TEACHING AND LEARNING
INTRODUCTION
In order to deliver good healthcare we need to train young physicians well. Our medical education and
training programmes should deliver well-motivated practitioners who continually learn and develop
throughout their careers. Throughout this process, the teacher plays a crucial role by facilitating the
learning process, giving feedback to trainees, being a role model and assessing trainees.
Most medical teaching is an every day activity that has to compete with other priorities including busy
clinical commitments.
Although many physicians are involved in training and most regard teaching as an intrinsic part of their
occupation, few have had the opportunity to formally learn teaching techniques. This is even more
relevant nowadays because of new insights into learning and teaching and the broadening spectrum of
competencies involved in clinical care.
'It goes without saying that no man can teach successfully who is not at the same time a
student.'
Sir William Osler
This module will help you to understand how people learn in medical practice and how training takes
place. Most trainees are involved in some sort of teaching and therefore fulfil trainee and trainer roles
as indeed pertains to personnel at all levels of the healthcare system.
1/ UNDERSTANDING HOW PROFESSIONALS LEARN
Becoming a specialist in intensive care medicine takes years of training. Most of a trainee's and
practitioner's learning and continuing professional development takes place in the clinical setting ('on
the job'), with the rest from 'off the job' courses, workshops, simulation sessions, skills teaching and
self study.
In order to organise an effective training programme it is important to understand how adults learn in
professional practice and what influences this learning in both positive and negative ways. As clinical
teachers, we may ask ourselves what kind of learning we would like to see in (newly qualified as well
as experienced) physicians in medical practice. How can we influence learning and the formation of
learning habits in professional practice?
How do professionals learn?
Learning in practice is not like school learning
Learning in practice, as an adult, is different from learning in school,
as a child or student. Adults have amassed knowledge, skills and
experience. Their motives and need to learn are often related to the
competencies they need for their daily work. They learn while
pursuing goals at work.
Non scholae sed vitae
discimus (we do not learn
for school but for life)
Seneca
Childhood/school learning is mostly individual, explicit, intentional, and organised learning, whereas
learning in practice differs in that:
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Daily social interaction plays an important role.
Learning often happens implicitly and spontaneously.
Intentions may not be directed to learning, but to activities (to getting a job done, to
becoming a physician, to prove oneself, to survival).
Learning is not organised, but happens all the time – when no one is paying attention, and
as a side-effect of participation in the context of professional practice (or life).
Two important aspects of learning in practice are spontaneous learning from experience (experiential
learning) and planned learning. These are summarised in the following table and discussed in more
detail below.
Spontaneous experiential learning
T HINK
What do you remember of your 'first time' as an intern, resident, or new start in a
hospital department? What happened to you? What were your positive and negative
impressions?
By immersion
Trainees who start working in the intensive care unit (ICU) will not only learn how to solve clinical
problems, but will also learn what kind of organisation it is: what are the implicit rules, what is and is
not done, how do the staff behave, what kind of behaviour is expected from trainees, and how staff
interact with one another, newcomers, and with patients. This is learning by immersion. Trainees
learn by participating in the social context, by observing and adapting to the habits of the 'model'
practice. Trainees acquire the habits of the department without much explicit thought. Two important
characteristics of this type of learning are that 1) behaviour and performance become easier by
routine; so that no extra learning effort is needed and 2) the learning effects become deeply ingrained.
By doing
Trainees learn from their own direct experience in performing tasks. Although trainees may learn much
from their own problem solving, some of this learning may be rather by trial and error, hopefully without
adverse consequences. The tasks are not just the concern of trainees, but part of the activities in the
ICU. Intensive care practice is a social practice. The staff may comment on the performance of
newcomers, and discuss what they are doing. For more information see the PACT modules on
Organisation and management
and Communication skills
.
Role modelling
Trainees will have many opportunities to observe how more experienced
colleagues perform their tasks. This is called model
learning or observational learning. Who serves as a model depends on
who a trainee considers competent, attractive, powerful, and trustworthy.
Models can be positive or negative. Trainees may copy less desirable
behaviour from a negative model. It is very difficult to learn alternative
better behaviour in the absence of a good model. When suboptimal
behaviour is accepted as the norm (probably more likely in a small unit or
institution), newcomers will adapt to the norm most of the time.
'Junior doctors do not
simply learn from
consultants, but learn to be
like the consultants they
admire and respect'
Alan Bleakley (2002)
Social interaction
What it means to be a physician and how to become one, becomes clearer to trainee physicians while
participating in medical practice. Trainees learn from experienced physicians but also from social
interaction with and between patients, nurses, administrative and paramedical professional staff,
ambulance personnel etc. The daily interaction teaches the trainee what it is to be a physician in that
location, and the respective positions of other participants.
NOTE
Every participant in professional practice is learning spontaneously; it happens all the
time, whether desired or not, and whether or not you are conscious of it. The results from
spontaneous learning in practice are quite marked, and have a direct and pervasive effect
on practice.
Spontaneous learning and its effects on practice, tend to be overlooked. The advantages and
disadvantages are listed in the table below.
Spontaneous
learning in
practice
Socialisation and individual differences
The word socialisation is often used to refer to the spontaneous learning by which newcomers learn
to adapt to a new environment. It is not a one-way process – what trainees learn spontaneously from
experience in your department also depends on what they bring to the situation: their prior knowledge
of medical practice, self-awareness, preferred ways of learning, expectations, hopes and fears.
Trainees learn from their own perspective, or frame of reference. Thus, socialisation is mediated by
the individual frame of reference.
Trainees may differ in several ways. What differences do you think are important in their
learning? What is the importance?
