Essay: A portfolio of teaching plans in medical education

A portfolio of teaching plans in medical education
Medical education has evolved over the last few decades and “doctors must be prepared to teach and learn not only within their own profession but also across disciplines”(Peyton,1998).
The Department of health initiative UMC ISS (undergraduate medical curriculum implementation support scheme) had a huge impact on medical education. New teaching and learning methods are introduced into the medical curriculum as problem based learning video teaching and web-based learning ,and the National agency responsible for monitoring educational quality is set up as a Quality Assurance Agency( QAA) and GMC is looking in detail at how education is being provided.
In The Doctors as Teachers(1999 )the GMC noted that teaching skills can be learned and those who except special responsibility for teaching should take steps to ensure that they develop and maintain the skills of a competent teacher.
This document highlights five teaching methods and the application of learning theories provided to doctors and medical students from the University of Birmingham medical school.
One to one teaching
“My method (is) to lead my students by hand to the practice of medicine, taking them every day to see patients in the public hospital, that they may hear the patients ‘symptoms and see their physical findings. Then I question the students as to what they have noted in the patients and about their thoughts and perceptions regarding the cause of the illness and the principles of treatment” Dr Franciscus de la Boe Sylvius,17th century professor of medicine at the University of Leyden, Netherlands
“One to one” is the default teaching mode for the apprentice model currently favored in medical education. It can however vary from a carefully planned tutorial reflecting student needs or even a simple reflective conversation after a busy surgery. The format and length of session may change but the principles and skills remain a constant and knowledge and application of them will improve anyone’s teaching. Clinical teaching often involves seeking out opportunities for learners to practice clinical skills ranging from simple procedures to much more complex skills such as breaking bad news, or carrying out an operation.
One of the themes which is highly relevant to many vocational situations is to consider how a student or trainee makes the shift from novice to expert and how they become a professional. Schon’s (1987) work has been influential in looking at the relationship between professional knowledge and professional competence and the development of the ‘reflective practitioner’.
In medical education, much of the learning is necessarily experiential, there is a lot of ‘learning by doing’ as well as ‘learning by observation’(Kolb,1984). Training in operative surgery is an essential part in surgical teaching. The trainee has to progress from one level to another level by series of skills transfer. As described by W C Howell (1982) there are four phases of competences in learning model, each identified by different combinations of consciousness and competence, which every learner may pass through as they learn.
These stages are
A] Unconscious incompetence – this is the stage where they are not even aware that they do not have a particular competence.
B] Conscious incompetence – this is when they know that they want to learn how to do something but they are incompetent at doing it.
C] Conscious competence – this is when they can achieve this particular task but they are very conscious about everything they do.
D] Unconscious competence – this is when they finally master it and they do not even think about what they have such as when they have learned to ride a bike very successfully. (Howell, 1982, p.29-33)
Kolb (1984) was highly influential in describing how learning takes place and helping understanding of the learning process. His ‘learning cycle’ and Learning theories approaches the idea of learning as experiential (learning by doing). Kolb suggests that ideas are not fixed, but are formed and modified through the experiences we have and by our past experience. These concepts underpin prevailing ideas in medical and other professional education and training such as the reflective practitioner and becoming an expert. Providing opportunities for learners to develop these skills through practice, constructive feedback and facilitated reflection is essential.
Figure1 Kolb’s learning cycle
Exceptional potential of one to one teaching.
*It tackles current learning needs.
*It promotes autonomy and self-directed learning.
*It links prior knowledge with new clinical experiences.
*It enables opportunistic teaching.
One to one teaching is one of the most powerful ways of “influencing students.” It promotes active learning in clinical settings while modelling desirable personal and professional attributes. Students can also discuss his or her personal and professional attitudes and values which may not be possible in a larger group (P Cantllon,2003)
As suggested by Ausubel and colleagues (1978), the secret of education is to find out what the learner already knows and teach accordingly. With one-to one teaching we can — “customise” teaching as per learner’s needs.
Learners value feedback highly, and valid feedback is based on observation. As observed by Cantllon (2003) learning opportunities are wasted if they are not accompanied by feedback from an observer and the learner cannot reflect honestly on his or her performance. One to one teaching is ideally suited to encouraging reflective practice, because you can model the way a reflective practitioner behaves. Two key skills are (a) “unpacking “your clinical reasoning and decision making processes and (b) describing and discussing the ethical values and beliefs that guide you in patient care.
