity, but to be meaningful one must be sure that the assessment protocol provides data indicative of what one actually wants to know [10]. It is inappropriate to say that a tool is or is not valid full stop. Rather, one should consider the extent to which the scores derived from the tool enable one to draw valid inferences for specific purposes. In collecting observations of performance after all, the goal is generally to enable more abstract understanding of an individual‘s ability within the domain of interest. As such, to validate the use or interpretation of the ratings derived, as Kane has suggested, ―is to evaluate the rationale, or argument, for the claims being made‖ [11]. Whatever logical inferences one hopes to draw from the test scores should be made explicit and tested to determine the extent to which the available evidence supports the interpretations. In this way reliability can be thought of as a necessary, but insufficient aspect of validity in that if we infer that the assessment is capturing some aspect of an individual‘s competence, then the observations collected should be consistent whenever that individual is being assessed (e.g., regardless of
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who does the rating and when it is done). Similarly, the scores should not be influenced by variables that are considered unrelated to the competency of interest [12] (e.g., applicants to medical school should be selected based upon their personal qualities, past performances, and potential to grow into outstanding professionals rather than on the extent to which they look good in the ubiquitous interview uniform of a black suit and white shirt). The more one can be explicit and clear about the goals leading to the use of a particular assessment instrument the more obvious threats to validity should become. In establishing the case for the use of any assessment instrument educators should determine at which level of Miller‘s pyramid they seek to aim [13],1 what competency they are trying to assess [14], and whether or not that competency is represented comprehensively enough by the data collected [15]. No one assessment instrument is likely to achieve all goals and no one goal is likely to be met by any one assessment instrument. As such, it is wise to blueprint the program of assessment one has created against the goals of the educational program in addition to considering the psychometric properties of each assessment protocol independently [15,16]. It is only when the yin of assessment and the yang of curriculum align that education can truly be considered optimally effective as assessment and curriculum should consume and support each other, feed off of one another, and seamlessly transform into one another.
Figure 1. Miller‘s pyramid13 (adapted from Norcini, 2003)35.
1
Miller‘s pyramid (see Figure 1) is a vitally important construct for educators charged with evaluation in the health professions as it draws our attention to consider ability at multiple levels including the extent to which one ―knows how‖ to apply their knowledge, is able to ―show how‖ to apply it, and actually ―does‖ what is expected in practice rather than simply focusing on whether or not one ―knows‖ what one is expected to know. I speak from first hand experience trying to learn French as an adult that there can be a very big discrepany between what one knows, what one knows how to do, what one is able to demonstrate, and what one actually does.
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Educational Impact Indeed, one could argue that the educational impact of an assessment protocol is the most important aspect of its utility. It is broadly recognized that assessment protocols influence learning, not only through indirect means such as prompting review and practice, but also through direct means as recent research has suggested that testing yields greater pedagogical benefit than repeated study [17,18]. Still, we typically discuss the influence of assessment on learning when the protocol has a detrimental effect on the culture of the educational program rather than considering how the assessment protocols can be tailored in an intentional way to promote the goals of the program [19,20]. Here, in part, is where the need for compromise comes into play as the most influential protocol may not be the most reliable or valid. The most reliable and valid are rarely the most feasible and the most feasible or the most reliable may not be the most readily accepted. The importance of compromise and related contextual factors will be considered in more detail through the presentation of multiple examples in the following section.
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CASE STUDIES The creation of problem-based learning (PBL) was part of a still growing trend towards enabling students to take control of their own learning, to focus on competencies beyond medical knowledge, and to enable assessment and learning to take place in a context that better represents what health professionals are expected to do in their actual practices [21] . As a result, this educational philosophy and traditional examination formats align quite poorly [22,23]. End-of-course exams tend to be teacher-centred as deciding upon what to test requires the generation of learning objectives and those objectives inevitably take on priority in the minds of the students, for better (because they highlight what an expert educator considers important) or worse (because students want to pass the exam above all else). This chapter is not the place to debate the merits of this approach to learning, but PBL is mentioned in this context because it nicely highlights the challenge of marrying assessment protocols to educational intentions and because resolving that tension has proven to be one of the highest hurdles educators working within problem-based learning environments have had to overcome [24].
The “Triple Jump” Educators at McMaster University sought to rise above that challenge, in part, by generating an assessment technique that mimics what learners are expected to do when solving clinical problems [25]. To assess students‘ ability to direct their own learning, find clinically relevant information, and synthesize it in a meaningful way, learners were required to participate in a ―triple jump.‖ They met with a tutor for 30 minutes, during which time they were given a problem to solve and discussed the approach they would take. They then had 2 hours to undertake an independent information search prior to meeting with the tutor for another 30 minutes to synthesize what they found. The approach has many merits including
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the fidelity of the simulation, the avoidance of simply testing factual recall, and the breadth of focus. Empirically, the assessment approach was put to the test with the inter-rater reliability proving to be reasonable for a relatively low stakes exam. All of this led to the triple jump becoming a formal part of the assessment protocol at McMaster and in many other institutions [26]. Given these merits, however, it will likely surprise many that Geoff Norman, one of the co-investigators in the original research, refers to the triple jump as the biggest mistake of his career. The error Norman identified did not arise from the reasoning behind the approach being unsound or the studies being performed poorly – neither is the case – but rather, that the investigators had the data available that indicated the approach‘s fatal flaw (very poor interproblem reliability), but didn‘t recognize it. At that point in history the medical education community was just beginning to appreciate the existence of context specificity (known as case specificity at the time, the label referring to the finding that performance on one case tends to be poorly predictive of performance on the next case) [27]. Since then it has become clear that this is a very robust phenomenon [28], the result being that students‘ performance on any assessment protocol that focuses on a single case (or small number of cases) will likely be driven in large part by chance. If a student is fortunate to be presented a test case with which she has some previous experience then she will have her performance inflated relative to the same student with poorer luck who gets presented with a test case that is completely new to her. In such instances, the test must be considered invalid for the purpose of indicating the student‘s ability as at best it is measuring only the student‘s ability with that particular case. We recognize this problem quite readily in the context of MCQ exams – no one would dream of offering even a moderate stakes MCQ exam with only one question – yet we have been slow to recognize that the same intuition should be applied to other testing formats as well. This is not to say that the triple jump could not be made reliable – on the contrary, it is likely that the assessment format could be quite useful if we were able to test students on many cases. The problem is that mounting a triple jump with even 10 cases would require 30 hours of testing time, a number that is inconceivable to most institutions even prior to multiplying it by the number of students who would need tested.
Multiple-choice Examinations It is for this reason that assessment strategies that generate many observations in minimal time continue to thrive. MCQ tests, as strong a lightning rod as there is for eliciting criticism, are effective because one can observe ―performance‖ once per minute using standard testing protocols. At the same time, the continued use of MCQs is not just a case of the drunk looking for his keys under the lightpost because that‘s where he was able to see. It is true that minds as notable as Nobel laureate Richard Feynman have criticized MCQs by noting that ―after a lot of investigation, I finally figured out that the students had memorized everything, but they didn‘t know what anything meant‖ [29]. I would humbly counter that there is absolutely a danger of rewarding rote memorization with bad MCQs, but that MCQ testwriting strategies have evolved to the point that quite high correlations can be seen between performance on well-written MCQ-based examinations and very real patient outcomes including cardiac mortality a decade or more into practice [30,31]. Describing how to write
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MCQs well is beyond the scope of this chapter, but excellent guidance is provided by Case and Swanson [32]. With respect to implementing MCQ-type exams in a manner that minimizes cramming behaviour and maximizes the alignment with student-centred learning, I would also alert the reader to the notion of progress-testing, which began at Maastricht University, moved to Canada in the early 1990s, and seems to be experiencing growing popularity internationally [33,34]. Within this model of assessment, students are assessed repeatedly throughout their tenure in an educational program on the knowledge-base they are expected to develop by graduation. The more continuous nature of this assessment protocol (as opposed to generating single point-in-time assessments that may better represent what happened to the student the night before the exam than how well the student is able to perform in general) illustrates another approach to sampling performance and allows students to track their progress more directly while also judging their pace with respect to what they should expect to achieve.
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Performance-based Assessment Having mounted this brief defense of MCQ-type tests it is important to note that they are indeed likely limited to assessing the base of Miller‘s pyramid. That is, while MCQs can be of great value for assessing knowledge they are unlikely to enable an assessment of what a practitioner actually does in his practice. Knowledge is a critically important determinant of practice, but it is insufficient given the breadth of competencies we expect health professionals to maintain. The apex of the pyramid (i.e., the ―does‖ the individual actually practice as he should) remains difficult territory to traverse – it is not completely uncharted, but understanding how physicians‘ actual practice can be assessed in a way that is reliable, valid, feasible, acceptable, and has an appropriate steering influence is a problem that currently consumes the focus of many of the best innovators and researchers in the field with that nut not yet having been cracked [35]. In the middle of Miller‘s pyramid, however, where attention turns to assessing whether or not individuals are able to ‗know how‘ and ‗show how‘ they would perform certain skills considerable progress has been made and it is interesting to note the consistency between the principles discussed above and those that derive from experience with performance-based assessment protocols. The mini clinical evaluation exercise (mini-CEX) [36], direct observation techniques [37], encounter card models of performance [38], and the objective structured clinical examination (OSCE) [39], are but a few examples of strategies scholars in health professional education have devised to deal with the need to sample performance repeatedly while maintaining flexibility of focus and fidelity of the situation. The main differences across these various techniques tend to be implementation strategy and the amount of structure or standardization built into the protocol. In the OSCE, for example, simulated patients are usually recruited and trained to present a patient case with consistency such that every assessee has a comparable experience. At the other extreme, the other techniques listed above tend to result in more idiosyncratic, but more authentic, assessments because they depend on what the assessee and assessor find on the ward, in clinic, or in the physicians‘ offices when the assessment is to be conducted. Common across the approaches, however, is the
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accumulation of multiple observations, thus helping the assessors to overcome the problem of context specificity. Common criticism of these approaches (with the exception of the OSCE) is that they tend to rely entirely on subjectivity, assessors using a 5, 7, or other-point scale to indicate their perceptions of the assessee‘s performance. Anyone who has been involved in any capacity with a student in difficulty will recognize the tendency to discount subjective ratings of performance as being an indication of personality clashes, the harshness of the examiner, or some other variant of ―subjective ratings are not valid.‖ Even with the OSCE, however, which was developed in part as a strategy for enabling objectivity to come to bear on student assessments [40], the issue is not as simple as ―subjectivity bad, objectivity good‖ [41,42]. Hodges, et al., for example, conducted a study aimed at testing the construct-validity of the scores resulting from an OSCE by comparing the performance of medical students, postgraduate residents, and practicing physicians [43]. To the surprise of many the investigators reported that subjective global ratings of performance and objective checklists were equally reliable yet only the subjective ratings demonstrated the pattern of data that would be suggestive of construct validity – more experienced practitioners outperforming those with less knowledge/skill. Much could be said in relation to this finding, but for our purposes there are three fundamental lessons that should be drawn: (1) Objectivity is not easily defined – even an act as simple as whether or not someone washed their hands is open to interpretation as few things fall along a dichotomous dimension in the way that checklists would lead us to believe; (2) Not everything that can be counted should count – expertise in clinical domains is not defined by comprehensiveness as experts are expert in part because of their ability to generate the correct answer without undertaking each and every step that a novice requires, thereby making it necessary to avoid rewarding thoroughness over quality; and, (3) Although it is much maligned, subjectivity is not inherently bad – what matters in terms of whether or not subjectivity should be relied upon is the way in which it is used rather than whether or not it is used. One individual‘s impression of a single case encounter is unlikely to provide a valid basis on which to judge a student‘s ability. An accumulation of systematically collected subjective judgments, however, can provide better information than more ―objective‖ or more comprehensive criteria and has the potential to allow valid assessment of a broader array of competencies than purely objective indications of performance will allow. Indeed, the combination of the latter conclusion (that subjectivity is not inherently bad) and awareness of the importance of sampling performance with repeated observations has recently begun to facilitate understanding of ways in which we can improve upon other assessment strategies that have historically proven to be difficult areas in which to gather trustworthy observations. We have seen, for example, that the judgments made during selection interviews [44,45] and tutorial-based assessments [46] improve upon the adoption of sampling-based assessment strategies despite the fact that subjective biases remain in play in each instance. Furthermore, recent evidence appears to suggest that the difficulties inherent in self-assessing one‘s own ability arise in part due to cognitive constraints with respect to mentally aggregating across past events [47]. How we might further harness the strength of human judgment in the context of assessment while minimizing its disadvantages, however, remains an area in need of further research.
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CONCLUSION Paul Feyerabend, the Austrian-born philosopher of science and self-professed anarchist became famous by arguing that progress in scientific thought should not be conceived of as being driven by the adherence to universal rules of methodology [48]. Rather, with respect to methodology, he argued that ―‘Anything goes‘ is not a ‗principle‘ I hold … but the terrified exclamation of a rationalist who takes a closer look at history‖ [49]. In writing this chapter I have resisted the urge to provide a list of ―acceptable‖ assessment techniques because Feyerabend‘s model of science seems a closer metaphor to current conceptions of assessment. With highly variable needs it is necessary to be flexible with respect to how we undertake the assessment of health professionals and their students. If one‘s goal is to implement a high stakes licensing examination that will determine whether or not an individual qualifies to practice medicine, then reliability and validity should be prioritized even if it means requiring the investment of greater resources. If, in contrast, one‘s primary goal is to ensure that students engage actively in their tutorial groups, for example, then one might quite defensibly worry less about reliability and validity in favour of ensuring the assessment protocol has a positive educational impact. As long as the decisions are made deliberately and in a manner informed more by standards of quality than by blind faith, then ―anything goes‖ is an appropriate credo. Where problems arise are instances in which the criteria that define the utility of assessment instruments are not considered when making decisions about which assessment protocols to implement or how to ensure a link between the impact of one‘s assessments and the goals one maintains. The triple jump, discussed extensively above, continues to be used by the undergraduate MD program at McMaster University despite the criticisms I have described here [50]. The tool is known to be unreliable, so it is not used to make pass/fail decisions, but students and tutors consider it to have a substantial enough educational impact that it remains part of the curriculum. As such, this example demonstrates an intermingling and blurring of the boundaries between assessment techniques and curricular design that is quite desirable in most instances. The more assessment strategies can be blueprinted to the desired knowledge/behaviours the curriculum is designed to promote and the more the assessment strategies themselves are used as a pedagogical intervention, reinforcing the curriculum, rather than operating as an independent or counter-productive force, the better. In addition to the five aspects of utility discussed in detail throughout this chapter, left somewhat implicit has been another set of principles that should be taken into account when determining whether or not one‘s assessment protocol is fit for purpose. These principles are not often a central focus in the literature as they require considering one‘s approach to assessment holistically rather than focusing on the utility of a single assessment format. They are (a) diversity (ensuring that all competencies are covered at the various levels of Miller‘s pyramid rather than simply focusing on the roles that may be easier to measure), (b) triangulation (considering multiple aspects of competence to construct a sensible whole), (c) redundancy (using multiple assessment instruments to converge on an appropriate judgment of any one competency), (d) relevance (ensuring that each instrument and each question within each instrument directly relate to the focus of the educational milieu), and (e) tailoring (to the ability level of the assessees and the context within which the assessment takes place).
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Using these criteria and those outlined in van der Vleuten and Schuwirth‘s utility model to generate a context-appropriate program of assessment is as important for the assessee as it is for the institution and the profession. We know that valid feedback enhances performance when delivered in a context appropriate manner [51] and the more we can do as educators to ensure that our assessment protocols are credible (both in perception and reality) the more we can trust that students will benefit from the guidance they receive regarding how to improve. Leaving responsibility for determining one‘s strengths and weaknesses entirely in the hands of the students themselves is a risky proposition as there is ample evidence to suggest that learners are not always well positioned to judge their own ability levels or identify remedial strategies that can help them overcome whatever flaws are identified [52,53]. A fine balance must be achieved between the provision of feedback and assessment fatigue, between engaging learners in reflective practices and helping them recognize the danger in relying solely on their own perceptions, between advocating for the collection of subjective assessments from assessors and overcoming the intuition that each subjective assessment should be attended to in isolation, and between treating assessments as measurements of success and using those assessments as pedagogical interventions in their own right. Finally, I would be remiss to not point out that in large part student reactions to assessment practices will be driven by the values and ideals of the role models present in their chosen community. Throughout this chapter I have largely focused the discussion on issues of trainee assessment, but the same principles need to be considered in the context of the maintenance of competence protocols adopted by the health professions. Cohen, in referring to the importance of ensuring adequate assessment is built into curricula has noted ―they don‘t respect what you expect; they respect what you inspect‖ [54]. We as educators and professionals within the community, however, also need to recognize that ―they‖ also respect what they ―detect‖; the more we are open to critique of our own practices the more we can ask students to actively learn from the variety of assessment techniques to which we provide them access.