Deliberate learning in practice
The recognition of the power and nature of spontaneous learning is a starting point for stimulating
learning in practice in a more conscious and deliberate way. Deliberate learning builds on spontaneous
learning, but asks questions and provides clarification. The implicit nature of spontaneous experiential
learning becomes subject to explicit questioning, discussion and reflection in order to improve one's
clinical competence. Are we doing the things the way we say we are doing them? And are we doing
the right things? Can we improve?
First of all, you have to think about whether your department and hospital offers the optimal medical
practice, for patients as well as for trainees and other participants. What kind of medical practice is
offered as a learning environment? Are trainees immersed in the best practice possible? Do trainees
have the best opportunities for observational learning? What do trainees observe? What kind of social
interaction is taking place? In what kind of everyday conversations are your trainees expected to
participate?
Spontaneous learning happens when no one is aware or paying attention.
Deliberate attention is needed to go further – hence the term deliberate learning.
The concept of experiential learning is often used with the suggestion of a learning cycle moving from
experience to concept formation, evaluation, and testing hypotheses in intentional experimentation.
Experiential, spontaneous learning in itself does not necessarily, let alone automatically, include
conscious concept formation, or testing of these concepts in subsequent actions. However, learning
does not automatically happen that way! Explicit efforts are needed to progress from experiential
learning to reflective learning.
NOTE
The best clinical practice is also the best environment in which to learn clinical
practice.
You may stimulate deliberate learning in practice by providing:
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The best medical practice for spontaneous learning
Good role models, who explain the rationale behind what can be observed, and who help
novices to notice what there is to observe
Tasks that are challenging enough to learn from (but safe enough), so that the novice may
progress from relatively simple and partial tasks to full responsibility
Observation and feedback, tailored to the individual trainee and based on fair and clear
evaluative criteria
Questions to assess trainees' present levels of competence in all relevant domains.
When trainees go to different hospitals during their training, they may learn more consciously and
reflectively from their experiences in these different hospitals. Explain why training in different
places could counter possible disadvantages of only experiential learning, and stimulate more
reflective learning?
2/ HOW TO STIMULATE PROFESSIONAL LEARNING
Clinical teachers serve a dual role: they provide patient care and they teach. The challenge of clinical
teaching is how to balance patient care responsibilities with teaching responsibilities. As a clinical
teacher, you stimulate and evaluate trainees' learning.
Teaching in the clinical setting
Being taught in the clinical setting is essential to becoming a fully qualified physician. It offers the
potential for attaining skills in clinical history taking, patient examination and diagnosis, management,
and skills in collaboration, organisation, communication and professional attitude.
Stimulating learning in the clinical setting includes: role modelling, organising trainees' participation
and feedback, planning your teaching and using clinical events to benefit your trainees. Below, we
discuss these aspects of teaching 'on the job' in clinical practice.
Role modelling
Whether you want it or not, trainees learn much from you as a role
model (see Task 1
). Thus, conscious role modelling is an
important method for helping trainees acquire the knowledge and
'Example is not the main
thing in influencing others,
skills, as well as the values, attitudes and behaviour associated with
professionalism, humanitarianism and ethical practice.
it is the only thing.'
Albert Schweitzer
Characteristics of positive role models include personal qualities
(such as compassion, a sense of humour, integrity), clinical skills
(such as proficiency as a diagnostician and effective interaction with
patients and their relatives), and teaching skills (such as ability to
explain difficult subjects and a non-threatening style).
Experienced physicians who have been identified by trainees as
positive role models are those who spend more time on teaching,
participate more often in faculty development programmes,
emphasise interactions between patients and physicians and the
psychosocial aspects of medicine, give more in-depth specific
feedback to learners and last but not least, they enjoyed teaching.
Give examples on how to make role modelling explicit to your trainees.
Organising participation and providing feedback
Trainees learn from participating in the clinical setting (see Task 1
). Traineeship involves moving
from peripheral to full participation in practice. When trainees start they are relative outsiders who are
not yet fully part of what is going on. They need to learn what it is to be a responsible physician in this
particular setting. The task of the trainer is therefore to assist this process, by introducing trainees as
incoming colleagues, by assigning meaningful tasks with increasing responsibility, and by providing
constructive feedback.
Imagine how your clinical practice looks to newcomers, and think of what and
who trainees need to know, and how do they get acquainted as soon as
possible? Who and what can be of help? You may want to write an introductory
manual for new trainees.
Level of competence
Before assigning tasks to trainees you need to know their level of competency. Even if known, it is
advisable to discuss with your trainees what you want them to do and why, so that they may give their
views about what they need to learn. The golden rule is 'balance between safety and challenge'.
When you assign tasks which are too difficult, you are threatening the safety – not only of your
patients, but also the necessary safety for trainees' learning.
When tasks are too difficult, trainees may learn to take risks which are too great, or they may get
discouraged and start thinking about another career choice. When tasks are too easy, trainees stop
learning. Of course, tasks still need to be done, but as a clinical teacher you need to make sure that
trainees have sufficient tasks to learn from. This also implies that in the course of time you go from
easier (and/or partial) to more complex (and complete) assignments for your trainees.
To guide the learning process it is essential that trainees receive feedback. The purpose
of feedback is to inform them about what is good in their professional behaviour and what needs
improvement, why and how. In order to be able to provide feedback it is necessary for the teacher to
know about a trainee's performance. This may sometimes be based on what you hear from others.
However, as a responsible teacher you also need to create opportunities to observe trainees yourself.