SESSION 2 – A lecture bedside clinical teaching
Clinical teaching usually directly involving, patients and their problems, lies at the heart of medical education. Clinical teaching focuses on real problems in the context of professional practice and trainees are motivated through active participation.
Professional thinking, behaviour, and attitudes are “modelled “by teachers. Clinical teaching not only allows trainee to improve their skills of history taking and physical examination but also test them on decision making and professionalism. Despite these potential strengths, clinical teaching has been much criticised for its variability, lack of intellectual challenge, and haphazard nature (Spencer.John,2008).
As explained by Spencer (2008) there can be many challenges of clinical teaching
*Time pressures
*Competing demands—clinical (especially when needs of patients and students conflict); administrative; research
*Often opportunistic—makes planning more difficult, Increasing numbers of students
*Fewer patients (shorter hospital stays; patients too ill or frail; more patients refusing consent)
*Often under-resourced
* Clinical environment not “teaching friendly” (for example, hospital ward).
Bedside teaching still remains an ideal venue for the trainee to attain new skills in a real environment as it meets all the possible goal’s as explained by McLeod and Harden (1985).
Possible Goals of Clinical Teaching McLeod and Harden (1985)
* Accumulate and record information about patient.
*Perform complete and orderly physical examinations.
* Perform skills procedures.
*Interpret data.
*Solve scientific and professional problems.
*Communicate information reliably.
*Develop familiarity with health care services and facilities.
*Develop appropriate attitudes to patients and allied health care workers.
* Accumulate factual healthcare knowledge.
*Acquire positive attitudes to independent learning.
A Structure for Bedside Teaching
One model of effective bedside teaching (Cox 1993) divides the activities teaching activities into
• Before the bedside
• At the bedside
• After the bedside
Before Bedside-
Trainers should establish the trainee’s knowledge base and brief them about the patient. Trainee should be aware of their learning objectives and all trainees should have a clear allocated role as who would take a history and who would do clinical examination.
At the bedside-
Trainers should lead as a role model for a good doctor-patient relationship. He should involve all the students in discussion and should focus only on the learning outcome and not discuss complex management plans over the patient’s head.
After the bedside –
Trainer should give a constructive feedback and an effective debrief to the trainees.
The session Planning—The session was planned for a small group of third year medical students in surgical rotation at Sandwell hospital in February 2016. Students had a brief power point presentation on examining abdomen (see Appendix 1). We had a discussion of relevant signs and symptoms for the various pathologies in abdominal examination. Such discussion activates prior knowledge and provides framework and structure for the task.
Experience— An initial demonstration was followed by a student performing the examination. One student interviewed the patient for a detailed medical history and other student performed a focused physical examination under my supervision. Rest of cohort were observing the examination.
Reflection—History taking and examination were discussed and students received a verbal feedback on their approach to examine abdomen. Students then observed a demonstration of abdominal examination by me, while the rest observed and reflected on their performances.
Theory—copy of my power point presentation were handed out to the students(appendix2).
Kolb (1971) had introduced four distinct learning styles of learners in a given learner population. Kolb referred to these as diverging, assimilating, converging and accommodating.
Figure 4, illustrates the learning abilities of Kolb’s four-part model in relation to the learning process associated with this SGT session.
Fig 4 Kolb’s Model
Sir William Osler’s dictum that “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” appears very true for this teaching session.
Simulation based teaching
Medical simulation has been increasingly used in Medical education over the past decade. It aims to imitate real patients, anatomical regions and clinical tasks to mirror the real life circumstances allowing trainee to practice their skills in a risk-free environment (Scalese. R,2007 ).
There is a significant departure from traditional “See one do one “approach to simulation based training in recent years. Simulation has already been used in training as flight stimulator for pilots /astronauts and in warfare games, and now these models are used in medical education like critical care, anesthesia and emergency care.
With continuing changes in health care has led to decrease availability of real patients as the learning opportunity & simulation fills this gap very effectively. One of the major advantage of simulation based learning is the ability to tailor the teaching needs, according to learner’s experience level and its reliability and transferability from learning environment to clinical practice (Maran & Glavin ,2013 ).
Teaching Sessions
Session: Simulation based learning and the role of the effective debrief
The scenario consisted of a post-operative patient feeling light headiness and thirsty. The scenario progressed from hypotension leading to hypovolemic shock due to haemorrhage (See Appendix 1). This simulation was carried out using the iStan (CAE Healthcare, USA) human patient simulator at the Hollier Simulation Centre – Good Hope Hospital, Sutton Coldfield. The candidates were from a small group of 5th year medical students, who take part in a weekly simulation based teaching session.