REFERENCES [1] [2] [3] [4]
[5]
Flexner A. Medical Education in the United States and Canada. New York: Carnegie Foundation; 1910. Dudek NL, Marks MB, Regehr G. Failure to fail: The perspectives of clinical supervisors. Academic Medicine 2005;80:S84-7. Epstein RM. Assessment in medical education. New England Journal of Medicine 2007;356:387-96. Murphy DJ, Bruce DA, Mercer SW, Eva KW. The reliability of workplace-based assessment in postgraduate medical education and training: A national evaluation in general practice in the United Kingdom. Advances in Health Sciences Education;14:219-32. van der Vleuten CP, Schuwirth LW. Assessing professional competence: From methods to programmes. Medical Education 2005;39:309-17.
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Kevin W. Eva Streiner DL, Norman GR. Health Measurement Scales (3rd ed.). Oxford: Oxford Medical Publications; 2003. Haertal EH. Reliability. In Brennan RL, Editor. Educational Measurement (4th ed.). Westport, CT: Praeger Publishers; 2006. Downing SM. Reliability: On the reproducibility of assessment data. Medical Education 2004;38:1006-12. Norman GR. The morality of medical school admissions. Advances in Health Sciences Education 2004;9:79-82. Downing SM. Face validity of assessments: Faith-based interpretations or evidencebased science? Medical Education 2006;40:7-8. Kane MT. Validation. In Brennan RL, Editor. Educational Measurement (4th ed.). Westport, CT: Praeger Publishers; 2006. Downing SM, Haladyna TM. Validity threats: Overcoming interference with proposed interpretations of assessment data. Medical Education 2004;38:327-33. Miller GE. The assessment of clinical skills/competence/performance. Academic Medicine 1990;65:S63-7. Frank JR (Ed.). The CanMEDS 2005 Physician Competency Framework: Better standards. Better physicians. Better care. Ottawa: The Royal College of Physicians and Surgeons of Canada; 2005. Lurie SJ, Mooney CJ, Lyness JM. Measurement of the general competencies of the accreditation council for graduate medical education: A systematic review. Academic Medicine 2009;84:301-9. Murphy DJ, Bruce D, Eva KW. Workplace-based assessment for general practitioners: Using stakeholder perception to aid blueprinting of an assessment battery. Medical Education 2008;42:96-103. Larsen DP, Butler AC, Roediger HL 3rd. Test-enhanced learning in medical education. Medical Education 2008;42:959-66. Kromann CB, Jensen ML, Ringsted C. The effect of testing on skills learning. Medical Education 2009;43:21-7. Newble DI, Jaeger K. The effect of assessments and examinations on the learning of medical students. Medical Education 1983;17:165-71. Norman GR. Problem-solving skills, solving problems, and problem-based learning. Medical Education 1988;22:279-86. Barrows HS. Problem-based, self-directed learning. JAMA 1983;250:3077-80. Norman GR. What should be assessed? In Boud D, Feletti G (Eds.). The Challenge of PBL. New York: St. Martin‘s Press;1991. Nendaz MR, Tekian A. Assessment in problem-based learning medical schools: A literature review. Teaching and Learning in Medicine 1999;11:232-43. Blake JM, Norman GR, Smith EKM. Report card from McMaster: Student evaluation at a problem-based medical school. The Lancet 1995;345:899-902. Painvin C, Neufeld V, Norman G, Walker I, Whelan G. The ―triple-jump‖ exercise – a structured measure of problem solving and self-directed learning. Annual Conference on Research in Medical Education 1979;18:73-7. Smith JM. Triple-jump examination as an assessment tool in the problem-based medical curriculum at the University of Hawaii. Academic Medicine 1993;68:366-72.
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[27] Elstein AS, Shulman LS, Sprafka SA. Medical problem solving: An analysis of clinical reasoning. Cambridge, MA: Harvard University Press; 1978. [28] Eva KW. On the generality of specificity. Medical Education 2003;37:587-8. [29] Feynman R. Surely you‟re joking Mr. Feynman. New York: WW Norton and Co.; 1997. [30] Ramsey PG, Carline JD, Inui TS, Larson EB, LoGerfo JP, Wenrich MD. Predictive validity of certification by the American Board of Internal Medicine. Annals of Internal Medicine 1989;110:719-26. [31] Tamblyn R, Abrahamowicz M, Dauphinee D, Wenghofer E, Jacques A, Klass D, Smee S, Blackmore D, Winslade N, Girard N, Du Berger R, Bartman I, Buckeridge DL, Hanley JA. Physician scores on a national clinical skills examination as predictors of complaints to medical regulatory authorities. JAMA 2007;298:993-1001. [32] Case SM, Swanson DB. Constructing written test questions for the basic and clinical sciences (3rd ed.). Philadelphia, PA: National Board of Medical Examiners; 2002. [33] Blake JM, Norman GR, Keane DR, Mueller CB, Cunnington J, Didyk N. Introducing progress testing in McMaster University‘s problem-based medical curriculum: Psychometric properties and effect on learning. Academic Medicine 71;1996:1002-7. [34] Muijtjens AMM, Schuwirth LWT, Cohen-Schotanus J, van der Vleuten CPM. Differences in knowledge development exposed by multi-curricular progress test data. Advances in Health Sciences Education 2008;13:593-605. [35] Norcini JJ. Work based assessment. BMJ 2003;326:753-5. [36] Norcini JJ, Blank LL, Arnold GK, Kimball HR. The Mini-CEX (Clinical Evaluation Exercise): A preliminary investigation. Annals of Internal Medicine 1995;123:795-9. [37] Hardie EM. Current methods in use for assessing clinical competencies: What works? Journal of Veterinary Medical Education 2008;35:359-68. [38] Bandiera G, Lendrum D. Daily encounter cards facilitate competency-based feedback while leniency bias persists. CJEM 2008;10:44-50. [39] Harden RM, Gleeson FA. Assessment of clinical competence using an objective structured clinical examination (OSCE). Medical Education 1979;13:41-54. [40] Hodges BD. The Objective Structured Clinical Examination: Three decades of development. Journal of Veterinary Medical Education 2006;33:571-7. [41] van der Vleuten CP, Norman GR, Graaff E. Pitfalls in the pursuit of objectivity: Issues of reliability. Med Educ. 1991;25:110-118. [42] Norman GR, van der Vleuten CP, Graaff E. Pitfalls in the pursuit of objectivity: Issues of validity, efficiency and acceptability. Med Educ. 1991;25:119-126. [43] Hodges B, Regehr G, McNaughton N, Tiberius R, Hanson M. OSCE checklists do not capture increasing levels of expertise. Academic Medicine 1999;74:1129-34. [44] Eva KW, Rosenfeld J, Reiter HI, Norman GR. An admissions OSCE: The multiple mini-interview. Medical Education 2004;38:314-26. [45] Eva KW, Reiter HI, Trinh K, Wasi P, Rosenfeld J, Norman GR. Predictive validity of the Multiple Mini-Interview for selecting medical trainees. Medical Education 2009;43:In press. [46] Eva KW, Solomon P, Neville AJ, Ladouceur M, Kaufman K, Walsh A, Norman GR. Using a sampling strategy to address psychometric challenges in tutorial-based assessment. Advances in Health Sciences Education 2007;12:19-33.
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[47] Eva KW, Regehr G. Knowing when to look it up: A new conception of self-assessment ability. Academic Medcine 2007;82:S81-4. [48] Chalmers AF. What is this thing called science? (3rd ed.). New York: McGraw-Hill Education; 2004. [49] Feyerabend PK. Against method: Outline of an anarchistic theory of knowledge. (3rd ed.). New York: Veso; 1975. [50] Cunnington J. Evolution of student assessment in McMaster University‘s MD Programme. Medical Teacher 2002;24:254-60. [51] Shute VJ. Focus on formative feedback. Review of Educational Research 2008;78:15389. [52] Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence. JAMA 2006;296:1094-102. [53] Regehr G, Eva KW. Self-assessment, self-direction, and the self-regulating professional. Clinical Orthopedics and Related Research 2006;449:34-8. [54] Cohen J. Foreword. In Stern DT, Editor. Measuring medical professionalism. Oxford: Oxford University Press;2004.
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In: Medical Education: The State of the Art ISBN: 978-1-60876-194-4 Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 107-120 © 2010 Nova Science Publishers, Inc.
Chapter 10
THE ROLE OF PORTFOLIOS IN TEACHING AND ASSESSING PROFESSIONALISM Martina Kelly
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ABSTRACT The fiduciary relationship between patients and doctors is under threat. Commercialism, the increased politicisation of medicine and a series of well-publicised examples of medical negligence have stimulated professional organisations worldwide to reassert the centrality of core principles for medical practice. Professional competence goes beyond the application of knowledge and skills to encompass humanism, accountability, altruism and the pursuit of excellence. There is an explicit expectation that practicing professionals can demonstrate these abilities across the continuum of their careers. Yet these are complex concepts, which challenge traditional methods of teaching and assessment. How best to teach ‗honour‘? Can integrity be measured? How can society ensure continued commitment to good practice? Portfolios offer many advantages in this regard. They afford a unique insight into a learner‘s perspective; their flexible format encourages learner engagement and they provide a longitudinal collection of evidence supporting stated objectives. Fundamental to portfolio construction is the role of reflective learning, a metacognitive process that enables physicians deal with the complex challenges that are the cornerstone of medical practice. However, portfolio use poses many difficulties. They are resource intense and require commitment on behalf of staff and students. Their individualistic nature challenges standard psychometric measurement commonly employed in medical assessment. Most importantly, despite a plethora of literature, there is a dearth of empirical research available to inform classroom practice, in particular with regard to outcome studies. The most important question of all remains unanswered – will engaging in reflective practice produce better doctors? In this chapter, these issues will be discussed in more detail. We begin our journey by considering the definition of professionalism. We then examine how portfolios support teaching of professionalism. Some tips on how to successfully incorporate
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Martina Kelly portfolios into your course are given, followed by an overview of some the key issues in terms of assessment. The discussion is rooted in undergraduate medicine, although many of the principles apply to postgraduate and ongoing professional education. The overarching aim of this chapter is to foster reader‘s interest in the use of portfolios in the teaching and assessment of medical professionalism.
„The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head.‟ William Osler, 1925 [1]
INTRODUCTION
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What makes a good doctor? ‗To be a doctor means much more than to dispense pills or patch up or repair torn flesh and shattered minds.‘ (Felix Marti-Ibanez, 1968) [2] In fact, it can be difficult to define.[3] However, patients and doctors all over the world agree on one thing; knowledge and skills alone are not enough – a good doctor is one who cares. It is surprising then that traditional medical education has focused primarily on the acquisition of knowledge and skills. This is no longer the case. The new millennium has seen an explosion in the literature on professionalism, sparked by a series of well documented failures by doctors to meet legitimate societal concerns [4, 5, 6] and encroachment of the common market [7, 8]. The expectation that the internalisation of the value systems of the good doctor will happen by default is no longer accepted. There is now widespread support that professionalism must be taught actively and explicitly [9, 10, 11, and 12]. The issue is given added urgency by studies indicating that lapses in professional behavior observed in medical school are associated with subsequent unprofessional conduct in practice [13, 14]. Table 1. Language highlighting the tension between business and medical models of care Medicine as profession
Medicine as business
Primum non nocere Self-sacrifice Doctor Patient Health Morbidity Collegiality Death
Caveat Emptor Self-interest Service provider Consumer Commodity Collateral damage Competition Endpoint
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WHAT IS PROFESSIONALISM? Professionalism refers to the means by which individual doctors fulfil the medical profession‘s contract with society - "a set of values, behaviors, and relationships that underpins the public trust in doctors."[15] More than one hundred definitions of medical professionalism exist; each dependent on the type and nature of the professional organization where it originated [16]. These definitions have similar aspirations, combining ethical and sociological perspectives [17, 18, 19, 20, and 21]. Recently, there has been criticism that definitions describe attributes, rather than behaviors, which has serious implications in terms of how best to teach and evaluate professionalism [22, 23]. Stern and Arnold [24] address this dilemma by proposing that professionalism ‗is demonstrated through a foundation of clinical competence, communication skills and ethical and legal understanding, upon which is built the aspiration to and wise application of the principles of professionalism: excellence, humanism, accountability and altruism.‘
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Professionalism
E X C E L L E N C E
H U M A N I S M
A C C O U N T I B I L I T Y
A L T R U I S M
Ethical and Legal Understanding Communication skills Clinical Competence (knowledge of medicine)
Diagram 1. A definition of professionalism (Arnold & Stern, 2006).
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Martina Kelly Table 2. Relating principles of professionalism to behavior
Principle
Attributes
Demonstrated by….
Excellence (a commitment to exceed ordinary standards)
Life-long learning
Participation in continuing medical education Research Teaching Quality of care measures Clinical risk management Clinical governance Critical incident analysis Reporting conflicts of interest Leadership Standard setting Public service Advocacy Charity and voluntary work
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Improving quality of care Accountability (taking responsibility for the doctor-patient relationship)
Self-regulation
Altruism (prioritize patient‟s best interests)
Selflessness
Humanism (concern and interest in people)
Empathy Respect Compassion Honor Integrity
Ability to take different perspectives Team-work Confidentiality Informed consent Respect for culture and gender Caring and comforting Not cheating in exams/ academic work
This definition demonstrates that professionalism is a concept that goes beyond cognitive abilities, whilst encompassing the fundamental importance of core knowledge and skills. The principles of excellence, humanism, accountability and altruism are then examined in detail. These principles are summarized in table 2, with some examples of their associated behaviors. Professionalism is a dynamic concept, a ‗continual striving‟ towards principles [24]; moulded in response to the ever changing needs of the society we serve. It varies with our experience e.g., physicians may prioritize different aspects at various stages of their career [25, 26, and 27]. Unfortunately evidence would show that medical school is not always a fertile ground to learn these values – in fact some values may even decline during professional training [28, 29, and 30]. Hilton and Slotnick [31] describe this process of attrition and attainment as students develop from student to mature professional (see Figure 1). So we can see that the concept of professionalism is complex, incorporating knowledge, attitudes and skills. It varies across the continuum of a practitioner‘s life and is not a stable precept. Unsurprising then that we need a range of tools to teach and capture the multidimensional nature of professionalism. Portfolios emerge as a suitable mechanism to address many of these challenges.
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Figure 1. Proto-professionalism: a model to describe influences on the development of professionalism that transforms a medical student to a mature professional (Hilton & Slotnick) Medical Education Vol. 39, 1 Pages: 58-65, Copyright 2005 Blackwell Publishing Ltd.