Providing feedback
When providing feedback, keep the following in mind:
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NOTE
It is about specific, observed performance (and does not include statements about the
person, unchecked assumptions or vague statements)
It informs about which performance is good (reinforcement, so that this behaviour will be
maintained)
It informs which performance shows weaknesses, mistakes, omissions, including why, and
what is the desirable behaviour
It is individual – adapted to the competency level and to the personal characteristics of your
trainees. For example, you may want to encourage trainees who are doing fine but feeling
insecure, and you may want to be more strict with trainees who overestimate their
competency
Invite trainees to self-assess (an important professional competency).
Anybody may provide feedback (subconsciously), just by their reactions to trainees.For
instance, nurses, physiotherapists, paramedics and patients give informal feedback,
verbal and non-verbal (e.g. body language). In giving your trainees educational feedback
you may want to think about the informal feedback that they have already received in
practice.
For more information see the PACT module on Communication skills
When delivering feedback to your trainees or students, the following
structure can be helpful in making the feedback meaningful, recognisable
and by creating a safe environment.
Step 1. Ask the trainees what was good in their professional behaviour.
Step 2. Provide your feedback.
Step 3. Ask the trainees what could be improved concerning their
professional behaviour.
Step 4. Provide your feedback.
Step 5. Let the trainees think of alternative behaviours, ask for a summary
and what they will do in a subsequent situation. In that way you can check if
your trainees did understand the message.
.
Tell your trainees what they
need to know
Positive feedback is easily confused with only saying good things about a trainee such as
'you did well and you were nice to that patient'. But feedback should focus on the
trainee's specific actions and what you observed.
Examples: 'when the patient said he was afraid he was going to die you stopped your examination and
asked him where that fear came from. That made me conclude you really listened to the patient'. Or
'when the family was very upset and agitated, you stayed very calm, you spoke very calmly and clearly
and told them you respected their feelings. At that point the family relaxed a little'.
Use the five steps described above to deliver feedback to your trainees or colleagues.
Analyse how the method works: can you say what has to be said? Do trainees accept the
feedback? Do they improve after the feedback session? What do trainees think about this
way of delivering feedback? (A good way to analyse a feedback session is by videotaping it
and then watching it, alone or with colleagues or peers).
Planning teaching moments and strategies
Trainees expect clinical teachers to: take time to teach, give feedback, tailor the teaching to the
learner, and use opportunities to teach. This means that, if you want to teach in an effective way, you
have to
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T HINK
Prepare for clinical teaching by planning when and how to teach (planning)
Use a variety of teaching methods to involve your learners actively and serve individual
needs (adapting teaching strategies)
Evaluate and reflect after teaching (evaluating and reflecting).
How often do you keep the above points in mind when teaching?
Planning
The first and most important point in planning is that you start to recognise opportunities for teaching in
practice. Ask yourself which moments and events are most valuable for your trainees to learn from,
and plan to use them. Planning helps to sharpen expectations, clarify roles and responsibilities,
allocate time for instruction and feedback, and focus learners on important priorities and tasks.
Sharpen expectations
At the beginning of each rotation or clinic, it is important to communicate clearly the expectations.
Introduce people to each other, formulate learning goals, ask trainees to formulate personal goals and
clarify responsibilities and expectations of both the learner and the teacher. You might plan which
patients you want your trainees to discuss and ask them to prepare accordingly. And/or you think in
advance which questions you will ask them and what special points to explain.
Create a positive learning climate
Learners are more likely to ask questions, pursue learning issues and contribute to the group's
learning if a safe and respectful learning environment is created. This can be achieved by
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Demonstrating enthusiasm for teaching
Knowing trainees / participants by name
Asking for personal goals
Encouraging interaction and discussion
Showing respect to trainees and others.
Briefing participants / learners
When novice learners are left to their own devices, they often spend too much time with the patient
and don't elicit the important information required for patient care. Prepare learners for an upcoming
patient, for instance by asking what the most important complications are or what information they
need to differentiate competing diagnoses. More advanced learners can be invited to discuss cases
with the senior staff.
Why would it be important to explain in advance to novice learners what they can expect to see, for
instance during rounds or on the ward?
Adapting teaching methods
Excellent teachers have a repertoire of teaching strategies to involve trainees actively and meet learners'
needs. They can select the most appropriate method for the learner. Some examples:
Select clinical cases according to trainees' level
Novice learners should be assigned to evaluate patients with more straightforward, typical problems.
Advanced learners should be challenged with more complicated cases. Stimulate trainees to learn more
about the diagnosed disease(s), such as pathophysiology and aetiology. A good way to achieve deeper
understanding is to ask them to prepare a short presentation for the following day or week. In this way you
can also check their understanding.
Adapt feedback to individual learner
When you know the trainees you are aware what kind of learners they are, and you adapt feedback
accordingly. Are they good scientists, but forget to communicate what they are doing? Provide feedback on
both aspects and explain why it is important to share. Are they very friendly and communicative, but
sometimes neglectful? Provide feedback on both aspects, and stress the danger of being neglectful. Are
they lacking self-confidence? Focus on positive feedback (things they do well) and provide reassurance.
Use questions to 'diagnose' learners and to stimulate active learning
Questioning is a key strategy for both effective patient care and teaching. As a physician you use
questioning every day with your patients. With your patients you want to learn what is bothering them,
what is going well, what they want to know about their condition, and you want to check their
understanding of the information you gave them. You can also use these skills when teaching
trainees.
As an expert you may tend to ask long, complex questions. Try to realise what the underlying
questions are. For example, you want to ask your trainees which of several patients they would treat
first. This implies underlying questions about each patient (What do you see? What does it indicate?
What else do you need to know and why? How do you find out? Is it life threatening?) and
necessitates a comparison of the answers to decide which patient needs treatment first.
With appropriate questioning you find out what your trainees do (not) know sufficiently well, what
hinders their professional development, and what they think of your teaching. By asking questions you
can trigger reasoning, problem solving, and other higher cognitive skills.