This scenario took place in Hollier simulation in centre at Good Hope Hospital. Hollier is a facility for the West Midlands to train doctors, dentist, nurses and works with collaboration with the University of Birmingham and medical School .
Hollier Centre specializes in a high fidelity simulation .Medical students were briefed before the scenario and were aware of their expectations and their learning outcomes after the scenario. Two students were send at one time into a room with simulated patient [high fidelity mannequin] and a nurse to help the students. Scenario was played as preset clinical presentations and mannequin was controlled by a computer in behind a glass wall. Scenario was recorded and played live in the room for rest of the cohort.
Fidelity is the extent to which true appearance and behavior match with a simulated environment. The simulation at Hollier is a high fidelity simulation with computer-driven programs to control cardiovascular and respiratory function in the mannequin it allows students to interact as they would do in real life situations.
Miller (1954) describe two types of fidelity- physical fidelity and physiology fidelity. These principles were applied using the scenario at Good Hope hospital.
Physical
In relation to environment and equipment used
Psychological
In relation to the applicability of the scenario to real world and progression of events in scenario vs. real world
Use of interactive high fidelity human patient simulator The scenario was based on a real world patient also used in ATLS assessment
The room – recreation of a hospital ward with controllers / teacher located in a separate room behind a two-way mirror The time taken for deterioration similar to what would be expected in real world
Equipment – All equipment necessary were made available as required Hierarchy of senior support available similar to most NHS hospitals
Figure 1: Means by which high physical and psychological fidelity were achieved during this
The scenario was allowed to unfold as per preset guidelines till the learning outcomes were met. Students were not only assessed for their medical knowledge and skills but also for their situational awareness. Students were assessed for personal and a team situational awareness and also anticipation of patient progress during the scenario.
Situation awareness (SA) refers to a person’s perception and understanding of their dynamic environment. This awareness and comprehension is important to make appropriate decisions in medical care settings (Wright .M.C,2004).
As detailed by Wright (2004) the level of SA possessed by a practitioner is critical to the outcome of the patient. Measurement of SA can be used to evaluate trainee and identifying areas of deficiency. The results can be used to improve training and education of medical practitioners and to improve system design. This will support medical practitioners in attaining a high level of SA for a better patient outcome.
The SLAM Technique can be applied universally (Construction – Health and safety for the construction industry, 2016).
SLAM consists of four simple steps:
STOP Engage your mind before your hands. Look at the task in hand.
LOOK at your workplace and find the hazards to you and your team mates. Report these immediately to your seniors.
ASSESS the effects that the hazards have on you, the patients, procedures, and the environment. Ask yourself if you have the knowledge, training and tools to do the task safely.
MANAGE If you feel unsafe stop working. Tell your seniors and workmates. Tell your seniors what actions you think are necessary to make the situation safe.
The scenario was recorded and the students were debriefed in a small group with audio/visual feedback. The debrief provides a safe environment for the candidate to reflect, understand, ask questions and learn. The debrief also facilitates learning amongst the remaining members of the group who were not physically present in the simulation room.
Hertels & Mills (2002) describe three elements of effective debrief
1 Acknowledgement of participant’s emotions.
2 Discussions of the role that participant held during the simulation.
3 A summary reviewing the simulation in terms of learning objectives and explorations of how the knowledge and skill demands from simulation exercise can be applied to future simulation
It is very important to ensure that the feedback provided should be in line with the overall learning outcomes of the programme, teaching session or clinical activity in which the learner is engaged (web cite). Giving feedback is an important part of experiential learning and as described by Kolb (1984) – learning happens in a circular fashion, that learning is experiential (learning by doing), and that ideas are formed and modified through experiences. These ideas underpin the idea of the ‘reflective practitioner’ and the shift from ‘novice to expert’ which occurs as part of professional development.
The learning cycle requires four kinds of abilities or learning contexts:
• concrete experience – learners are enabled and encouraged to become involved in new experiences
• reflective observation – gives learners time to reflect on their learning
• abstract conceptualization – learners must be able to form and process ideas and integrate them into logical theories
• active experimentation – learners need to be able to use theories to solve problems and test theories in new situations.
One of the major advantage of the simulation experience is the debrief which helps to transform the simulation experience into learning through reflection, feedback and discussion.