PORTFOLIOS AND PROFESSIONALISM Portfolios may be defined as a collection of work that demonstrate that learning has taken place [32] In its simplest form, a portfolio is a compilation of documents - digital or paper based. In terms of professional development however, reflection is a key requirement of the portfolio process [33, 34, and 35]. Dewey [36] defines the process of reflection as "an intellectualisation of the difficulty or perplexity that has been felt (directly experienced) into a problem to be solved, a question for which the answer must be sought" (p: 107). He continues to consider reflective thought as 'active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusions to which it tends'. Dewey‘s work was progressed by Schön (1983) as he studied doctors (amongst others) at work [37]. He was particularly interested in how doctors dealt with complex problems in real-time. Schön proposed that the education of professionals should focus on enhancing their ability to reflect. Portfolios are a useful tool to help foster reflection as students transform the description of an experience into understanding the learning derived from that experience. Entries are used to explore activities facilitating a transformation of perspective – students are expected to demonstrate ‗a personal investment – evident in the student‟s selection of contents, the criteria for selection and the student‟s self-reflection‘ [38]. The expectation is
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that careful consideration of one‘s experiences will foster practical wisdom or ‗phronesis‘ [39, 40]. Portfolios are well suited to the teaching and assessment of professionalism for a number of reasons. They give insight into the learner‘s world, unique for each student. They also provide authentic, context specific documentation of learning. Thus students can reflect on issues pertinent to their own learning, rooted in their experience. Students are actively involved in constructing meaning, fostering a deep approach suitable for life-long learning [41, 42]. Using a portfolio approach gives students time and space to consider their learning. Ginsberg et al (2000) [43] advise that ‗context, conflict and resolution are foundational criteria for measuring the quality of professionalism.‘ Reflective entries in a portfolio, by definition, should have some element of uncertainty as their starting point. How students resolve these issues (and provide evidence of same) is at the core of reflective practice. Students are therefore encouraged to reflect on difficult situations; not only in relation to gaps in their knowledge but also ethical or interpersonal dilemmas. This allows mentors to focus on the reality of medical training as opposed to how it should be. In contrast to traditional teaching methods in medical education, process is just as important (perhaps more so) than outcome. This is important in relation to professionalism where the end does not justify the means; educators are increasingly paying attention to how their students make decision and weigh up the pros and cons of various choices. In this way, portfolios represent a distinct pedagogical approach, one which seeks to document how our students learn. Portfolio practice builds on the traditional apprenticeship model prevalent in medical education by fostering a one-to-one relationship with a staff member as mentoring is an important aspect to maintaining a portfolio. The close interaction between students and staff fosters a supportive learning environment; negative experiences (common in medical training) can be turned into positive ones. The issue of honesty and confidentiality area given considerable attention in the literature as portfolio entries tend to be personal. Is it fair to ask students to share their innermost thoughts? The ‗making public‟ [44, 45] of information is a critical factor in successful use of portfolios as without this there is the danger that the process becomes too introspective [46, 47, 48]. In terms of reflective learning Brockbank & McGill (19980[49] refer to the idea of ‗reflexive dialogue‘. emphasizing that ‗reflective practice undertaken through reflective dialogue with another, or others, may promote transformational learning.‘ This is of particular importance in terms of ongoing professional development and revalidation, as critical self- appraisal is considered a fundamental component of this process. Yet, it is suggested that physicians have a limited ability to accurately self-assess [50]. The authors suggest that the processes currently used to undertake professional development and evaluate competence may need to focus more on external assessment. By embracing Boud‘s (1999) [51] stance that ‗self-assessment should not imply an isolated or individualistic activity; it should commonly involve peers, teachers and other sources of information‘ discussion of portfolio entries offer a suitable means to seek external validation whilst retaining a learner centred focus. As Eva and Reughr (2008) [52] continue, Boud‘s model of ‗self-directed assessment‘ describes a pedagogical activity of looking outward for formative and summative assessment of one‘s current level of performance.
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DEVELOPING A PORTFOLIO Expanding on the steps proposed by Friedman Ben-David et al [53], Table 3 provides an overview of some key areas to address when adopting a portfolio approach. Suggestions are made on the types of competencies it is possible to examine. Table 3. Steps in establishing portfolio based assessment Step
Key issues
What is the purpose of the portfolio?
Formative (work-based portfolio) Summative (outcome-based portfolio)
What competencies are being assessed? (relate to overall course, assessment blueprinting) What material will be included?
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(keep it lean[67] and smart[57])
How will it be assessed?
Establish reliability and validity evidence Evaluate the process
Both – will students have the option of synthesizing material?[54] Develop self-awareness [55] Foster self-directed learning [56,57,58,59] Develop empathy [60, 61,62,63,64] Stimulate deep learning [47,65] (Moon, 2000, Sobral, 2000) Develop critical thinking [40,66] Learning plans Critical incident reports or a successful case (we learn from what we do well!) Audit Evaluation forms e.g. from faculty, peers or patients Notes on readings (e.g. novels or poems, humanities or social sciences), critical review of articles Video clips, audio clips, CD rom material Almost anything is possible, but students appreciate some guidance. To prevent the portfolio becoming unwieldy consider a word count. Flexibility and a sense of ownership are identified as key to success[68] Quantitative or qualitative approach? Global or graded? Prepare rubrics for examiners; develop guidelines for decisions Quantitative: minimum inter-rater reliability Qualitative: credibility, dependability [69] Establish audit trail and external review processes Possible areas to examine include; Learning environment (student and faculty views) Learner‘s self-assessment skills Learner autonomy Clinical problem solving
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Underpinning these steps is the need to involve both students and faculty in the process. Although there is much written on reflection and portfolio use, both approaches are relatively novel for medical practitioners. As Branch and Paranjape (2002) [70] conclude, ‗while feedback is not used often enough, reflection is probably used even less.‘ They postulate that a potential barrier may be „personal discomfort with exploring emotions‟. Indeed, studies exploring faculty views on reflection would suggest some reticence with the concept, even when acknowledged as a useful skill [71]. Fryer-Edwards, Pinsky and Robins (2006) [72] suggest a number of ways to ensure ‗faculty buy-in‘; including using a slide presentation featuring Picasso‘s evolving self-portraits to illustrate the concept of self-reflection fostering professional growth. Likewise, students may view reflection as an unnecessary workload [73, 74]. A number of studies have shown that students with less academic and professional maturity need support and clear instructions when starting out [75, 76]. In terms of reflective practice students may benefit from support and structured discussions initially as they learn to change the focus of their learning from what (content) to how and why (process). Frameworks such as those proposed by Johns [77] or Moon [47] are helpful in this regard. As the students‘ skills develop, flexibility should be allowed to display the personal qualities of the student [68].
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ASSESSING PROFESSIONALISM USING PORTFOLIOS The role of portfolios in assessment has been written about extensively [53, 66, 78, 79, and 80]. Portfolios avoid a reductionist approach to assessment, allowing multiple views over time. The need for such longitudinal assessment of professionalism has been identified [81]. However, much controversy remains. How can we standardise our assessment to ensure they are reliable and valid, yet retain a flexible, student centred approach? Predictably, studies have shown that failure to assess portfolios may undermine their use [41, 73]. Yet a number of authors express concern that introducing assessment will inhibit reflection and diminish its value [49, 51, 82, and 83]. It is gratifying to note that studies examining the combination of formative mentoring and summative assessment in a single portfolio [57, 68] did not report this conflict between learning and assessment. A practical suggestion to overcome this issue is to engage different instructors for formative and summative purposes e.g. in Maastricht all mentors form part of the portfolio committee but do not mark their own students‘ portfolio for summative purposes. An additional safeguard is the Patchwork Text assessment [54]. This requires students to present a series of fragments created over time from their learning experiences, synthesized into a final submission. At present portfolios are not widely used for high stakes examinations. This primarily relates to concerns about the lack of evidence of reliability and validity [84]. Inter-rater reliability has been examined in a number of studies [85-91] Driessen et al [92] in a recent systematic review estimate that inter-rater reliability averages 0.63 (Spearman co-efficient), indicating moderate agreement. A value of 0.8 is recommended for high stakes examination. To achieve high levels of inter-rater reliability of portfolios should be carefully introduced to well prepared students and should be of uniform content. Using a small pool of experienced,
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trained scorers who use clearly articulated criteria is advisable. Assessors need to have a shared understanding of the purpose of assessment and a deep understanding of expected student performance. There is some evidence that using these principles may increase interrater reliability [89, 90]. A number of institutions include interviews, a ‗professional conversation‟ [93], to supplement the written work [32, 55, and 94]. In particular, attention should be given to how the material selected relates to overarching competencies [95]. Evidence supporting these claims should be sought. Interviews have the potential to contribute to course evaluation in addition to their role in student assessment [82, 94]. Recently Burch & Seggie (2008) [96] have suggested that a 30-minute structured interview is a feasible and internally consistent method of assessing reflective portfolios. They suggest that this may overcome resource issues when using portfolio based assessment. It is interesting to note that Pitts & Cole, who have conducted considerable research on inter-rater reliability, suggest that qualitative approaches are more appropriate for portfolio based assessment [97]. The adoption of a holistic interpretive approach is supported by Webb (2003) [98] and Driessen (2005) [99]. Thus issues of credibility, transferability, dependability and confirmability need to be addressed in a systematic manner., interested readers are guided to a case study presented by Driessen and colleagues [99].
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CONCLUSION Professionalism is a core part of medical education. Although a complex concept, which varies over time, it is possible to teach. Teaching the cognitive base and providing opportunities for the internalization of its values form the basis of this endeavour. [100] The use of reflection to examine key experiences fosters critical thinking and equips students for a life of learning. Conflict is part of daily professional life; we are torn between the need to be objective and the need to care; how do we balance the needs of the individual with the needs of the majority; are we willing to stand up and be counted, even if that means potential threat to our position? Portfolios offer students and teachers the opportunity to explore and document the professional development of both parties in longitudinal fashion. Their use is time intensive and requires commitment – portfolio based learning is based on mutual trust – the very thing we are trying to inspire. Yet this process is essential if we are to maintain our social contract in the contemporary world.
RESOURCES Reference text on Professionalism: Stern T. (editor) Measuring Medical Professionalism. NY: Oxford University Press; 2006 Reference text on Portfolios: Friedman Ben David M, Davis MH, Harden RM, Howie, PW, Ker J, Pippard MJ. AMEE Medical Education Guide No. 24: Portfolios as a method of student assessment. Med Teach. 2001; 23(6):535-551. The Eportfolio website of Faculty of Medical Sciences Computing & School of Medical Education Development, Newcastle University, is full of tips and has key articles.
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Reference text on Reflection: Moon J. A Handbook of Reflective and Experiential Learning. UK: Routledge Falmer; 2004
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[10]
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[19] Cruess SR, Johnston S, Cruess RL. Profession: a working definition for medical educators. Teach Learn Med 2004;16:74–6. [20] Epstein R, Hundert E. Defining and assessing professional competence. JAMA 2002;287(2):226-235. [21] Haffery FW. Definitions of professionalism: a search for meaning and identity. Clin Orthop Relat Res 2006;449:193-204. [22] Wear D, Kuczewski MG. The professionalism movement: can we pause? Am J Bioeth. 2004 Spring;4(2):1-10. [23] Leo T, Eagen K. Professionalism education: the medical student response. Perspect Biol Med. 2008 Autumn;51(4):508-16. [24] Arnold L, Stern D. What is Medical Professionalism. In Stern T.(editor) Measuring Medical Professionalism. NY: Oxford University Press; 2006. [25] Rudy DW, Elam CL, Griffith CH. Developing a stage-appropriate professionalism curriculum. Acad Med 2001;76:503-504. [26] Brownell AKW, Cote L. Senior residents views on the meaning of professionalism and how they learn about it. Acad Med. 2001;76:734-37. [27] Rowley BD, Baldwin DC Jr, Bay RC, Karpman RR. Professionalism and professional values in orthopaedics. Clin Orthop Rel. Res. 2000;378:90-96. [28] Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students‘ perceptions of their ethical environments and personal development. Acad Med 1994; 69:670-79. [29] Self DJ, Olivarez M. Retention of moral reasoning skills over the four years of medical education. Teach Learn Med 1996;8(4): 195-199. [30] Patenaude J, Niyonsenga T, Fafard D. Changes in components of moral reasoning during students medical education: a pilot study. Med Educ 2003; 37:822-829. [31] Hilton S, Slotnick H. Proto-professionalism: how professionalization occurs across the continuum of medical education. Med Educ 2005;39:58-65. [32] Davis MH, Friedman Ben-David M, Harden RM, Howie P, Ker J, McGhee C, et al. Portfolio assessment in medical students‘ final examinations. Med Teach 2001; 23: 357-66. [33] Pinsky LE, Monson D, Irby DM. How excellent teachers are made: reflecting on success to improve teaching. Adv Health Sci Educ 1998;207-215. [34] Epstein RM. Mindful practice. JAMA. 1999 Sep 1;282(9):833-9. [35] Stern DT, Cohen JJ, Bruder A, Packer B, Sole A. Teaching humanism. Perspect Biol Med. 2008 Autumn;51(4):495-507. [36] Dewey, J. How We Think: A Restatement of the Relation of Reflective Thinking to the Education Process Boston: D.C. Heath;1933. [37] Schön, D. The Reflective Practitioner, New York: Basic Books;1983. [38] Gisselle O, Martin-Kneip Becoming a Better Teacher. Alexandria,Virginia, USA: ASCD;2000. [39] McKeon R. (Ed)The basic works of Aristotle. New York: McGraw Hill;1941. [40] Mezirow, J. How critical reflection triggers transformative learning. In: Mezirow J. , editor. Fostering Critical Reflection in Adulthood: A Guide to Transformative and Emancipatory Learning. San Francisco: Jossey-Bass; 1990. pp. 1–20. [41] Snadden D, Thomas ML. Portfolio learning in general practice vocational trainingdoes it work? Med Educ 1998; 32(4): 401-6.
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In: Medical Education: The State of the Art ISBN: 978-1-60876-194-4 Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 121-129 © 2010 Nova Science Publishers, Inc.
Chapter 11
CULTURAL COMPETENCE IN MEDICAL EDUCATION Patrick Henn
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ABSTRACT Graduates of medical schools are required to provide health care for communities that are increasingly diverse with respect to cultural, ethnic, religious and racial backgrounds. The "demographic transition" model suggests that the world will see increasing migration for economic reasons from the developing world to the developed world with a consequential increase in cultural, ethnic, religious and racial diversity. Inequalities in the delivery of health care to minorities have been well documented. The Institute of Medicine identified cultural competence training of health professionals as a potential means to improve quality of care and reduce health disparities between ethnic minorities and the majority population. Graduates in the medical profession will therefore need to have the knowledge, skills and attitudes with respect to cultural competence to help meet these challenges. Key themes and components of cultural competence need to be developed and incorporated into the curriculum of medical education. To date this strategy shows promise at improving the knowledge, attitudes and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of service across racial and ethnic groups is lacking. Many studies lack methodological rigour and this limits the evidence for the impact of cultural competence training on improving health care for minorities. Further research is needed and more attention paid to the design, evaluation and reporting of cultural competency training programmes.
INTRODUCTION Graduates of medical schools in many parts of the world are required to provide quality clinical care, deliver quality health care provision, design quality health care services and develop quality health care policies for communities that are increasingly diverse with respect to cultural, ethnic, religious and racial backgrounds. From the individual patient‘s perspective
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this implies being able to access health care that will enhance health outcomes and eradicate the disparities in health care provision that currently exist as a consequence of the patient‘s ethnic, social or racial backgrounds. For the individual medical practitioner this demands a level of competency with respect to the cultural, ethnic, religious and racial backgrounds that may influence health and health care for their individual patient or the communities in which they serve. Therefore within the field of medical education at both undergraduate and post graduate level the curriculum should provide graduates with the relevant knowledge, skills and attitudes to help them to overcome these particular challenges in health care delivery at an individual or community level. In essence there is a need for medical practitioners to be culturally competent with respect to their individual patient or the communities in which they serve.
BACKGROUND
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Demographic Trends and Health Disparities There is a significant difference in the growth rate in population by a factor of 20 between the developing world and the developed world [1]. McCarthy describes these global demographic trends in the context of the model of the "demographic transition." This model demonstrate the changes to the dynamics of population growth compared to earlier patterns and suggests that the world will see increasing pressures for migration because of economic reasons from the developing world to the developed world [2]. Based on this model we can assume increasing cultural, ethnic, religious and racial diversity among populations. Even in relatively homogenous populations such as the Republic of Ireland this is evident. In the 2006 Census the number of non Irish nationals living in the Republic of Ireland represented 10% of the population. This is an increase from the previous 2002 census where 5.8% of the population were non nationals, reflecting an increase of 87% in non nationals living the Republic of Ireland over this period of time [3]. In the UK the Black and Minority ethnic groups account for 73% of that country‘s total population growth in recent years [4]. In the USA the demographic changes indicate a continual increase in racial and ethnic populations with diverse language and cultural backgrounds. The prediction from the USA census is that racial and ethnic minority populations will account for almost 90% of the overall growth in population over the period 1995 to 2020 [5]. In the USA 32 million people speak a language other than English in the home and there are more than 300 languages spoken [6]. Inequalities in the delivery of health care to minorities have been well documented in the USA [7].When compared to the majority population group, minority ethnic groups have for example disproportionately more cerebrovascular disease, diabetes, HIV/AIDS, and tuberculosis [8]. In the UK disparities in the quality of health care have been demonstrated as inferior for minorities when compared to the majority population. This occurs in disorders as diverse as heart disease, cerebrovascular disease, cancer, prenatal care and mental health [9] [10] [11] [12] [13]. Similar disparities in quality of health care have been reported in the USA for example in diabetes, in HIV/AIDS and in asthma [14].Members of minority ethnic groups with disabilities also experience disparities when compared with the majority population. In the Irish context minority ethnic groups with disabilities are largely an invisible group in Irish
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society. They are open to discrimination on the basis of ethnicity so for example Travellers with disabilities may be confronted by anti-Traveller bias [15]. Significant challenges are presented to medical professionals by this increasing cultural, ethnic, religious and racial diversity in populations and the inequalities in health care experienced by ethnic minorities.