When asking questions, it can be helpful to have different purposes and levels of questions in
mind. What purposes and levels of questions can you distinguish? Give examples.
Read more about questioning and listening skills in the following reference and in the PACT module
on Communication skills
Utilisation of clinical practice
eaching at the bedside
Bedside teaching includes any teaching done in the presence of the
patient, regardless of the setting. Certain situations require bedside
teaching such as demonstrating and practising physical diagnosis,
communication and procedural skills. Besides educational
advantages, such as the possibility to directly observe clinical skills,
there is evidence that patients favour bedside teaching and report
better understanding of their illness. Of course this excludes using
patients for extensive skills teaching which should be done in
simulated or virtual situations. It also excludes the type of clinical
teaching where the patient's role is to demonstrate the teacher's
superiority and importance!
Good clinical practice is at
the heart of good clinical
teaching!
Prideaux et al (2000)
An effective strategy for bedside teaching includes: attending to
patient comfort, using focused teaching methods and managing
group dynamics. The latter refers to making sure every trainee
profits, stimulating interaction between patient and trainee and
between you and the trainees.
Clinical rounds
Clinical rounds are well known for their importance in postgraduate professional development. If well
prepared, they provide very valuable learning experiences for both trainer and trainee. A distinction
can be made between teaching rounds and business rounds.
Teaching rounds
Teaching rounds can be clinical rounds where time is reserved explicitly for teaching. It could also be
a more formal session where a single case or several cases are selected for examination and
discussion. The latter fits well in undergraduate and early postgraduate training. The disease process
is a central theme, with clinical assessment (history taking and physical examination) as the starting
point from which discussion can develop.
Consider the following points:
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Treat the patient with respect, even when the patient is unconscious. When possible
involve the patient. Ask permission in advance; explain the purpose; during the teaching
don't only talk about but firstly with the patient
 Choose clear goals that are appropriate to the trainee, the setting and patients' problems
 Adapt the teaching strategies to the existing needs, capabilities and experience of the
learners
 Actively involve learners, e.g. by asking them to perform (parts of) the investigation, asking
them to explain what they are doing, and what their opinion is
 Give feedback on their performance afterwards (not in the presence of the patients)
 Summarise at the end or ask your trainee to summarise.
Business rounds
These rounds are more part of everyday working in the hospital. In this type of round, the patient, their
treatment and progress are the central focus. You are role modelling in this work situation. Junior staff
can take the opportunity to safely display their diagnostic competency, proposed treatment and followup capabilities. The outcome of clinical interventions on a disease process in severely ill patients
provides instant feedback on the problem-solving and decision-making skills of those involved. This
provides excellent motivation to learn further, not only on the round, but also in other associated
formal teaching activities.
More information can be found in
Morning report
During the morning report one party accounts for patient care (diagnostic and therapeutic actions)
during the previous night, and the other party is taking over. If these sessions are conducted in an
interesting and active way, they can be a valuable learning experience and offer a good opportunity to
assess the progress of trainees. The following areas can be practised and assessed during the
morning report: prioritising a patient's problems; making clear distinctions between sick and less sick;
recognising the need for actions; requests for additional investigations are well thought out and based
on a good differential diagnosis; and formulating a clear conclusion.
Tips:
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Use a simple format for the presentation of the patient
Actively involve the trainees in choosing which patients are discussed
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Ask questions to clarify, motivate etc
Choose a chairperson who is responsible for structure and time
After trainees have seen senior staff model the morning report, ask trainees to chair
sessions (taking turns)
Start and end on time
Remember how tired the person who is presenting is relative to those starting work!
Analyse the morning report in your department. How is it organised? Can it be
improved in terms of a learning event for participants? What does it take to
make these improvements? Who do you need to make these changes?
Teaching 'off the job'
Teaching 'off the job' comprises quite different formats such as lecturing, small group teaching, and
skills training. However, any planned teaching session can be broken down into three key elements:
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Set
Dialogue
Closure
Set During the set it must be clear for trainees
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What they will learn (objectives)
Why it is important (motivation)
How the content is related to other parts (e.g. of a course) or practice
What is expected of the trainees and the trainer (e.g. should trainees listen, or should they
be practising, can they ask questions).
Dialogue is the crucial part of a planned session which involves the interaction of the trainees and the
trainer. It includes elaboration on the main messages of the session (in lectures), or working on an
assignment to reach the learning objectives (in small group teaching, workshops, and skills training).
NOTE
When preparing a teaching session always try to focus on the key
message: what should your learner never forget after this teaching session.
Closure has three elements
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Review (ask for questions; check if objectives have been reached)
Summarising (by trainer or participant)
Terminate the session.
What is the benefit of asking for questions before the summary and termination of a teaching
session?
Lecturing
Large group teaching has long been seen as a method of teaching in medical education. But over the
past decades the role has been questioned. Adults learn more effectively through active participation
and lectures are criticised for being too passive a learning experience. However, a good lecturer
activates the audience in a variety of ways.
A lecture is appropriate when the aim is to:
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And/or
Deliver information that is not available in another way
Stimulate interest, raise curiosity, motivate
Adapt information to the level of the audience
Underline specific information
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Provide the learners with the overall picture
Ensure shared knowledge (e.g. within a team).
about the lectures you enjoyed immensely in your medical career and lectures that you
thought were really bad. What made these lectures so good or so bad? What did the
lecturer do?
T HINK
Preparation
Structure your lecture according to the three main components identified
The secret to giving an
above. You may want to divide the second part (dialogue) into several steps, effective presentation is in its
depending on your goals.
preparation
Important points
 Think of a good start. Try to imagine what would grab the
attention of your audience – and focus their attention on
what you want to say. A story? A strange-looking slide?
Part of a movie? A statement? Tip: observe how
advertisements try to capture your attention and think of
possibilities to do the same
 Limit your messages. Don't cram your lecture with too
many goals. It is better to get across one main point than
to drown your audience in your expertise. Keep it simple
 Use examples for each of your messages. Start with an
example (from practice) and use it during the more general
explanation to illustrate what you want to convey (theory).
Don't restrict your message to abstract theory.
Preparation includes being aware of the setting and preparing the use of material such as slides.
When preparing the set you should think about the environment. What does the room look like, how
does the lighting work, is there a laptop available etc. Be as familiar with the environment as possible.
Be clear about the role of the audience. Can they interrupt you? If so, prepare to tell them and to
invite them to do so. Also think of how you may want to stop the audience participating if you
anticipate time problems. You may have to choose between audience participation and completing
your lecture.
Use of slides or other audiovisual materials
Here is a short guide to presentation and effective use of slides.
During your presentation
When conducting a teaching session, you always deliver your message in more than one way. As
well as content, learning is also dependent on how you deliver your message and what your body
language is saying.
NOTE
A confident start forms the basis of a successful presentation
Helpful tips to make your presentation even more effective:
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Be prepared and focus on your role as lecturer.
Maintain eye contact; in a large room this requires looking around (from left to right, front to
back, and vice versa).
Don't stand like a statue – but don't move around too much either.
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Avoid distracting the audience e.g. by playing with keys or coins, fiddling (e.g. fingers
through your hair, rubbing your nose).
Speak clearly and loudly – exaggerate as if you were an actor.
Use a microphone if necessary (check if the audience can hear you clearly).
Speak slower than you normally do, for your audience needs time to think (at least when
you tell them something that they do not know already).
Avoid turning your back (don't speak to your slides).
Slides and visual material
Their value should not be underestimated. It helps people to remember your message, it can help
them to make sense of complex ideas and it can help to keep their attention. You may also use slides
as your notes, your backbone of the presentation.
Beware of:
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Too many words. Think 'bullet points' and avoid textual sentences.
Too many slides e.g. use one slide per minute (rule of thumb).
Unnecessary information on the slides (e.g. logos, names, numbers). No need to give full
references for example, just enough to allow the listener to look up the reference on
pubmed afterwards.
Misspelling and too many typefaces.
The use of green, red or other difficult to read colours for text.
Insufficient contrast between background and text.
Too many visual effects. These make the file large and hard to carry on a 'memory stick'
and the lecture venue may not have the software to 'play' videos etc.
Useful information about how to deliver a lecture can also be found in
NOTE
T HINK
How much do people remember from several activities?
Although no more than a rule of thumb, the National Training Laboratories, Virginia
USA say (as a percentage)
about how you learn from teaching your trainees. If teaching is such an excellent way to learn,
what does it mean for teaching? Can you think of ways to turn your trainees into teachers?
Small group teaching
Small group teaching may take different forms, for instance workshops and discussion groups. It has
some advantages over lecturing in that it actively involves learners. Well organised small group
teaching
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Allows learners to develop generic skills like problem-solving, interpersonal, presentational
and communication skills
Allows learners to question and challenge assumptions and to develop deeper
understanding of a topic through discussion. A deeper understanding will facilitate the
application of what is learned in the future and in new situations
Allows learners to develop skills and attitudes for team work
Requires active involvement which tends to stimulate motivation and a positive attitude
towards what is learned
The key to successful learning in a small group lies with the teacher.
Describe two major roles of a teacher in small group teaching.
You can read more about small group teaching techniques and the role of the teacher in
Practical skills teaching
The traditional approach of learning psychomotor skills by practising on patients has
obvious drawbacks, especially with novice learners. Today, patient safety requires skills
training off the job as much as possible, e.g. in so-called skills centres. Here students,
residents and specialists can be trained in new skills using (dead) animals, manikins,
simulators, virtual technology and standardised patients.
Most skills training is based on several stages including demonstration, explanation, and
practise with feedback.
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Expert demonstration of the skill can be done live by a trainer or virtually, and is
necessary to provide the novice with a picture of the different elements as well as
the whole event
To understand the skill, trainees need an explanation of what they see: why is it
done this way? Should it always be done this way or may (part of) the skill be
done in another way? In what cases? What are risks of changing (part of) the
activities?
Next, trainees need to practise the specific psychomotor skills. Sometimes a skill
needs to be subdivided if it is complex
When practising, trainees need feedback to inform them about their progress
In the end an integrated, fluent application is required: automation is reached by
sufficient practice.

A teaching model, very well appreciated by surgical skills training, is the so-called four-stage
model
Stage 1 Demonstration: instructors demonstrate the skill
Stage 2 Verbalisation: instructors demonstrate the skill and explain what they are doing
Stage 3 Formulation: instructors perform the skill while learners tell them what to do
Stage 4 Practice: learners perform the skills and say what they are doing.
Here, you can see a video of the ATLS fourstage model.
The four-stage model mainly focuses on acquiring a specific skill and therefore on the first
phase of skill learning. It does not include repeated practice and feedback. The explanation
is focused on the activity and not so much on understanding the background and context.
Other teaching models may vary in specifying stages, in providing extra steps, or repeating
earlier stages. In practice, you may vary the model because of your trainees' level of
competence, their speed of learning and what skills you want your trainees to acquire.
When you think of learning to perform an operation, a whole range of skills may be involved
that can be learned separately, but need to become a whole in the end.
Although skills training usually starts in isolation from clinical practice, it should
be followed by guided practice in real life. In real life, inform your trainees
beforehand which part they are expected to do, so that you don't need to
interrupt unexpectedly, leaving your trainees wondering what they did wrong.