CULTURAL COMPETENCE AND MEDICAL EDUCATION
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Defining Cultural Competence The development of the concept of cultural competence in health care came initially from the work in the field of medical of medical anthropology [16]. In these studies anthropologists using the observation methodologies of the discipline of anthropology explored the doctor patient relationship in terms of medical culture and the interaction between culture, health beliefs and health behaviour. They have identified the traditional culture of Western medical practice as having a strong focus on the disease process and by in large paying little attention to the impact of cultural and psychosocial factors on health [17]. This clash of cultures between traditional medicine and culture at the individual level is graphically portrayed in the book The Spirit Catches You and You Fall Down. This account describes the tragic unfolding of the life of a 3 month old girl Lia a member of the Hmong tribe who were forced to flee Laos for the USA in 1975. Lia develops epilepsy and is treated by well meaning and well intentioned western trained English speaking physicians. Her parents believe that her seizures are caused by a flight of her soul from her body and called her condition by its Hmong name quag dab peg (―the spirit catches you and you fall down‖). Her parent‘s spoke no English the hospital staff no Hmong. Both Western and Hmong traditions were well intentioned towards Lia. The misunderstanding and confusion that arises as these two cultures clash and their impact on Lia, her parents and physicians unfold in this tragic story [18]. Ethnic background and social status are inherently linked. Racial stereotyping and social privileges of class groups in a society are reflected in, and are as real in health care provision [17]. There is also an intrinsic power differential in the doctor patient relationship in favour of the former [19]. The emergence of the field of ―cultural competence‖ has developed as one strategy to address these issues of health disparities and so enable medical professionals to work more effectively in a cross-cultural environment. In the context of cultural competence the goals are for health provision that is cognisant of, respectful of, and responsive to the health beliefs, practices, cultural and linguistic needs of patients from diverse cultural backgrounds. The purpose of cultural competent health care is to help improve health and health outcomes for this group of patients. In terms of defining cultural competence there is certainly no universally accepted definition. The Office of Minority Health in the USA has adapted this definition from Cross et al and defined cultural competence as [20] [21]: ―a set of congruent behaviours, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in cross-cultural situations. ‗Culture‘ refers to integrated patterns of human behaviour that include the language,
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Patrick Henn thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious or social groups. ‗Competence‘ implies having the capacity to function effectively as an individual and an organisation within the cultural beliefs, behaviours, and needs presented by consumers and their communities.‖
STRATEGIES FOR INTEGRATING CULTURAL COMPETENCE TRAINING INTO MEDICAL EDUCATION
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In 2003 the Institute of Medicine‘s report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care identified cultural competence training of health professionals as a potential means to improve quality of care and reduce health disparities between ethnic minorities and the majority population [22]. One of the challenges that now face medical educators is to design teaching and learning experiences to help prepare medical students to deliver effective health care and develop effective relationships with patients who will differ from them ethnically, racially, culturally and linguistically. What then should be the key themes and components of culture that should be incorporated into the undergraduate curriculum? Tervalon‘s paper describes these key themes and components. [23]. These include the rationale for learning about: culture and cultural basics (such as definitions, concepts, culture in the social sciences, relationships of culture to health and health care and health systems as cultural systems) health status data on for example demographics, epidemiology, health disparities and the historical context. the tools and skills for cross-cultural clinical encounters for example interviewing skills and the use of interpreters. characteristics and origin of attitudes and behaviours of providers of health services community participation including the use of expert teachers, community-school partnerships and the community as a learning environment the nature of institutional culture and politics. Kawaga –Singer and Kassim-Laha describe an anthropological evaluation of the fundamental relationship between culture and health. They suggest a guideline for the clinician to use that will enable them to evaluate disease and illness within its cultural context and provide a framework for the clinical skills required in order to negotiate and reach jointly agreed targets for care [24]. Gregg and Saha in their paper warn of the dangers of too narrow or to broad an approach to cultural competence as this may in fact reinforce stereotypes and contribute to rather than reduce cross-cultural misunderstanding [25]. The authors stress five central concepts to counter this. Firstly that culture matters in health and health care, secondly that learning about culture per se is not a panacea for health disparities, thirdly that culture race and ethnicity are distinct concepts, fourthly that culture is mutable and multiple and finally context is critical because culture is ultimately inseparable from its social and economic context. Arguments have also been put forward for specific areas of focus with regards to the teaching of cultural competence. Eiser and Ellis argue that teaching and
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learning methods should use specific content and they use the African-American minority‘s interaction with the American health care system as a paradigm. They include the use of actors in workshops which have the added advantage of participants receiving observer feedback on their interactions [26]. Barnet argues for specific skills training to facilitate communication when hearing loss is involved as the prevalence of hearing loss is greater than for example heart disease, asthma, or diabetes. The author argues that appropriate curricular content can enhances a student‘s ability to ―hear‖ these patients [27]. Eddey and Robey argue that cultural competence education should be extended to include ―the culture of disability‖ and point out that this is a pan ethnic culture for which a certain set of competencies are required such as communicating with patients who have deficits in verbal communication and avoidance of infantilizing speech [28].
EVALUATION OF CULTURAL COMPETENCE TRAINING IN MEDICAL EDUCATION
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Betancourt provides a framework for evaluation of cultural competence training in medical education. Firstly the evaluation of students in relation to cross cultural education and secondly evaluation that links the curriculum to health outcome measures [29]. The author links the evaluation for cross cultural education to attitudes, knowledge and skills as follows: Attitudes – standard surveying – structure interviewing – self awareness assessment – presentation of clinical cases – OSCE – video or audio taped clinical encounter Knowledge – pre test and post test evaluation using e.g. MCQ – unknown clinical cases – presentation of clinical cases – OSCE Skills – presentation of clinical cases – OSCE – video or audio taped clinical encounter The author suggests three questions to link the curriculum to health outcomes. Do students learn what is taught? Do students use what is taught? Does what is taught have an impact on care?
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EVIDENCE FOR EFFECTIVENESS OF CULTURAL COMPETENCE TRAINING IN MEDICAL EDUCATION This is the era of evidence based medicine. The evidence based approach must also act to inform the development and ultimate benefit of cultural competence in medical education. A survey or sixteen medical schools in Canada showed that eight of the medical schools had listed explicit criteria on cultural sensitivity in their curricular objectives and three of the schools included cultural sensitivity in their clerkship evaluation forms. The authors concluded that inclusion of multicultural health content within the curricula remained an ongoing problem and identified the need for more research on effective curricular content [30]. Kai, Bridgewater and Spencer carried out a series of focus group interviews on a mixture of undergraduate and post graduate students‘ perceptions and their perceived training needs in relation to cultural and ethnic diverse care. The authors concluded that their study points to inadequate training of students as the participants had a broad but superficial understanding of multicultural issues. Teaching was perceived as inadequate by the students and limited largely to ethnic patterns of disease and most students felt a need for greater training [31]. Beagan investigated the exposure to a new course Physicians, Patients and Society at a Canadian medical school. This course addresses social and cultural issues in medicine. The author compared two groups one prior to the introduction of the course and the second after the introduction of the course. This study found that those who had the course as part of their curriculum did not demonstrate increased awareness of social and cultural issues compared to those who did not have this course in the curriculum. In general students had concluded that learning about social and cultural issues made little or no difference when they did their clinical rotations. The author concluded that for medical schools to produce doctors who are sensitive to and competent working with diverse communities there is a need for a balance between attention to ―difference‖, attention to self, and attention to power relations in this aspect of the curriculum [32]. Lempp and Seale in their qualitative study focused on medical students‘ views about their experience in relation to ethnicity and gender within the context of the hidden curriculum at a British medical school. Some students from an ethnic minority commented on the discrepancy between the ethnic composition of the medical student intake and the ethnic composition of the medical profession suggesting that this could have a negative implication for their career prospects. Despite claiming no experience of gender difference during medical training, female and male students expressed gender stereotyping for example the physical strength and competitiveness stereotypically associate with men is required for a career in surgery [33]. Shapiro et al conducted a study on medical students in their first year of clinical training to assess their perceptions of the cultural competence curriculum at a public university school of medicine in the USA. The results suggested that the cultural competence curriculum increased awareness in terms of bias in both self and in others but was less effective in teaching specific interventional skills. That the cultural competence curriculum did not always provide sufficient help to them to find a balance between group specific knowledge and respect for individual differences. The authors concluded that future research needs to address such issues as perceived relevance, stereotyping, and political correctness in developing cross cultural training programs [34]. Wear and Kuczewski in their paper suggest three processes to improve medical students perceptions‘ and understanding of people living in poverty. First increase the socioeconomic
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diversity of medical students, second promote empathy through curricular efforts and thirdly focus more directly on role modelling [35]. In their systematic review of health care provider interventions to improve cultural competence of health care providers Beach et al concluded that as a strategy it shows promise at improving the knowledge, attitudes and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of service across racial and ethnic groups is lacking. They recommend that future research should focus on these outcomes and should determine which teaching methods and content are most effective [36]. In a second systematic review Price et al examined the methodological rigor of studies using cultural competence training to improve health care for minorities. They concluded that a lack of methodological rigour in studies limits the evidence for impact of cultural competence training on improving health care for minorities. They suggest that more attention should be paid to the design, evaluation and reporting of cultural competency training programmes [37].
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CONCLUSION Inequalities of health care provision continue to exist. The diversity of populations with respect to racial, cultural, ethnic and religious backgrounds will significantly increase in many countries in the developed world over the coming years. There are many reasons for health care inequalities. Cultural competence should not be seen as and indeed is not a panacea for these issues. However, cultural competence with respect to health care has now become an essential part of the medical practitioner‘s repository. Key themes and components of cultural competence need to be developed and incorporated into the curriculum of medical education. To date this strategy shows promise at improving the knowledge, attitudes and skills of health professionals. However, evidence that it improves patient adherence to therapy, health outcomes, and equity of service across racial and ethnic groups is lacking. Many studies lack methodological rigour and this limits the evidence for the impact of cultural competence training on improving health care for minorities. Further research is required and more attention paid to the methodology of this research in the design, evaluation and reporting of cultural competency training programmes.
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Patrick Henn Wan H, Hobbs F. Minority Population Growth: 1995 to 2050 The emerging minority marketplace. Washington, (DC): U.S. Department of Commerce, Minority Business Development Agency; 1999. Smith S, Gonzales V. All health plans need culturally and linguistically appropriate materials. Healthplan 2000;41:45-48. Smedley BD, Stith AY, Nelson AR, editors. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, (DC): National Academics Press; 2003. Centre for Disease Control and Prevention. Healthy People 2001: final review. [Online]. 2001[cited 2009 Feb 11]. Ward PR, Sylvesr R, Sharma P. Are GP practices prescribing for coronary heart disease drugs equitable? A cross sectional analysis in four primary care trusts in England. J of Epidemiol Community Health 2004;58:89-96. Bourke J, Sylvester R, Sharma P. Ethnic variations in the management of patients with acute stroke. Postgrad Med J 2006;82:13-15. Neal RD, Algar VL. Sociodemographic factors and delays in the diagnosis of six cancers: analysis of data from the ‗National Survey of NHS Patients: Cancer‘. Br J Cancer 2005;92:1971-75. Rowe RE, Garcia J, Davidson LL. Social and ethnic inequalities in the offer and uptake of prenatal screening and diagnosis in the UK: a systematic review. Public Health 2004;118:177-89 McKenzie K, Bhui K. Institutional racism in mental health care. BMJ 2007;334:64950. Kaiser Foundation. Key Facts Race, Ethnicity and Medical Care. [Online]. 2007 [cited 2009 Feb 11]. Pierce M. Minority ethnic people with disabilities in Ireland: Situation identity and experience. Dublin: The Equality Authority; 2003. Kleinman A, Esinberg L, Good B. Culture, illness, and care: clinical lessons from anthropologic and cross cultural research. Ann Intern Med. 1978;88:251-59. Hardwood A. Ethnicity and Medical Care. Cambridge (MA): Harvard University Press; 1981. Fadiman A. the spirit catches you and you fall down. a Hmong child, her American doctors, and the collision of two cultures. New York: Farrar, Straus and Giroux; 1997. Tervalon MR, Murray-Garcia J. Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education. J Health Care for the Poor and Undeserved 1998;9(2):117-25 The Office of Minority Health. What is cultural competency? [Online]. 2005 [cited 2009 Feb 11];[2 screens]. Cross TL, Bazron BJ, DennisKW, Issacs MR. Towards a culturally competent system of care: A monograph of effective services for minority children who are severely emotionally disturbed. Washington (DC): National Technical Assistance Center for Children‘s Mental Health, Georgetown University Child Development Center; 1989. Smedly BD, Stith AY, Melson AR editors. Institute of Medicine: Unequal Treatment: Confronting Racial and Ethnic Disparities in health Care. Washington (DC): National Academies Press; 2003. Tervalon M. Components of culture in health for medical students‘ education. Acad Med 2003;78(6):570-76.
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[24] Kawag-Singer M, Kassim-Lakha S. A strategy to reduce cross- cultural miscommunication and increase the likelihood of improving health outcomes. Acad Med 2003;78(6):577-87. [25] Gregg J, Saha S. Losing culture on the way to competence: The use and misuse of culture in medical education. Acad Med 2006;81(6):542-46. [26] Eiser AR, Elis G. Cultural competence and the African American experience with health care: The case for specific content in cross cultural education. Acad Med 2007;82(2):176-82. [27] Barnet S. Communication with deaf and hard of hearing people: A guide for medical education. Acad Med 2002;77(7):694-700. [28] Eddey GE, Robey KL. Considering the culture of disability in cultural competence education. Acad Med 2005;80(7):706-712. [29] Betancourt JR. Cross-cultural medical education: conceptual approaches and frameworks for evaluation. Acad Med 2003;78(6):560-69. [30] Azad N, Power B, Dollin J, Chery S. Cultural sensitivity training in Canadian medical schools. Acad Med 2002;77(3):222-28. [31] Kai J, Bridgewater R, Spencer J. ‗‖Just think of TB and Asians‖, that‘s all I ever hear‘: medical learners‘ views about training to work in an ethnically diverse society. Med Ed 2001;35:250-56. [32] Beagan BL. Teaching social and cultural awareness to medical students: ―it‘s nice to talk about it in theory, but ultimately it makes no difference‖. Acad Med 2003;78(6):605-14. [33] Lempp H, Seale C. Medical students‘ perceptions in relation to ethnicity and gender: a qualitative study. BMC Medical Education [Online]. 2006 [cited 2009 Feb 11];[6 screens]. [34] Shapiro J, Lee D, Gutierrez D, Zhuang G. ―That never would have occurred to me‖: a qualitative study of medical students‘ views of a cultural competence curriculum. BMC Medical Education [Online]. 2006 [cited 2009 Feb 11];[6 screens]. [35] Wear D, Kuczewski M. Medical students‘ perceptions of the poor: what impact can medical education have? Acad Med 2008;83(7):639-45. [36] Beach MC, Price EG, Gary TL, Robinsson KA, Gozu A, Palacio A et al. Cultural competence: a systematic review of health care provider educational interventions. Med Care 2005Apr;43(4):353-73. [37] Price EG, Beach MC, Tiffany LG, Robinson KA, Gozu A, Palacio A. A systematic review of the methodological rigor of studies evaluating cultural competence training of health professionals. Acad Med 2005;80(6):578-86.
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In: Medical Education: The State of the Art ISBN: 978-1-60876-194-4 Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 131-138 © 2010 Nova Science Publishers, Inc.
Chapter 12
STUDENT CHOICE IN MEDICAL EDUCATION Geraldine Boylan and Áine Hyland "The greatest educational opportunities will be afforded by that part of the course which goes beyond the limits of the core and that engenders an approach to medicine that is constantly questioning and self-critical" Tomorrow‟s Doctors, General Medical Council UK, 2003.
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ABSTRACT Medical education is evolving at a rapid pace and it is not possible to teach medical students all they need to know. Medical educators throughout the world have sought to change the way medical courses are delivered and to introduce a range of optional or elective subjects to allow students study areas of particular interest. These options are usually referred to as Student Selected Components (SSCs). These options provide students with a way to customise their own learning and to follow particular career interests. These electives are also a very useful vehicle for students to undertake research projects, particularly when they run concurrent to the core curriculum. SSCs can also be used to develop diversity between medical schools as they can allow educators to develop modules in areas of particular strength at the individual institution.
INTRODUCTION Medical Education is evolving at a rapid pace in Ireland and throughout the world. Medicine remains a popular profession and entry level requirements remain very high in all countries, making it a highly competitive discipline. Most courses in Ireland and the UK are of five years in duration though some shorter four year courses for graduates are now emerging.