Simulation
Simulation and virtual reality are becoming widely established and have the advantage of
offering learner-centred education, away from clinical responsibilities at any convenient
time.
High-fidelity simulation can accurately recreate the conditions of an ICU and generate a
high degree of realism. Crisis management, team working and communication can be
taught alongside skills and procedures.
The most important features of high-fidelity simulations are
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Feedback is provided during the learning experience
Learners can practise repeatedly
The simulator is integrated into the curriculum
There are increasing levels of difficulty for learners to practise
The simulator is adaptable to multiple learning strategies
The simulator can represent a wide variety of patient problems.

At present, high-fidelity simulations are being developed using the Patient Challenges from
the PACT modules. These simulations are being developed by the SAINT (Simulation
Applied to Intensive Care Medicine and Nurse Training) group within the ESICM.
A video of a simulation and the debriefing is currently under development
Dealing with difficult situations
What if your audience is more experienced than you?
This may seem quite threatening. Two points to think about. Firstly: who is your target
audience? In reality, only a few people in the audience may be more skilled or specialised.
When you are asked to teach, your target audience does not consist of the more
experienced and more educated colleagues. Think of the learning goals you have set for
your lecture or group work. These goals are meant for your trainees, and they rightfully
expect you to be oriented towards them. A lecture, explanation, assignment or whatever you
prepare should not be filled with specialised details. They would only distract and confuse
your audience. So, maintain your message.
Secondly, if some people in the audience know more than you do, use them. Ask if they can
describe examples from their rich experience. When you get a difficult question, ask them to
help you. Recognise their contribution. Show that you are happy with their help. There is
nothing wrong with not knowing everything. If, however, experts get carried away with their
superb specialised knowledge, you may have to remind them to keep the target audience in
mind! Finally, of course it is always important to be well prepared for your teaching.
3/ HOW TO ASSESS CLINICAL COMPETENCE
A NECDOTE
A trainee in intensive care medicine was very skilled in performing tasks, but when
observing him it was noticed that he often forgot to communicate with other staff. Also,
it was said that this trainee made several near-mistakes. The supervisor decided to
have a talk with him. She mentioned the near-mistakes and suggested he go to a
training course to practise the relevant skills. The trainee objected and denied what the
supervisor had been told.
This anecdote illustrates one important goal in assessing trainees; that is identifying the
'trainee in difficulty' and the reason for difficulty. For most trainees however, assessment will
(or should) be an opportunity for personal development and be relatively non-threatening
and positive.
Assessment of clinical competence is not easy. Competent clinical performance includes
many aspects such as interpersonal and management skills that go beyond the medical
knowledge or technical skills that are traditionally the focus of assessment. Also,
assessment needs to come as close as possible to measuring authentic performance in
practice. However, the responsible clinical teacher is not always around to observe trainees'
performance. In recent years, assessment methods have been developed to include
performance in practice, to involve others in assessment, and to combine different forms of
assessment as inputs for overall assessment.
The five w-questions about assessing clinical competence are discussed below: why, when,
what, who, what ways?
Why do you assess clinical competence?
Formative assessment
You may want to do formative assessments of your trainees' clinical competence, directed
at giving feedback. In that case your goal is to stimulate your trainees' learning. You want to
be as precise and concrete as possible about good and weak parts in their performance.
Make sure that trainees understand clearly what parts need improvement, why and how.
But don't forget to be explicit about their good performance as well. Recognition of good
performance is important to ensure they continue this good performance (reinforcement)!
Formative versus summative assessment
You may want to do summative assessments of clinical competence, directed at taking
decisions about your trainees position in the training programme. Are the trainees ready to
proceed to the next stage? Have they acquired all necessary competencies to be a more
senior colleague? A decision to pass or fail has serious consequences and must therefore
be based on adequate (valid and reliable) assessments.
Too often only summative assessment is done in an explicit way. However, formative
assessment provides an important educational tool: 'assessment drives learning'.
The quality of summative assessment may also improve when you pay more attention to
formative assessment, resulting in you being better informed about trainees' progress.
Identifying poor performance is an important goal of both formative and summative
assessment. In formative assessment you still have the opportunity to give extra attention to
a trainee in difficulty.
When you document your formative and summative assessments in trainees' portfolios, you
stand on firm ground if you have to take negative or positive decisions about the trainees'
progress. (See also the portfolio section ).
When do you assess clinical competence?
Formative, informal assessment should be done quite often in various situations.
Possibilities include immediately after patient discussions, debriefings, clinical rounds,
presentations. Keep the assessment short, don't try to be complete, address only one or two
points at a time.
T HINK
of possibilities in your situation to give feedback, and turn this into a good clinical
teaching habit.
For trainees, organise appointments with them at least twice a year, to discuss their
progress in a more comprehensive and formalised way, but still with the formative goal of
providing feedback.
Summative assessments take place whenever a formal decision needs to be taken about a
trainee's progress in the training programme: entering the next stage, completing the
programme, or stopping because of inadequate results. In a well-structured training
programme it should be clear when, about what, and with what consequences summative
assessments will be made e.g. once a year.
Analyse your training programme and identify when formative and summative
assessments take place. Are these sufficient? Are trainees well informed about
the assessments? Is the trainer sufficiently well informed to make decisions
concerning the trainees?
What do you assess?
The attributes required of a physician are numerous and no single test can distinguish
between a 'bad' or a 'good' physician. Attributes include generic skills and attitudes, such as
communication and team-working, as well as specialised knowledge and skills relevant to
each specialty. Assessment increasingly focuses on actual performance and therefore on
the competencies of a trainee.
There are several models that describe these competencies. For training in intensive care
medicine, a competency-based programme is described within the CoBaTrICE project
(see
) and this forms the basis for the assessment.
In 1990, Miller devised his pyramid to illustrate the shortcomings of assessment in medical
education (see illustration on the next screen). Knowledge assessment is at the base of his
pyramid, not because it is most important, but because it is done the most: in written or oral
form we test what the student knows. Skills assessment is the next step of his pyramid:
students 'show how', e.g. in skills stations. This type of assessment is done quite a lot, but
less often than knowledge testing. Trainees' performance in clinical practice is not assessed
very often or adequately. And we hardly ever assess the top of the pyramid: the actual
performance of responsible physicians.
Miller's message was that we need far more assessment as we get higher up the pyramid.
As a consequence, the pyramid should become more like a chest of equally filled drawers.
By 2006, more ways of assessing clinical performance have been developed, although
more development and implementation are still needed.
Miller's Pyramid,
illustrating shortcomings in
the assessment of clinical
skills, with overlaid 'chest
of drawers'
Who is assessing?
The clinical teacher may not be the only person who does the assessment. Of course the
principal clinical teacher is responsible for assessments taking place, and has the final
responsibility for summative assessments. Other people that are or can be involved are
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NOTE
Staff members of several departments (assessing parts of the programme)
The trainees themselves (reflective self-assessment reports)
Peers (when they have been working together or at least been able to observe
each other)
Paramedical and allied healthcare professionals (e.g. nurses, paramedics,
physiotherapists, nurse practitioners, physician assistants)
Patient evaluations (specific aspects of trainees' performance).
Self- and peer assessment are important ways to prepare for lifelong learning
and to involve new physicians in team-learning.
Gathering information from different sources is called multi source or 360 degree
feedback. The different perspectives give special value to this information. Peers, other
healthcare professionals, and patients may note different things to the staff. A positive as
well as a negative assessment is made stronger when different sources are in agreement.
When sources are not in agreement it is important to find out what causes the differences in
evaluation, especially before it is used in a summative way.
It may happen that the assessment by different sources conflicts with trainees' selfassessment. You may find those who overestimate and those who underestimate
themselves. In the first case you will need a firmer approach to make sure trainees
understand and accept the assessments, and are prepared to work on improvement. When
trainees underestimate themselves, you also need to make sure they understand and
accept the assessments – in this case so that they will be ready to move on to a next level
of competency with more self-confidence.
What ways of assessment do you use?
There is no one perfect way of assessing a trainee's competence and performance. You
need a mix of different methods and sources to arrive at an adequate assessment, just like
you use quantitative and qualitative information from different sources when you are
evaluating a patient's condition.
Methods of assessment off the job include ways to assess knowledge, such as
standardised oral exams, written and internet-based exams (multiple-choice questions like
the European Diploma in Intensive Care (EDIC) exam), and ways to assess technical or
communication and interpersonal skills, such as the Standardised Patient Examination
(SPE) or OSCEs (Objective Structured Clinical Examination).
Other methods are more appropriate to assess performance on the job, where knowledge,
skills and attitudes need to be integrated into behaviour. Such methods are usually based
on observation of performance in practice. It is useful to base assessment on repeated
observation of different situations by different observers, to make the assessment
more valid and reliable. (See below). Possible methods include the Mini-CEX (Clinical
Examination), patient presentation evaluation, short questionnaires (for multi source
feedback), critical appraisal of a topic (CAT), Objective Structured Assessment of Technical
skills (OSAT) and logbooks.
What would test medical competence better: open-ended questions or multiple-choice
questions? Give arguments.
Whatever instruments you choose for assessing trainees, they always should be valid,
reliable, feasible, provide feedback, and detect poor performance in time:
Validity Does the assessment measure what it purports to measure (content validity)? Do
the assessment tasks predict future performance accurately (predictive validity)?
Reliability If an assessment is repeated with the same trainees, they should get the same
results. Results should not be due to accidental circumstances or coincidence.
Feasibility Can the assessments be undertaken within time and staff constraints?
Assessments should fit well with the training programme and the working day.
Feedback Does the assessment encourage learning? Does the assessment help the
trainee identify strengths and weaknesses? There are strong positive links between
assessment, good feedback and further learning.
Early warning Does the assessment system detect poor performance early? Poor
performance may trigger closer supervision and further assessment or raise questions
about the training environment.
Portfolio and personal learning plans
A portfolio is a collection of evidence which, when taken together, demonstrates
competence and expertise. In addition to the formal acquisition of competencies which form
the core of the CoBaTrICE programme, there are many other aspects of clinical practice
and professional development which can be included, such as research and audit activities,
teaching received or delivered, courses attended, work-place based assessments, case
summaries, log books, personal reflections or letters from patients and relatives.
CoBaTrICE has produced the CoBaFolio template as a means of enabling trainees to
collate evidence of competence. The trainee is the owner of the portfolio.
You may ask your trainees to write a personal learning plan. Such plans can be made to
cover parts of the programme (module, placement). The trainee describes 1) learning
needs, 2) learning activities, and 3) evidence of learning that will be put into the portfolio.
You discuss and agree on the plan with your trainee. This learning agreement is part of the
portfolio.
A portfolio is also a suitable way to organise your assessment programme (overall formative
and summative assessments). Trainees are asked to write self-evaluation reports, in which
they summarise the results of the various assessments and reflect on these assessment
data. Formative discussions with your trainees result in plans for learning in the period
ahead. You agree on what activities they will undertake and what assessments will be
carried out. For summative purposes, you evaluate the data and self-evaluation in order to
make your decision.