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The trend in Medical education is to provide the ‗core‘ knowledge to all students so that they develop the requisite knowledge, skills and attitudes to become competent practitioners. Providing all the requisite core knowledge is becoming increasingly difficult given the rapid advances taking place in the field of medicine and science. In order to address this, medical educators throughout the world have sought to change the way medical courses are delivered. There is a general move away from the more didactic preclinical and clinical courses to a more integrated curriculum that introduces clinical contact from the outset and encompasses problem based learning and research led teaching from the outset. A range of optional or elective subjects have also been introduced in most medical schools and these provide an opportunity for students to further a particular interest area and to develop key generic skills such as research and communication skills. These options are usually referred to as ‗student selected components‘. Medical curricular reform has also seen the introduction of more diverse teaching, learning and assessment methods. The end of year exam burden for medical students is high and the move towards more formative and continuous assessment is a welcome move.
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CHOICE IN MEDICAL EDUCATION The idea of a core curriculum with options was first described in Tomorrow‟s Doctors - a report on medical education published in the U.K. in 1993. The options were first called Special Study modules to fit in with a modular curricular system. However, it soon became clear that not all curricula were modular and the way in which options were provided did not have to be in this format. Hence in the 2003 revision of Tomorrow‟s Doctors (1) they were renamed Student Selected Components (SSC‘s). This document states that between 25-33% of curricular time should be devoted to SSCs and that at least 60% of SSCs should be in subjects related to medicine, whether laboratory-based, or clinical, biological or behavioral, researchoriented or in humanities related to medicine. SSCs should support the core curriculum and allow students to; learn about and begin to use research skills; have greater control over their own learning and develop self directed skills; study, in depth, topics of particular interest outside the core curriculum; develop greater confidence in their own skills and abilities; present the results of their work verbally, visually or in written format; consider potential career paths through experience in different clinical environments. Hence the SSC programme can be seen as that part of the curriculum that allows students to have choice in their medical education and to develop the skills and attitudes necessary for a future of lifelong learning which will subsequently allow them to update their knowledge and skills throughout their professional careers. This means that many SSCs are expected to have a substantial element of self-directed learning incorporated, with a concomitant decrease in traditional didactic lectures and tutorials. SSCs are generally of three main types:
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The core in depth e.g. Genetics of human disease, Related to or complementing the core e.g. Medical Computing, Art in Medicine Unrelated to the core e.g. Languages, Art appreciation In this way, students are given the option to pursue a wide range of subjects which may be related to specific medical interests, to career aspirations or may simply help to broaden their development and educational experience. Harden and Davis in their 1995 paper described how SSCs could solve many of the problems in medical education (2). They believed that when linked to a core curriculum the SSCs could:
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Provide students with an opportunity to study in greater depth an area of their choosing Facilitate the development of integrated themes giving a multidisciplinary and multiprofessional direction to the curriculum Facilitate competencies such as communication skills Allow an extension of the range of subjects or topics covered in the curriculum. This allows students to sample possible areas of later specialism. Provide diversity between medical schools. A range of interesting SSCs may attract potential students and influence their choice of medical school. Facilitate a range of teaching resources Attract and reward both students and staff. In the Medical School at University College Cork, like many other Medical Schools throughout Ireland and the UK, students are presented with a menu of options in the first 3 years of the course. These options can be of 3 main types; options that go deeper than the core, those that are related to the core and those that are unrelated to the core. In this way, students are given the option to pursue a wide range of subjects which may be related to specific medical interests, to career aspirations or may simply help to broaden their development and educational experience. Over the final two years of the undergraduate medical course, students organise a research project in an area of particular interest and initially complete a comprehensive literature review and a research proposal before embarking on the research project per se. At the end of the 5 year course, students have attained all the desired learning outcomes course of an SSC programme. The structure of the SSC programme can take a number of formats and these are comprehensively covered by Harden and Davis (2). SSCs can be integrated into the core curriculum, run concurrently, run as intermittent blocks throughout the curriculum or run sequentially. In the Medical School at UCC, SSCs run concurrently with the core curriculum and SSCs are taken over one or two semesters in each year. This is particularly advantageous for research based SSCs as they can run throughout the whole academic year and it gives students time to apply for ethical approval and conduct a research project over a longer period of time. This is also particularly useful if students are participating in ongoing institutional research. Concurrent SSCs also allow students to participate in courses run by other schools in an institution e.g. the Sciences, Engineering, Arts, Business and Law. In UCC, we also allow our students to self-propose their own SSC and this has proved very popular with students who really engage with their chosen subject area and generally do very well in the end of year assessment. Examples of current self proposed SSCs by medical students in UCC
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include robotic assisted gynaecological surgery, the development of a video for patients on breast reconstructive surgery, the development of a novel method for communication skills teaching and the establishment of a unique scheme for delivering medical supplies to hospitals in developing countries. The SSC must be designed entirely by the student and they must ensure that any activities planned are feasible within their busy schedule. Students must submit a module plan to the SSC coordinator and arrange a meeting to outline the preparations and meetings conducted to set up the course. The student then has to write the learning outcomes for the module and the assessment method and date are set. All medical Students taking this option are given the UCC Learning Outcomes handbook to guide them through this process. This option is particularly suitable for highly motivated students and involves quite a lot of work at the beginning of the module. However students develop key transferable skills during a module of this type which are invaluable for a future of lifelong learning. It is clear from the literature that medical schools throughout Ireland and the UK have devised their own SSC programmes and there is great diversity in the content, duration and structure of the programmes offered. In the UK, a paper on the implementation of the report Tomorrow‟s Doctors, undertaken in 2002 stated that all schools had implemented an SSC programme (3). However, the authors acknowledges that in some schools, SSCs were only found in particular parts of the course, some were of short duration and others lacked definition of objectives and assessment strategy. A recent review of the SSC literature (4) has highlighted the types of SSCs on offer in UK medical schools. There are no reports of the SSC programmes available in Irish Medical Schools. Many of the SSCs in the UK are attractive and innovative, including for example, modules in health promotion, complementary therapy, ethics, medical illustration, literature and art in medicine (5-16). In 2006 the General Medical Council issued a report called Strategic Options for Undergraduate Medical Education (17). This report surveyed GMC members including medical schools, academic groups, royal colleges, professional associations, regulatory bodies, other health service groups, patient groups, and charities. One of the specific questions asked of the respondents was ‗whether Student Selected Components (SSCs) should become a larger part of undergraduate curricula‘. Most respondents did not support increasing SSCs in the curricula. Some argued that between 25-33% was too much since it left little time in the curriculum for ‗core‘ subjects. Other respondents felt the time should actually be reduced, partly so that students would then be able to make more realistic choices later in their training on the basis of learnt awareness of their own strengths and weaknesses. It was also difficult for some medical schools to offer real choice to students if 25% of overall curricular time was required. It is interesting to note in this report that a criticism raised about medical education in some schools was that the curriculum was designed to suit the institution rather than the student. While there was a strong emphasis in the curriculum on ‗patient centeredness‘ this rarely translated to ‗learner centeredness‘. Some respondents suggested that alternative pathways could be made available through medical education to suit individual learners, making SSCs a larger part of the curriculum. Respondents also felt that SSCs could be used to increase inter-professional learning. When it came to specific questions on supporting the learner, many respondents highlighted the need to support students to become self-learners, enabling them to recognise their own
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strengths and weaknesses. It was thought that, given the current large medical intake, not enough time is given to supporting and guiding students, particularly those who were having difficulties academically. It was also felt that medical schools should help learners to find ways of learning that ‗most suit them and to help them identify genuine interests through Special Study Modules (SSMs) and intercalated degrees‘. One medical school stated that: ‗The ability of individual schools to include specific strengths as themes within their curriculum (as SSCs) is an important element of diversity and strength in the UK system as a whole‟. More recently, the Scottish Medical Schools SSC liaison Group have developed a consensus statement on the purpose of SSCs in medical education in Scotland (18). They state: ‗Student Selected Components (SSCs) are an integral part of the undergraduate medical curriculum, contributing to the overall curricular learning outcomes and providing students‘ choice in studying, in depth, areas of particular interest. The principal learning outcome is the progressive development of skills in research, critical appraisal, and synthesis of evidence for maintaining good medical practice. The SSCs contribute to the development of a broad range of personal and professional skills, such as team working, communication, time and resource management, teaching and education skills, the ability to reflect and self-directed learning. They also provide opportunities to explore career options‘.
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They also outline 12 useful tips for implementing an SSC programme in medical schools. They state that in order to make an SSC programme work, a number of key factors must be in place and these include: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
A wide choice of subjects Clearly defined learning outcomes for each SSC Full integration into the curriculum Guidance, resources training and support for staff and students Motivation and commitment from staff and students Group working – multidisciplinary and multiprofessional Tutor diversity Tutor training Innovation and good ideas Robust and flexible assessment Course evaluation essential
CONSTRUCTIVE SUMMATIVE AND FORMATIVE FEEDBACK TO STUDENTS The Northern UK medical schools SSC consortium has formed a working party to develop a consensus on the common purposes and the learning outcomes achievable within a diverse group of medical schools and the assessable key tasks (19-20). A number of groups have tried to assess the key transferable skills possible in SSC programmes and this is particularly true of Professor Murdoch-Eaton‘s group in Leeds University (19-22). Murdoch-
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Eaton believes that the most important aspects that SSCs aim to develop in students are the attitudinal objectives – ‗the need for active acquisition of knowledge, the capacity for self evaluation, ability to cope with uncertainty, acceptance of the need to contribute to the advancement of medical knowledge, and an awareness of the need for continuing professional and educational development‟ (23).
OPPORTUNITIES IN THE SSC PROGRAMME SSCs present a unique opportunity for Medical Schools to develop programmes that build on the strengths of the individual institution. This is particularly true in the case of research based SSCs. SSCs present a unique opportunity for students to develop research skills during their undergraduate training. Research based SSCs enable undergraduates to become directly involved in the research work of the institution, experience what it is like to be a member of a research team and take part in cutting edge research. In UCC we have noticed that a significant proportion of students appear to be deliberately choosing SSCs that could potentially involve them in research or result in a publication very early into their undergraduate training.
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SSC ASSESSMENT Assessment of SSCs can prove challenging given the diversity of modules and approaches being developed. In a recent evaluation of an SSC programme (4) this issue was raised by students who felt that assessment should be on a pass fail basis. This was primarily due to the perceived differing work loads attached to courses in the SSC programme and is an issue that has been discussed in the literature. Fowell (24) describes the situation very clearly in the following statement, „….the very diversity and flexibility they welcome pose a number of problems for assessment of SSMs‟. Fowell‘s group has adopted an objective-based, criterion-referenced assessment for SSCs in order to ensure parity of assessment across the wide range of SSCs. There is an opportunity for the Medical school to introduce a new assessment scale for the SSC programme like this that takes account of the wide diversity in module types, disciplines, and tutors.
CONCLUSION In conclusion, SSCs are an exciting development in medical education and the opportunities that exist are great in an era of rapidly advancing science. As curricular load increases, more and more elements of the traditional curriculum may have to be incorporated into this pathway. This has certainly begun to happen in the UK, and as core curricular modules become more and more specialized, students may have to tailor their medical degree more carefully as they progress through the course.
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REFERENCES [1] [2] [3] [4] [5] [6] [7]
[8] [9] [10]
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[11] [12] [13] [14] [15] [16] [17] [18]
[19]
General Medical Council. Tomorrow's Doctors: recommendations on undergraduate medical education. London: General Medical Council; 2003. Harden RM, Davis MH. AMEE Medical Education Guide No 5. The core curriculum with options or special study modules. Med Teach 1995;17(2):125-50. Christopher D, Harte K, George CK. The implementation of Tomorrow's Doctors. Med Educ 2002;36:282-8. Boylan G. Early-stage Evaluation of a Student Selected Components Programme in an Undergraduate Medical Curriculum. Ireland: University College Cork; 2008. Downie RS, Hendry RA, Macnaughton RJ, Smith BH. Humanizing medicine: a special study module. Med Educ 1997 Jul;31(4):276-80. Fletcher G, Agius RM. The special study module: a novel approach to undergraduate teaching in occupational medicine. Occup Med (Lond) 1995 Dec;45(6):326-8. Greenfield SM, Wearn AM, Hunton M, Innes MA. Considering the alternatives: a special study module in complementary therapy. Complement Ther Med 2000 Mar;8(1):15-20. Lewith GT, Owen D. Complementary medicine: the Southampton undergraduate experience. Complement Ther Med 2000 Sep;8(3):202-6. Morton R. Special study modules in medical illustration in the undergraduate medical curriculum. J Audiov Media Med 2000 Sep;23(3):110-2. Newbegin RM, Rhodes JC, Flood LM, Richardson HC. Student-selected components: bringing more ENT into the undergraduate curriculum. J Laryngol Otol 2007 Aug;121(8):783-5. Seabrook MA, Lempp H, Woodfield SJ. Extending community involvement in the medical curriculum: lessons from a case study. Med Educ 1999 Nov;33(11):838-45. Wylie A. Health promotion in medical undergraduate education--are special study modules pragmatic options? Med Educ 2000 Nov;34(11):952-3. Lancaster T, Hart R, Gardner S. Literature and medicine: evaluating a special study module using the nominal group technique. Med Educ 2002;36:1071-6. Boggis C, Davidson C. A special study module in hospital management. Med.Educ. 36, 1092. 2002. lazarus P, Rosslyn F. The Arts in medicine: setting up and evaluating a new special study module at Leicester Warwick medical school. Med.Educ. 37, 553-559. 2003. Hampshire A, Avery AJ. What can students learn from studying medicine in literature. Med.Educ. 35, 687-690. 2001. General Medical Council. Strategic Options for Undergraduate Medical Education – Final Report. 2006. Riley SC, Ferrell WR, Gibbs TJ, Murphy MJ, Cairns W, Smith S. Twelve tips for developing and sustaining a programme of student selected components. Med Teach 2008;30(4):370-6. Murdoch-Eaton D, Ellershaw J, Garden A, Newble D, Perry M, Robinson L, et al. Student-selected components in the undergraduate medical curriculum: a multiinstitutional consensus on purpose. Med Teach 2004 Feb;26(1):33-8.
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[20] Stark P, Ellershaw J, Newble D, Perry M, Robinson L, Smith J, et al. Student-selected components in the undergraduate medical curriculum: a multi-institutional consensus on assessable key tasks. Med Teach 2005 Dec;27(8):720-5. [21] Whittle SR, Murdoch-Eaton DG. Development of lifelong learning and self-evaluation skills through special study modules. Med Educ 2001 Nov;35(11):1073-4. [22] Jha V, Duffy S, Murdoch-Eaton D. Development of transferable skills during short special study modules: students' self-appraisal. Med Teach 2002 Mar;24(2):202-4. [23] Murdoch-Eaton D. Student Selected Components Manual Leeds University, UK; 2008. [24] Fowell S, Ellershaw J, Leinster S, Bligh J. Assessment of special study modules: comparing apples and pears. M 32[2], 212-213. 1998.
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In: Medical Education: The State of the Art ISBN: 978-1-60876-194-4 Editors: R. Salerno-Kennedy, S. O‘Flynn, pp. 139-148 © 2010 Nova Science Publishers, Inc.
Chapter 13
FROM DRY ICE TO PLUTARCH’S FIRE – THE INTEGRATION OF RESEARCH AND TEACHING AND LEARNING Marian McCarthy, Bettie Higgs, Jennifer Murphy and Grace Neville
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ABSTRACT This chapter sets out to frame the teaching versus research debate, to provide an overview of the key concepts and language that inform it and to suggest ways of moving beyond the debate towards an integrated approach to research, teaching and learning. The tension between teaching and research is explored in the opening section. Issues regarding funding and promotion are introduced as catalysts in this debate. The movement towards a scholarship of teaching and learning, as defined in the Boyer (1990) paradigm and the work of the Carnegie Academy for the Advancement of Teaching, is then introduced as a way of bridging the gap between teaching and research. Interventions to embed research – teaching linkages in the infrastructure of higher education are then suggested. Finally, the benefits of enhancing the research – teaching link are outlined in some detail to advance the argument for the integration of research, teaching and learning. The chapter concludes with the idea that all students and all teachers are scholars – hence the inextricable link between research and teaching.
INTRODUCTION The Teaching – Research Debate The teaching - research debate is grounded historically in Newman‘s (1976) and von Humbolt‘s (1970) conceptions of the role of a university and the nature of research and
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teaching therein. Newman conceived of the university as a teaching institution primarily focused on the diffusion and extension, rather than on the production, of knowledge. This is in contrast to the German idea of the University as embodying both research and teaching, propounded most notably by Wilhelm von Humboldt (1970) and his concept of the generation of new knowledge in a context of close collaboration between research and learning. In representing the traditional model of the relationship between research and teaching growing out of this historical context (Fig. 1), Brew (2003, p. 11) demonstrates that research and teaching can inhabit quite separate domains:
Fig. 1 Traditional model of the relationship between teaching and research (from Brew 2003 p. 11).
Here, research is associated with a ―disciplinary research culture‖ in which academics, researchers and postgraduate research students generate knowledge. Teaching is viewed as taking place within a ―departmental learning milieu‖ and is therefore associated with the transmission of knowledge. The arrows in the diagram suggest that research and teaching are pulling in opposite directions, while the two lines in the middle represent the separation between the two. Such separation is indicative of the competition between time, resources and space for research and time, resources and space for teaching. Among the most exciting developments in higher education over the past two decades has been the blurring and, indeed, the challenging of these boundaries: boundaries between research and teaching, between teacher and learner, and between third and fourth levels. Boundaries become contested spaces where much creativity and innovation are generated. In this context, the past two decades in particular have witnessed a growing debate in which research and teaching are increasingly seen not as dichotomous or polarised activities, or as
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two separate, parallel activities, but as closely related elements of the same activity. In the context of this debate, Plutarch‘s adage, ‗the mind is not a vessel to be filled but a fire to be kindled‘ (Plutarch, c46-127 AD), resonates now arguably more than ever: Never has the educational philosophy behind this belief been more important: the changing world to be faced by today‘s students will demand unprecedented skills of intellectual flexibility, analysis and inquiry. Teaching students to be enquiring or research-based in their approach is not just a throwback to quaint notions of enlightenment or liberal education but central to the hard-nosed skills required of the future graduate workforce (Hammond in Jenkins et al. (2007), p 4).
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Mixed Messages The division between teaching and research has, on occasion, led to dual funding arrangements whereby research and teaching are each funded separately, with research taking the lion‘s share of resources. Unsurprisingly, the placing of a higher price on research can lead to a perceived downgrading of the status of teaching, now in danger of being viewed as the poor relation of research. Repeated statements about the importance of excellence in teaching can seem like empty rhetoric. A recent on-line study of the views of almost three thousand UK academics on the status of teaching in higher education has revealed telling discrepancies between theory and practice in this area: for instance, even among the researchintensive Russell Group of universities, 32% of respondents believe that teaching plays an important role in promotions against 89% who think that it should (Attwood, 2009). Junior staff members, in particular, believe that teaching is little valued in promotion. A strikingly high proportion of respondents – 92% – called for a change in the culture in universities to recognise the importance of teaching. One hears of people being ‗punished‘ for not performing well in research by being given extra teaching (though rarely being requested to undertake additional research to compensate for poor teaching) or being released from teaching as a reward for excellence in research, thus reinforcing the view of teaching as a Cinderella activity. Aron et al. (2000) showed that teaching excellence as evidenced by winning a ―Teacher of the Year Award‖ was not associated with a survival advantage in a research intensive medical school: In fact, short term (3-year) ―survival ‖ i.e. time of award to time of departure from the department was significantly decreased among teaching award winners. We found this ironic in a medical school with a reputation for having a longstanding commitment to medical education. (p. 2)
Indeed, within this overall ‗research versus teaching' equation, a ‗deficit model‘ operates whereby academics feel that time spent on their teaching is somehow taking away from their research. A recent Harvard report compiled by a task force on teaching and career development, consisting of nine senior academics, echoed mixed messages regarding the relative importance of teaching and research: Senior faculty… worry about what message to convey to junior colleagues building records for tenure consideration. ‗If chairs are to advise junior faculty to work hard on their teaching‘,
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Marian McCarthy, Bettie Higgs, Jennifer Murphy et al. explains one senior colleague, ‗they must feel confident they are not giving bad advice, that such advice will not diminish the junior faculty member‘s chance of receiving tenure‘. ‗There are still pockets of the University where winning the Levenson award for teaching as a junior faculty member is considered the kiss of death with respect to promotion‘, observes a second senior colleague [A Compact to Enhance Teaching and Learning at Harvard (2007), p 8).
Such mixed messages are equally prevalent in Ireland: At the turn of the Millennium, staff in University College Cork (UCC) could have been forgiven for thinking that discipline-based research was all that mattered in UCC, if you wanted to ‗get on‘. Older and wiser staff would be heard to say ‗concentrate on your research if you want promotion‘. But the winds of change are blowing through the institution, and the perceived dichotomy between teaching and research has been challenged. The new talk is of the scholarship of teaching. We always knew that good research could feed into teaching, benefiting our students, but now we are told that good teaching can improve our research. What‘s more, we are told that the experiences in the classroom can be part of our research! This is indeed new thinking. But do we all believe it? [Higgs (2004) p.27].
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The Integration of Research and Teaching and Learning Much radical debate on the integration of research and teaching and learning has been driven from North America, for instance by the Carnegie Foundation for the Advancement of Teaching, as well as by the initiatives that grew out of this, The Carnegie Academy for the Scholarship of Teaching and Learning (CASTL), and the International Society for the Scholarship of Teaching and Learning (ISSOTL). In his groundbreaking bestseller, Scholarship Reconsidered: Priorities of the Professoriate, Ernest L. Boyer, President of the Carnegie Foundation for the Advancement of Teaching from 1979 until his death in December 1995, called for a radical reappraisal of the ‗research versus teaching‘ dichotomy. In what amounts to nothing less than a fundamental reappraisal of the nature of scholarship, he challenged the higher education system in the United States thus: The most important obligation now confronting the nation‘s colleges and universities is to break out of the tired old teaching versus research debate and define, in more creative ways, what it means to be a scholar. It‘s time to recognize the full range of faculty talent and the great diversity of functions higher education must perform [Boyer (1990), p. xii, emphasis added].
Boyer believed that universities needed to move beyond traditional models of research and proposed a radically new integrated paradigm of scholarship as possessing four distinct but overlapping dimensions – the scholarship of discovery, the scholarship of integration, the scholarship of application, and the scholarship of teaching. Scholarship Reconsidered transformed the discussion. Instead of describing faculty roles in terms of the familiar trilogy of teaching, research and service, it argued that faculty were responsible for four basic tasks: discovering, integrating, applying and representing the knowledge of their scholarly fields [Edgerton (2005), p. xii].
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The first of these elements – the scholarship of discovery - comes closest to what scholars traditionally have in mind when they speak of research. The open, disinterested pursuit of knowledge, not knowing where this investigation may lead has long been at the heart of the academic endeavour. The scholarship of integration, on the other hand, encourages scholars in the direction of interdisciplinarity, encouraging them to make connections between and within disciplines, however seemingly isolated, disparate or fragmented, in order to derive meaning from complexity, and to help a larger and more coherent picture to emerge. The scholarship of application moves scholars towards engagement, towards solving problems at a societal level across a wide range of areas as theory and practice coalesce. The scholarship of teaching sees learning and the learner at the heart of the whole academic enterprise: the question is not ‗how do I teach?‘ but ‗how do I learn?‘ and ‗how do I enable my students to learn?‘ In this new order, there would be no hegemony; research, in the traditional sense, would be just one of four ways in which a scholar functions [McCarthy (2008), p. 9].
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In this ‗new order‘, teaching comes out of the shadows and makes itself as visible as its sister activity, research, had always done. Research has traditionally been a highly visible activity, expressing itself through verifiable, objective metrics such as numbers of publications, pages, citations, research reviews. Research activity is one that implies a community of scholars (peer-reviewers, team members, laboratory colleagues) and group activities such as conferences and collaborative projects. We celebrate research achievements and enable them to become community property: publications, successful grant applications, research awards. The traditional invisibility of teaching has arguably been most powerfully iterated by Lee S. Shulman, now President emeritus of the Carnegie Foundation for the Advancement of Teaching, for example in his book on Teaching as Community Property: We experience isolation not in the stacks but in the classroom. We close the classroom door and experience pedagogical solitude, whereas in our lives as scholars, we are members of active communities: communities of conversation, communities of evaluation, communities in which we gather with others in our invisible colleges to exchange our findings, our methods, and our excuses [Shulman (2004), pp.140-1].
Shulman, one of whose many research interests lies in medical education, also outlines the dangers of our teaching remaining less visible than our research: If teaching is going to become community property it must be made visible through artifacts that capture its richness and complexity. In the absence of such artifacts teaching is a bit like dry ice; it disappears at room temperature [Shulman (2004), p. 142].
Once public and visible, teaching can constitute the proper object of research and constitutes a form of research in its own right. Once public and visible, it possesses the attributes necessary, according to Shulman (1998), for an activity to become scholarship: it is subject to critical review and evaluation by members of one‘s community, and members of one‘s community begin to use it and to build upon it. Moving thus towards a holistic vision of research and teaching, Boyer recommends:
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Marian McCarthy, Bettie Higgs, Jennifer Murphy et al. Education is a seamless web, and if we hope to have centres of excellence in research, we must have excellence in the classroom. It is the scholarship of teaching that keeps the flame of scholarship alive [Boyer (1997)].
CREATING AN INFRASTRUCTURE TO SUPPORT RESEARCH INFORMED TEACHING AND LEARNING The establishment of The Irish National Academy for the Integration of Research and Teaching and Learning (NAIRTL) in May 2007 has gone a long way in the Irish context to addressing Boyer‘s call. NAIRTL is an inter-institutional consortium of universities and institutes of technology, which promotes innovation, supports development and sustains good practice that integrates teaching with research and learning. In the light of the literature (Elson et al, 2009; Griffiths, 2004; Healey, 2005) and the development of the Scholarship and Teaching and Learning (Boyer, 1990), NAIRTL has set out to unpack the various definitions of research, teaching and learning, providing an international context for understanding the integrative, complex nature of this ―seemless web‖ and stimulating faculty to weave their way into it through a series of grants and awards that are now key to the embedding of a supportive national infrastructure (NAIRTL, 2009). At an institutional level in any higher education context, embedding the teaching-research link can represent a seismic change: It requires a culture of inquiry-based learning… that starts with the very first day of college and is reinforced in every classroom and program [Hodge et al. (2007), p. 1]. Increasingly, universities feel confident to make assertions such as the following:
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A distinctive feature of study at the University of Sydney is its insistence on research-led teaching, both in content and delivery (Strategic Directions 2006-2010).
In a similar vein, the granting of parity of esteem to research and teaching in institutional mission statements and strategic plans can help to advance the integration of these activities beyond rhetoric into action. Such parity is also furthered worldwide by the introduction of annual rewards for research into innovative forms of teaching and learning, aimed specifically at fostering the integration of discipline-based research and research into student learning.
THE BENEFITS OF ENHANCING THE RESEARCH-TEACHING LINK The benefits of enhancing the research-teaching link are manifold. We are convinced that ‗re-shaping‘ or ‗reinventing‘ our disciplines and departments in a way that focuses more on the teaching-research nexus can aid students‘ learning, their pride in their discipline and department, staff morale, and the overall effectiveness of the department and the institution [Jenkins et al., (2007), p. 76].
Australian research has shown that the first main benefit to learners of being immersed in research-enhanced teaching is a deepened understanding of the transient, uncertain nature of
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knowledge as they are working from their undergraduate days onwards with researchers who themselves are pushing out the boundaries of existing knowledge within their discipline: However, the most important thing is that students get a sense of the currency of the application of their discipline to ‗real world‘ problems. The richer the course is in such illustrations, the more likely students are to identify with the discipline and see themselves as practitioners who will be able to transfer their knowledge and understanding from the university to the world of employment and the community as a whole [The TeachingResearch Nexus (2008)].
The second benefit cited is the enabling of students to build higher-order intellectual capabilities in order to enhance their skills for employment and to prepare for lifelong learning. Most of the academics interviewed for this Australian project believed that linking teaching and research developed students‘ generic and higher order skills of analytical and critical thinking, information retrieval and evaluation, problem solving, team and project work and communication―precisely the skills needed as they enter an increasingly complex, uncertain and globalised workplace after graduation: In a world characterised by uncertainty and… ‗supercomplexity‘ we need, not bodies of predefined knowledge, but rather the skills of finding out. Knowledge has become fluid and contestable. In its many domains of discourse, it has become a product of communication and negotiation. The students of the future are going to need the skills of inquiry—of research—if they are to be able to investigate and to learn and hence be employable in the future [Brew (2003), p. ix-x].
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The third benefit identified is the development of the students' own capacity to conduct research and enquiry, thanks to a teaching and learning environment that is structured to allow them to engage in ‗real‘ research work in their discipline. The Australian study suggests ways in which this may be done: Through Enquiry Based Learning and other student project work. By inviting students either to contribute to or to ‗shadow‘ a genuine research project (the tutor‘s or the Department‘s). By asking students to replicate for themselves some research already carried out. By involving students in the research culture of the Department and supporting them, through tutoring and mentoring, to offer their own commentary on current research issues or other ‗hot‘ topics. By building research methods classes into the students‘ degree programmes. Students working in these ways acquire a hands-on understanding of and respect for the values of their discipline, its processes of hypothesis construction and its evidence criteria, experience the importance of using data and processes with honesty and integrity, and develop habits of perseverance, as well as experiencing at first hand the excitement of discovery. Students steeped in practical opportunities of these sorts throughout their degree study will enter the professional world with an understanding of research methodologies; they will know how to conduct and evaluate research projects and they will have acquired the habits of Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
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Marian McCarthy, Bettie Higgs, Jennifer Murphy et al. evidence-based practice. With these abilities, graduates will be more ‗work-ready‘ in the first instance and more likely to develop into successful practitioners and lifelong learners in the ‗knowledge society‘ The Teaching-Research Nexus (2008)].
The fourth benefit identified is the enhancement of the students' engagement and the development of their capacity for independent learning. …student levels of engagement in learning are higher when they know about their teacher‘s research and can see its contribution to society, and when they feel that they themselves are at the forefront of theory and opinion. Student motivation, which can be a problem in the tertiary teaching and learning environment, is therefore going to be increased where the curriculum includes authentic, contemporary research issues, and engages students in thinking about them [The Teaching-Research Nexus (2008)].
It does not serve us well to polarise teaching and research as the myriad benefits of enhancing the research - teaching nexus are evident above.
CONCLUSION
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In conclusion, it could be argued that, in scholarly institutions, all teachers and all students are scholars. In her address, as the Annenberg Professor of History in the School of Arts and Sciences at Penn University on receiving the Ira Abrams Award for Distinguished Teaching in 1996, Drew Gilpin Faust elaborated on the interconnectivity of teaching, learning and research, a theme that she has continued to stress since taking up her appointment as President of Harvard in 2007: …we must work to explain and defend the research university… Those of you who soon leave academic life can aid by taking up the battle in the real world, by helping universities articulate their case in the realms of the media and politics. Those of us who remain behind as faculty can of course seek a public voice as well. But we have another responsibility. If we are to be able to make a plausible case for the research university, we must ensure that it does indeed fully dedicate itself to the ideal of integrated and interdependent teaching and learning… for this must serve as the foundation for its legitimacy and its defense. [Faust (1996)]
While many worthwhile initiatives are currently progressing (such as institutional centres for teaching and learning), institutional policies and national policies are vital in order to support the integration of research and teaching and learning so that it is embedded in the infrastructure:
For the students who are the professionals of the future, developing the ability to investigate problems, make judgements on the basis of sound evidence, take decisions on a rational basis, and understand what they are doing and why is vital. Research and inquiry is not just for those
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who choose to pursue an academic career. It is central to professional life in the twenty-first century [Brew (2007), p. 7].
Much has been achieved as a consequence of the passion and commitment of those involved in initiatives to integrate research and teaching and learning. As a result of these efforts, the higher education sector has recognised research-teaching linkages as an important area of development. Now that we have gained momentum, we cannot risk that our efforts disappear like Shulman‘s dry ice. The flame of scholarship must be kept alive through our constant vigilance in promoting the integration of research and teaching and learning at every opportunity.
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REFERENCES A Compact to Enhance Teaching and Learning at Harvard (2007) Faculty of Arts and Sciences: Harvard University. Aron, D. C., Aucott, J. N., Papp, K. K. (2000) Teaching awards and reduced departmental longevity: Kiss of death or kiss goodbye? What happens to excellent Clinical teachers in a research intensive medical school? Med Educ Online 5(3). Attwood, R. (2009) No apples for teachers, The Times Higher Education. Boyer, E. (1990) Scholarship Reconsidered: Priorities of the Professoriate, San Francisco: Jossey-Bass Boyer, E. (1997) in C. Glassick, M. Huber and G. Maeroff (1997) Scholarship Assessed: Evaluation of the Professoriate, San Francisco, CA: Jossey-Bass Brew, A. (2003) Teaching and research: new relationships and their implications for inquirybased teaching and learning in higher education, Higher Education Research and Development, 22 (1), 3-18. Brew, A. (2007) Imperatives and challenges in integrating research and teaching: A case study. Background paper for Carrick Institute for Learning and Teaching in Higher Education Discipline – Based Development Forum: Teaching/Research Nexus. Adelaide, 29-30 August, 2007 Edgerton, R. (2005) in K. O‘Mara and R. E. Rice, (eds.) Faculty Priorities Reconsidered: Rewarding Multiple Forms of Scholarship, San Francisco, CA: Jossey-Bass. Elsen, M., Visser-Wijnveen, G.J., van der Rijst, R.M., and van Driel, J.H. (2009) How to strengthen the connection between research and teaching in undergraduate university education, Higher Education Quarterly, 63 (1), 64-85. Faust, D. G. (1996) Talk about teaching: We are all teachers; We are all learners, Almanac Volume 43 (9). Griffiths, R. (2004) Knowledge production and the research-teaching nexus: The case of the built environment disciplines. Studies in Higher Education, 29(6), pp. 709–726. Healey, M. (2005) Linking research and teaching: Exploring disciplinary spaces and the role of inquiry based learning. In Barnett, R (Ed.), Reshaping the University: New Relationships between Research, Scholarship and Teaching, pp. 67–78, London, McGraw Hill /Open University Press.
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Higgs, B. (2004) The reflective coordinator, in A. Hyland, (ed) UCC as a Learning Organisation, Cork: UCC. Hodge D., Pasquesi, K. and Hirsh, M. (2007) From convocation to capstone: Developing the student as scholar. Conference paper in The Student as Scholar: Undergraduate Research and Creative Practice, Association of American Colleges and Universities, Network for Academic Renewal Conference Jenkins, A., Healey, M. and Zetter, R. (2007) Linking Teaching and Research in Disciplines and Departments, York: The Higher Education Academy. McCarthy, M. (2008) The scholarship of teaching and learning in higher education: An overview, in R. Murray, (ed) The Scholarship of Teaching and Learning in Higher Education, McGraw-Hill: Open University Press. NAIRTL (2009) Grants initiative: Guidelines for application. Newman, J. H. (1976) The Idea of a University: Defined and Illustrated, I.T. Kerr (ed), Oxford: Clarendon Shulman, L. (1998) Course anatomy: The dissection and analysis of knowledge through teaching, in P. Hutchings (ed), The Course Portfolio, Washington DC: the American Association for Higher Education Shulman, L. S. (2004) Teaching as Community Property: Essays on Higher Education, San Francisco: Jossey-Bass. The Teaching-Research Nexus (2008) A guide for academics and policy-makers in higher education: Benefits for students. University of Sydney, Strategic Directions 2006-2010. von Humboldt, W. (1970). On the spirit and the organisational framework of intellectual institutions in Berlin, Minerva, 8(2), 242–250
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CONTRIBUTOR LIST Dr. Geraldine Boylan, PhD Senior Lecturer in Medical Education, School of Medicine, University College Cork, Ireland
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Prof. Peter Cantillon Professor in Primary Care , Department of General Practice, Clinical Science Institute, National University of Ireland, Galway, Ireland Dr. Simon Edgar Consultant Anaesthetist, St. Johns Hospital, Livingston, Clinical Sub-Dean in the College of Medicine, Educational Coordinator, Scottish Clinical Simulation Centre, Stirling, University of Edinburgh, Scotland, UK Prof. Kevin W. Eva, PhD Associate Professor, Department of Clinical Epidemiology and Biostatistics, Program for Educational Research and Development, McMaster University, MDCL 3522, 1200 Main Street West, Hamilton, Ontario, L8N 3Z5, Canada Prof. Marilyn Hammick Visiting Professor, Birmingham City University, UK Consultant to Best Evidence Medical Education
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Contributor List Prof. Ronald M Harden Professor of Medical Education, University of Dundee, Scotland, UK Dr. Patrick Henn, Lecturer in Medical Education, School of Medicine, University College Cork, Ireland Dr. Bettie Higgs, PhD Senior Lecturer, Academic Coordinator of Ionad Bairre (UCC Centre for Teaching and Learning), University College Cork, Ireland Prof. Áine Hyland (Recently retired) Professor of Education and Vice-President of University College Cork. Vice-Chair of the Irish Research Council for the Humanities and Social Sciences Co-ordinator of the Graduate Education network of the Carnegie Foundation for the Advancement of Teaching and Learning
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Prof. David Kaufman, M.Eng, Ed.D. Faculty of Education, Simon Fraser University, 8888 University Drive, Burnaby, BC CANADA V5A 1S6 Dr. Martina Kelly Lecturer in General Practice, School of Medicine, University College Cork, Ireland Prof. David Kerins, MD, FRCPI, FACC, Dean, School of Medicine, Vice Head, College of Medicine and Health, University College Cork, Ireland Dr. Iain Lamb General Practice Associate Adviser in Post Graduate Medical Education for NHS Education, Scotland, Edinburgh, UK
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Contributor List Marian McCarthy, BA, HDE, DETE, M.ED, LTCL Lecturer in Education and Programme Co-ordinator, Certificated Courses in Teaching and Learning in Higher Education, ―Ionad Bairre‖, The Teaching and Learning Centre, University College Cork, Ireland Jennifer Murphy Project Manager National Academy for Integration of Research & Teaching & Learning (NAIRTL) Distillery House, North Mall Cork, Ireland Prof. Grace Neville Vice-President for Teaching & Learning University College Cork, Ireland Director of the National Academy for the Integration of Research & Teaching & Learning (NAIRTL)
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Dr. Siún O’Flynn Head of Medical Education School of Medicine, University College Cork, Ireland Dr. Rossana Salerno-Kennedy, MD Lecturer in Medical Education School of Medicine Brookfield Health Sciences Complex University College Cork Cork, Ireland
Prof. John Spencer Professor of Medical Education Newcastle University, Newcastle upon Tyne, UK
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INDEX
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A abuse, 36 academic performance, 21, 22, 29 academics, 11, 24, 43, 140, 141, 145, 148 access, 1, 4, 8, 19, 20, 21, 22, 28, 42, 52, 71, 89, 103, 122 accountability, 107, 109, 110 accreditation, ix, 29, 104 achievement, 3, 19, 20, 21, 22, 26, 28 acquisition of knowledge, 86, 88, 90, 108, 136 active feedback, 78 adaptation, 94 administrators, 2 adult learning, 12, 16, 47, 48, 50, 51, 73 advocacy, 93 age, 39, 52 agencies, 52 agreeableness, 26 AIDS, 122 alternatives, 77, 78, 137 altruism, 107, 109, 110 amplitude, 33 anatomy, 14, 40, 86, 96, 118, 148 anthropologists, 123 anthropology, 123 anxiety, 40 apples, 138, 147 applications, 3, 4, 6, 25, 143 aptitude, 19, 20, 21, 22, 23, 24, 27, 28, 29 articulation, 35 aspiration, 109 assertiveness, 82 assessment techniques, 102, 103 assessment tools, 3 assignment, 118 assumptions, 6, 11
asthma, 122, 125 attitudes, 12, 14, 41, 42, 49, 50, 68, 82, 83, 110, 121, 122, 123, 124, 125, 127, 132 authenticity, 64 authorities, 105 authority, 82 authors, 88, 112, 114, 124, 126, 134 autonomy, 20, 113 availability, 52 avoidance, 27, 99, 125 awareness, 12, 14, 61, 70, 71, 73, 79, 101, 125, 126, 129, 134, 136
B background, 40, 41, 43, 73, 123 baggage, 59 barriers, 66 behavior, 37, 108, 110, 116 behaviors, 109, 110 beliefs, 12, 33, 57, 59, 61, 62, 66, 67, 73, 123, 124 bias, 27, 28, 105, 123, 126 biochemistry, 86 biological sciences, 23 blocks, 4, 133 blogs, 52 blood, 71 BMA, 28, 43 brainstorming, 82, 84 breakfast, 76 by-products, 82
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Index
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C campaigns, 41 cancer, 118, 122 candidates, 19, 21, 22, 26, 27 cardiovascular disease, 54 career development, 141 caregivers, 119 caricature, 40 case study, 51, 87, 115, 120, 137, 147 census, 122, 127 cerebrovascular disease, 122 certificate, 21 certification, 105, 116 challenges, 2, 7, 8, 31, 32, 36, 41, 42, 44, 47, 50, 51, 52, 58, 60, 63, 66, 77, 91, 105, 107, 110, 121, 122, 123, 124, 147 channels, 2 character, 25, 44 charities, 134 child protection, 52 children, 54, 128 clarity, 69 class size, 88 classes, 2, 145 classroom, 2, 5, 13, 36, 50, 60, 64, 82, 107, 142, 143, 144 classrooms, 60, 61 clients, 49 climate, 9, 28 clinical assessment, 42 clinical examination, 26, 88, 100, 105 clinical trials, ix coaches, 13 cognition, 60, 61, 62, 64, 65, 67 cognitive abilities, 110 cognitive ability, 22 cognitive dimension, 29, 89 cognitive perspective, 60 cognitive process, 15 cognitive psychology, 68 cognitive research, 60, 62 cognitive theory, 12 cohesiveness, 85 cohort, 2, 28, 51 collaboration, 2, 8, 47, 48, 49, 50, 140 colleges, 60, 91, 134, 142, 143 collusion, 65 communication, 2, 5, 14, 24, 26, 32, 38, 52, 74, 78, 79, 84, 109, 120, 125, 132, 133, 134, 135, 145 communication skills, 14, 26, 38, 74, 79, 84, 109, 120, 132, 133, 134 communication technologies, 52
community, 3, 5, 8, 34, 36, 37, 39, 41, 44, 65, 95, 99, 103, 122, 124, 137, 143, 145 competence, 59, 70, 71, 73, 79, 88, 90, 94, 96, 102, 103, 104, 105, 106, 107, 109, 112, 117, 118, 119, 121, 123, 124, 125, 126, 127, 128, 129 competency, 50, 75, 89, 91, 97, 102, 105, 120, 121, 122, 127, 128 competition, 140 competitiveness, 126 compilation, 111 complexity, 15, 20, 33, 143 components, 33, 95, 117, 121, 124, 127, 132, 137, 138 composition, 126 computing, 6, 16 concentrates, 74 concentration, 71 conception, 82, 106 conceptual model, 13, 34 concrete, 15, 33, 93 conference, 90 confidence, viii, 32, 35, 41, 86, 88, 89, 132 confidentiality, 33, 42, 85, 112 configuration, 26 conflict, 112, 114 confusion, 95, 123 congruence, 6, 58 conscientiousness, 22, 26, 27 consensus, 19, 27, 68, 135, 137, 138 consent, 38, 42, 65, 110 constant rate, 7 construct validity, 101 construction, 22, 23, 90, 107, 145 constructivism, 12, 32 consulting, 49, 74 consumers, 124 contextualization, 16 control, 14, 33, 36, 43, 85, 86, 98, 132 cooperative learning, 14, 82 coronary heart disease, 128 correlation, 22 correlations, 23, 26, 99 costs, 7, 84, 88 course content, 64 covering, 4, 78 creative thinking, 85 creativity, 140 credibility, 40, 81, 86, 89, 94, 113, 115 critical thinking, 23, 87, 113, 115, 145 criticism, 99, 101, 109, 134 cues, 74 cultural beliefs, 124
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Index culture, 6, 40, 67, 76, 85, 98, 110, 116, 123, 124, 128, 129, 140, 141, 144, 145 curiosity, 59 currency, 24, 145 curricula, 31, 34, 36, 52, 81, 87, 103, 126, 132, 134 curriculum development, 39, 43 cycles, 33 cyclical process, 33
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D danger, 71, 99, 103, 112, 141 death, 142, 147 decision making, 21 decisions, 27, 36, 44, 75, 102, 113, 146 deductive reasoning, 27 defense, 100, 146 deficiencies, 61 deficit, 141 definition, 11, 22, 23, 36, 47, 94, 96, 107, 109, 110, 112, 116, 117, 123, 134 delivery, 1, 4, 8, 47, 48, 49, 50, 89, 121, 122, 144 demographic change, 122 demographic transition, 121, 122 demographics, 124 demography, 28, 43 demonstrations, 14, 15 Department of Commerce, 128 detection, 26 developing countries, 134 diabetes, 54, 122, 125 dichotomy, 142 differential diagnosis, 38 diffusion, 140 direct observation, 95, 100 disability, 125, 129 discipline, 6, 123, 131, 142, 144, 145 disclosure, 77 discomfort, 84, 114 discourse, 145 discrimination, 21, 96, 123 diseases, 33, 37 dissatisfaction, 60 dissenting opinion, 86 distance learning, 9 distress, 28 diversity, viii, 14, 20, 102, 121, 122, 123, 127, 131, 133, 134, 135, 136, 142 division, 82, 141 doctors, viii, 20, 21, 27, 28, 29, 42, 69, 71, 74, 107, 108, 109, 111, 116, 126, 128 drawing, 14 dream, 9, 99
drugs, 128 dry ice, 143, 147 duration, vii, 131, 134 dynamics, 40, 122
E editors, 9, 10, 128 educational experience, viii, 3, 8, 50, 58, 133 educational practices, 66 educational programs, 29 educational psychology, 6 educational system, 43 elaboration, 32 e-learning, 1, 2, 5, 6, 7, 8, 51, 52, 70 electives, 131 email, 1, 5, 6 emotions, 114 empathy, 21, 23, 26, 27, 113, 119, 127 employment, 21, 145 encoding, 15 encouragement, 76 endocrinology, ix engagement, 107, 143, 146 engineering, 86 environment, 2, 5, 6, 8, 9, 20, 31, 32, 33, 34, 36, 38, 39, 40, 41, 43, 44, 45, 57, 58, 61, 65, 66, 69, 75, 81, 83, 84, 85, 88, 89, 90, 94, 113, 123, 147 epidemiology, 124 epilepsy, 123 equipment, 84 equity, 121, 127 erosion, 117 essay question, 25 estimating, 19 ethical issues, 42 ethics, 134 ethnic culture, 125 ethnic groups, 121, 122, 127 ethnic minority, 122, 126 ethnicity, 123, 124, 126, 129 evolution, 19, 31, 39 examinations, 21, 24, 29, 42, 88, 99, 104, 114, 117 excuse, 77, 143 exercise, 73, 88, 90, 100, 104 expert teacher, 60, 61, 66, 124 expertise, 6, 27, 34, 58, 85, 101, 105 exploitation, 36, 37 exposure, 39, 43, 84, 126 external validation, 112
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Index
F face validity, 26, 27 facilitators, 51, 53 faculty development, 59, 62, 63, 64, 66, 67 failure, 12, 28, 114 fairness, 39 faith, 102 family, 39, 88 fatigue, 103 feedback, 7, 13, 15, 16, 35, 37, 38, 63, 64, 65, 69, 70, 73, 75, 76, 77, 78, 79, 83, 84, 85, 103, 105, 106, 114, 125 feelings, 42 fibula, 15, 16 fidelity, 95, 99, 100 flame, 144, 147 flexibility, 100, 114, 136 flight, 123 fluid, 73, 145 focusing, 15, 36, 37, 97, 102 football, 118 formula, 78 fractures, 15, 16 fragments, 114 friction, 50 funding, 139, 141 furniture, 65
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G gender, 26, 30, 42, 52, 110, 126, 129 gender stereotyping, 126 general practitioner, 104 generalization, 15 generation, 15, 98, 140 gift, 79 goals, 6, 12, 28, 40, 57, 63, 65, 93, 94, 97, 98, 102, 123 governance, 110, 116 GPA, 22, 24 grades, 22 graduate students, 126 grants, 144 group activities, 5, 143 group size, 42, 89 group work, 51, 82, 85, 87 groups, 3, 21, 23, 38, 49, 51, 52, 65, 70, 81, 82, 83, 84, 86, 89, 90, 102, 122, 123, 126, 134, 135 growth, 2, 7, 21, 122 growth rate, 122
guidance, 15, 16, 28, 35, 41, 43, 74, 75, 83, 93, 94, 100, 103, 113 guidelines, 70, 74, 113
H hair, 15, 16 hallucinations, 8 hands, 101, 103, 145 harm, 42 health, 20, 31, 36, 39, 41, 42, 43, 45, 47, 48, 49, 50, 52, 53, 74, 89, 94, 95, 96, 97, 98, 100, 102, 103, 116, 121, 122, 123, 124, 125, 126, 127, 128, 129, 134 health care, 31, 36, 43, 50, 53, 89, 116, 121, 122, 123, 124, 127, 128, 129 health care system, 125 health services, 124 health status, 124 hearing loss, 125 heart disease, 122, 125 heat, 94 hegemony, 143 high school, 20, 21 higher education, 6, 29, 50, 67, 81, 89, 90, 118, 139, 140, 141, 142, 144, 147, 148 HIV, 122 HIV/AIDS, 122 Hmong, 123, 128 honesty, 112, 145 hopes, 96 hospitals, 53, 84, 134 House, 151 human development, 60 humanism, 107, 109, 110, 117 humility, 59, 128 hybrid, 2, 87 hypothesis, 145
I ideal, 20, 32, 39, 52, 83, 146 ideals, 103 identification, 65 identity, 35, 41, 117, 128 idiosyncratic, 100 images, 14, 50 implementation, 9, 32, 48, 49, 51, 88, 91, 95, 100, 134, 137 incentives, 33 inclusion, 24, 27, 52, 126 indication, 101
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Index individual differences, 126 individual students, 3, 5, 82 industry, 21, 24 infection, 33, 36 inferences, 96 information processing, 86 information retrieval, 145 information technology, 43 informed consent, 33, 36, 42, 83 infrastructure, 1, 2, 139, 144, 146 innovation, 26, 63, 140, 144 insecurity, 5, 19 insight, 26, 78, 107, 112 institutions, 26, 50, 94, 99, 115, 124, 146, 148 instruction, 1, 4, 5, 14, 15, 17, 79, 88 instructional design, 6 instructional methods, 14 instructors, 79, 114 instruments, 102 integration, 32, 87, 135, 139, 142, 143, 144, 146, 147 integrity, 23, 26, 59, 107, 145 intellectual flexibility, 141 intelligence, 13, 22 intentions, 98 interaction, 5, 8, 32, 34, 38, 40, 70, 71, 81, 89, 112, 123, 125 interactions, 26, 125 interference, 84, 104 internalization, 115 internet, 1, 2, 4, 89 interpersonal communication, 23 interpersonal skills, 21, 41, 89, 120 interval, 75 intervention, 102 interview, 20, 21, 26, 30, 97, 105, 115, 120 intuition, 94, 99, 103 investment, 27, 102, 111 isolation, 5, 103, 143
J judges, 40 judgment, 101, 102 justice, 96
K knowledge acquisition, 63
L labour, 82 language, 13, 75, 122, 123, 139 languages, 122 leadership, 32 learning activity, 12 learning culture, 77 learning environment, 1, 2, 3, 4, 5, 6, 7, 8, 9, 16, 31, 35, 37, 40, 43, 45, 51, 57, 58, 59, 63, 64, 65, 66, 98, 112, 124, 145, 146 learning outcomes, 3, 7, 38, 49, 50, 119, 133, 134, 135 learning process, 12, 32, 34, 53, 82, 87 learning skills, 87, 88, 89 learning styles, 7, 20, 33, 69, 79, 85 learning task, 15, 82 lens, 58 liberal education, 141 lifelong learning, 6, 22, 132, 134, 138, 145 lifetime, 50 likelihood, 42, 129 line, 51, 141 links, 4, 35, 37, 73, 125 listening, 74, 82 logical reasoning, 25 longevity, 147
M maintenance, 84, 94, 103 majority, 21, 26, 43, 115, 121, 122, 124 management, 1, 2, 3, 8, 36, 37, 39, 49, 74, 75, 76, 128, 137 mapping, 3, 4, 9 market, 108, 116 marketplace, 128 mastery, 63, 71, 73 mathematics, 58, 67 meanings, 23, 58 measurement, 2, 94, 95, 96, 107 measures, 6, 21, 22, 28, 29, 74, 106, 110, 118, 125 media, 15, 25, 146 medical care, vii, 29 membership, 120 memory, 39, 59, 60 men, 126 mental health, 53, 122, 128 mental state, 74 mentor, 3, 73 mentoring, 112, 114, 145 mentorship, 62, 63
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158
Index
messages, 5, 12, 141, 142 meta-analysis, 29, 88 metabolism, ix metacognitive skills, 12 metaphor, 102 methodology, 102, 127 micro-teaching, 63 migration, 121, 122 minorities, viii, 121, 122, 123, 124, 127 minority, 24, 122, 125, 128 minority students, 24 miscommunication, 129 misconceptions, 33, 61, 96 misunderstanding, 2, 123, 124 model, 2, 5, 14, 20, 21, 27, 32, 33, 35, 37, 39, 40, 41, 44, 45, 53, 63, 69, 71, 74, 75, 79, 100, 102, 103, 111, 112, 119, 121, 122, 140, 141 modeling, 13, 34, 37 modelling, 59, 62, 63, 66, 79, 127 models, 13, 16, 26, 32, 34, 37, 38, 39, 52, 58, 64, 66, 69, 70, 73, 74, 77, 100, 103, 108, 142 modules, 52, 64, 131, 132, 134, 136, 137, 138 momentum, 21, 147 Moon, 113, 114, 116, 118 moral reasoning, 117 morale, 48, 144 morality, 22, 104 mortality, 53, 99 motion, 14 motivation, 22, 23, 26, 32, 40, 69, 85, 87, 88, 146 motor skills, 14 movement, 71, 117, 139 multicultural education, 128 multidimensional, 110 multimedia, 6 multiple factors, 48
N narratives, 51, 54, 119 nation, 142 National Survey, 128 navigation system, 4 negative experiences, 112 negotiating, 40 negotiation, 82, 85, 145 network, 150 networking, 3 nodes, 5 normal distribution, 96 nurses, 48, 54 nursing, 86, 119
O objectives, 40, 51, 70, 83, 87, 88, 98, 107, 126, 134, 136 objectivity, 101, 105 obligation, 94, 142 observations, 61, 64, 95, 96, 99, 101 obstacles, 58, 65 older people, 49, 54 online learning, 2, 5, 7, 16 opportunities, vii, 2, 3, 5, 7, 31, 32, 35, 36, 37, 38, 44, 51, 63, 66, 70, 115, 131, 135, 136, 145 opportunity costs, 40 order, 3, 25, 26, 34, 43, 51, 61, 65, 69, 78, 85, 87, 124, 132, 135, 136, 143, 145, 146 orientation, 40, 58 original learning, 79 OSCE, 26, 30, 42, 100, 101, 105, 125 outpatients, 37, 44 overlap, 24 overload, 86 ownership, 113
P pain, 84 palliative, 49 paradigm, 7, 8, 120, 125, 139, 142 paradigm shift, 8, 120 parallel, 38, 71, 141 parents, 123 parity, 136, 144 partition, 31 pass/fail, 102 passive, 6, 35, 38, 39, 41, 83 pathology, 39 pathways, 134 patient care, 58, 70 pedagogy, 1, 57, 58, 59, 61, 62, 68, 83 peer assessment, 5 peer review, 65 peers, 7, 14, 37, 50, 52, 65, 85, 112, 113 perceptions, 2, 44, 101, 103, 117, 126, 129 performance, 12, 14, 15, 16, 20, 22, 26, 29, 30, 58, 61, 70, 71, 76, 77, 78, 79, 82, 84, 93, 95, 96, 99, 100, 101, 103, 104, 112, 115 permission, iv permit, 116 perseverance, 145 personal qualities, 29, 97, 114 personality, 20, 22, 25, 30, 86, 101 personality traits, 22
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Index persuasion, 94 phronesis, 112 physical activity, 14 physical environment, 40 physical features, 2 physical sciences, 23, 24 physics, 23, 25 physiology, 86 Picasso, 114 pilot study, 117 planning, 4, 12, 32, 36, 37, 38, 45, 47, 50, 51, 57, 64, 66 platform, 6 policy makers, 47 politics, 124, 146 poor, 22, 48, 71, 76, 99, 129, 141 poor performance, 76 population, viii, 39, 49, 89, 91, 96, 121, 122, 124, 127 population group, 122 population growth, 122 portfolio, viii, 1, 107, 111, 112, 113, 114, 115, 118, 119, 120 portfolio assessment, 120 portfolios, 5, 20, 64, 107, 112, 114, 115, 118, 119, 120 positive feedback, 76, 77 positive reinforcement, 76 poverty, 126 power, 7, 24, 50, 94, 123, 126 power relations, 126 practical wisdom, 112 prediction, 29, 122 predictive validity, 20, 22, 23, 24, 26, 27, 29 predictors, 22, 28, 29, 105 prejudice, 21, 42 pressure, 28, 42, 43, 71 primacy, 58 priming, 37 prior knowledge, 6, 7, 32, 59, 62, 66, 87 private practice, ix private schools, 21 problem solving, 15, 25, 35, 60, 78, 79, 84, 86, 88, 90, 104, 105, 113, 145 problem-based learning, 5, 82, 84, 87, 88, 89, 98, 104 problem-solving, 13, 23, 26, 32, 83 problem-solving skills, 83 production, 6, 140, 147 professional careers, 132 professional development, 47, 53, 111, 112, 115, 118, 120 professional growth, 114
professionalism, 93, 106, 107, 108, 109, 110, 111, 112, 114, 116, 117, 119, 120 professionalization, 117 professions, 47, 48, 50, 94, 95, 97, 103 prognosis, 36 program, 64, 95, 97, 98, 100, 102, 103, 118, 144 project, 133, 145 properties, 105 proposition, 103 protocol, 93, 94, 96, 98, 99, 100, 102 psychologist, 13 psychology, 15 psychometric properties, 96, 97 psychosocial factors, 123 public health, 41 publishers, 4
Q qualifications, 19, 21 qualitative research, 120 quality assurance, 94, 95 quality control, 39 quality improvement, 49, 53, 54 questioning, 63, 131
R race, 124 racism, 128 range, 3, 4, 8, 20, 24, 37, 39, 41, 48, 69, 77, 110, 131, 132, 133, 135, 136, 142, 143 ratings, 39, 96, 101 reactions, 94, 103 reading, 4, 12, 51 real time, 5 reality, 8, 9, 84, 95, 103, 112 reason, 6, 52, 94, 99 reasoning, 13, 14, 23, 24, 25, 32, 88, 99, 105 recall, 15, 32, 83, 99 reception, 15 recession, 19 reciprocity, 65 recognition, 14, 20, 48, 70 recommendations, iv, 27, 29, 43, 137 redundancy, 102 refining, 26 reflection, 14, 33, 34, 35, 64, 76, 81, 83, 85, 87, 111, 114, 115, 117, 118, 119 reflective practice, 12, 32, 62, 103, 107, 112, 114, 118 regulation, 110
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
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160
Index
regulations, 52 regulatory bodies, 134 rehabilitation, 36 reinforcement, 15 relationship, ix, 24, 39, 49, 60, 61, 77, 107, 110, 112, 119, 123, 124, 140 relevance, 40, 53, 71, 79, 87, 88, 90, 102, 126 reliability, 20, 24, 26, 27, 94, 95, 96, 99, 102, 103, 105, 113, 114, 115, 119, 120 remediation, 16 repair, 108 reputation, 141 requirements, 33 reserves, 116 resilience, 26 resistance, 77 resolution, 112 resource management, 53, 135 resources, 1, 2, 3, 4, 43, 58, 75, 89, 102, 133, 135, 140, 141 respect, 50, 76, 100, 101, 102, 103, 121, 126, 127, 142, 145 responsiveness, 45 restructuring, 32 retention, 15, 16, 43 rewards, 33, 144 rhetoric, 43, 94, 141, 144 rings, 11 risk, 32, 54, 110, 147 risk management, 110 role playing, 14 role-playing, 8, 14 room temperature, 143 rotations, 126 routines, 63 rubrics, 113 rural population, 49
S safety, 31, 36, 48, 49, 54, 94 sampling, 100, 101, 105 satisfaction, 2, 30, 41, 42 schizophrenia, 8 scholarship, 139, 142, 143, 144, 147, 148 Scholastic Aptitude Test, 23 school performance, 27, 29 scores, 16, 21, 22, 23, 24, 26, 96, 101, 105, 120 search, 32, 98, 117 secondary education, 58 security, 28, 85 selecting, 15, 20, 28, 29, 105 self esteem, 50
self-assessment, 14, 106, 112, 113, 118 self-awareness, 14, 23, 41, 113 self-confidence, 85 self-efficacy, 12, 50 self-portrait, 114 self-portraits, 114 self-reflection, 14, 111, 114 self-regulation, 12, 34 self-study, 87 seminars, 63, 82, 84, 85 sensations, 39 sensitivity, 14, 126, 129 separation, 140 sequencing, 15 shape, 9 shaping, 9, 120, 144 sharing, 5, 42, 67, 89 signs, 38, 84 simulation, 31, 84, 87, 99 skills training, 90, 125 social care, 47, 48, 49, 52, 53 social construct, 82 social context, 39, 85 social contract, 115 social exclusion, 21, 24 social group, 21, 124 social network, 3, 5 social psychology, 32 social relations, 34, 40 social relationships, 34 social responsibility, 41 social sciences, 82, 113, 124 social skills, 82 social status, 123 social workers, 48, 54 socialization, 34 socioeconomic background, 21 software, 6, 118 solitude, 143 South Africa, 48 space, 8, 33, 43, 58, 65, 96, 112, 140 specialization, 39 specific knowledge, 126 spectrum, 35 speech, 125 staff development, 65 stakeholders, 4 standardization, 100 standards, 3, 4, 22, 29, 62, 65, 77, 102, 104, 110, 116 stereotypes, 52, 124 stereotyping, 123, 126 stimulus, 15 stimulus recognition, 15
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Index strategies, 6, 12, 14, 37, 43, 45, 61, 82, 94, 99, 100, 101, 102, 103, 120 strategy, 61, 79, 90, 95, 100, 101, 105, 121, 123, 127, 129, 134 strength, 95, 101, 126, 131, 135 stress, 69, 124, 146 stroke, 128 structuring, 87 subjective judgments, 101 subjectivity, 101 superiority, 31 supervision, 14, 83, 84 supervisors, 57, 64, 103 supply, 19 survival, 43, 141 symbiosis, 44 symptoms, 83 synthesis, viii, 6, 82, 87, 135
traditions, 123 trainees, 40, 42, 69, 74, 105 training, 2, 7, 12, 14, 15, 20, 24, 26, 27, 28, 33, 39, 42, 51, 52, 53, 54, 55, 57, 58, 88, 103, 110, 112, 118, 121, 124, 125, 126, 127, 128, 129, 134, 135, 136 training programs, 126 traits, 19, 21, 22, 23, 26, 27 transformation, 9, 111 transformational learning, 112 transition, 41 transmission, 140 trends, 90, 122 triangulation, 102 triggers, 117 trust, 26, 85, 103, 109, 115, 119 tuberculosis, 122 turnover, 36 tutoring, 145
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T talent, 142 targets, 124 taxonomy, 88, 91 teacher preparation, 68 teacher training, 39, 57, 59 teachers, 2, 4, 5, 15, 16, 28, 32, 33, 35, 36, 37, 38, 39, 43, 52, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66, 67, 68, 69, 73, 75, 76, 78, 79, 85, 86, 91, 112, 115, 117, 139, 146, 147 teaching experience, 59, 64, 83 team members, 143 technical assistance, 3 tension, 39, 98, 108, 139 tenure, 100, 142 territory, 32, 61, 100 test data, 105 test scores, 96 testing, 25, 93, 98, 99, 100, 101, 104, 105 theatre, 2, 32, 36, 39, 40, 45, 60 therapists, 54 therapy, 121, 127, 134, 137 thinking, vii, 5, 9, 12, 13, 14, 16, 23, 33, 37, 60, 63, 65, 66, 67, 71, 94, 142, 146 thoughts, 38, 112, 124 threat, 107, 115 threats, 97, 104 threshold, 19, 22, 24 timing, 52 tones, 40 tracking, 3 trade, 66, 108 tradition, 60, 94
U uncertainty, 32, 79, 112, 136, 145 undergraduate education, 44, 89, 137 uniform, 26, 97, 114 universities, 2, 3, 6, 24, 25, 48, 64, 91, 141, 142, 144, 146 university education, 147 updating, 4
V vacuum, 23 validation, 16 variability, 19, 21, 58, 96 variables, 97 variance, 20, 58, 61, 66 variations, 24, 128 vein, 144 venue, 90 vision, 7, 9, 143 visual images, 39 visualization, 14 vocational training, 117, 119 voice, 146
W war, 36 warrants, 21 welfare, 36, 38
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,
162 winning, 141, 142 witnesses, 65 work environment, 43, 59, 63 workplace, 32, 35, 43, 44, 49, 50, 64, 103, 145 World Health Organisation, 48 writing, 15, 23, 24, 25, 38, 40, 99, 102, 119, 120 writing tasks, 24, 25
Index
X x-rays, 15, 16
Y
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yang, 97 yin, 97
Salerno-Kennedy, Rossana, and Siún O’Flynn. Medical Education: The State of the Art : The State of the Art, Nova Science Publishers,