For examples of a portfolio, learning agreement and personal learning plan for trainees in
intensive care medicine, see
Why do you think it is important to ask your trainee to write a self-evaluation and discuss this with
you?
Finally, when evaluating trainees, it is very important to have clear criteria. Make sure you
discuss your criteria regularly with colleagues and other staff who are taking part in the
assessment. It is very common for different clinical teachers and staff members to have
different ideas about what is inadequate, sufficient, or excellent. Formulating criteria can
best be done for stages (e.g. years) in the training programme, so that you assess trainees
according to what you expect at a certain stage of the programme. It is important to make
the evaluation criteria as explicit as possible to your trainees. When they know what you
look for, they know what they need to learn. Assessment drives learning!
What measures can you take to make the assessment within your department as valid and
reliable as possible?
Useful websites on
assessment http://cte.umdnj.edu/student_evaluation/evaluation_clinical_tools.cfm
http://www.urmc.rochester.edu/smd/stdnt/handbook/AppA.pdf
http://www.acgme.org/outcome [Assessment, Table of methods]
http://www.comsep.org/Curriculum/StrategiesAssessment/SectionC.htm
http://www.medicine.ufl.edu/3rd_year_clerkship/evaluation_grades.asp
Dealing with difficult assessment situations
What can you expect from trainees?
When a new trainee starts, you need to ascertain their level of competency. You need to
discuss this issue with your trainee and you may find a portfolio helpful in this discussion.
(See Task 3
). Take time to get to know your trainee, and to keep in touch with their
competency development. It is the basis for your responsibility as a teacher/supervisor.
What if your trainee lacks motivation?
When a trainee seems to lack motivation, do not react judgmentally. Find out why. Maybe
the trainee is just not such an extrovert as you'd expected? If motivation is indeed lacking, is
it temporary? What is the cause? Problems at home (partner, children, a move to a new
house)? Or is the trainee disappointed about the work? Are long hours exhausting your
trainee? Do they have doubts about their own abilities? Are they questioning the career
choice? Discussing the problem, recognising the difficult situation, and giving the trainee
some space to find solutions, may be enough to help the trainee back on track. If your
trainee has really lost motivation for intensive care medicine altogether, the best thing to do
may be to offer encouragement to think about an alternative.
There is no time for observation and feedback
Clinical teachers often complain about the time it takes to observe trainees and give them
feedback. And of course it is difficult to build in time for this in a very busy practice. Here are
some suggestions for finding ways to incorporate observation and feedback
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Discuss with colleagues and trainees opportunities within the daily practice
where observation and feedback can be easily incorporated
Plan moments for observation
It is not necessary to have very long observations. Often short observations (e.g.
five minutes) can give you enough information for feedback. It is more helpful to
give a little feedback rather than too much
Feedback at the end of a round, a morning report or case presentation doesn't
cost observation time
Convince staff and trainees of the importance of these observations and
feedback
Use any available time together with your trainees (e.g. when walking through
the hall, while washing hands, taking off gloves) to ask questions, to listen, to
recall events and give feedback.
What to do with a trainee in difficulty
Characteristics of a trainee in difficulty may include reluctance to ask for help, poor
communication skills, lack of responsibility, frustration and anger, a disregard for
punctuality, or a failure to see that there is a problem. The underlying causes of difficulty
may be related to personal, environmental or adaptive factors.
During routine practice, incidents that give cause for concern about a trainee
can be considered as early warning signs.
To identify a trainee in difficulty and remediable causes, key questions to ask include
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Is this an isolated incident or is a trend/repetition evident?
Does the trainee have the insight to recognise the problem?
Can the incident be turned into a learning opportunity?
What questions does the case raise about the learning environment?
Do other colleagues have same experiences?
What can you do?
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Focus on patients' as well as the trainee's safety
Ensure the trainee knows how, when and who to call for help
Discuss the event with the trainee and reflect on how to handle such an event in
the future
Make this incident a learning opportunity
Communicate clearly with the trainee and document this carefully
Increase formal and informal monitoring, supervision and review of the trainee
and the learning environment.
4/ HOW TO PLAN FOR LEARNING
The curriculum
Today, the definition of a curriculum includes all the planned learning
experiences of a school, educational institution or postgraduate
specialty training: what should be learned (content), how it should be
learned (teaching and learning strategies), how it should be assessed
(assessment process) and how the whole is evaluated.
Curriculum has its roots in the
Latin word for track or race
course. From there it came to
mean course of study or
syllabus
Postgraduate specialist education is built on top of a long
undergraduate medical education and in some countries an
additional internship. Postgraduate training is primarily work-based
and the learning environment is not a teaching environment but a
highly complex and busy work-based system whose primary role is
providing a service to patients.
Internationally, professional bodies are increasingly responding to
society's needs and various models specify the roles of future
physicians and the expected learning outcomes. In essence, these
models are quite similar (see Ringsted reference, below).
Some models which have been described are the outcome-based
model, the seven roles of the CanMEDS model, the six general
competencies used in the USA and (in the UK) the 12 generic
aspects of the role as a consultant.
Competency-based curriculum
In developing a training programme for medical education, the competency approach has
become prominent at most stages of undergraduate and postgraduate medical training in
many countries.
Competencies are the ability to adequately carry out a professional activity in a specific
authentic context by integrating knowledge, skills and attitudes. Competencies are not
directly visible or measurable, but are demonstrated when performing tasks.
Competencies for the intensive care physician are defined within the CoBaTrICE project.
They define the minimum standard of knowledge, skills and attitudes required for a
physician to be identified as a specialist in intensive care medicine. They have been
developed with the intention of being internationally applicable but able to accommodate
national practices and local constraints. They comprise 102 competence statements
grouped into 12 domains.
Developing a curriculum
For specialty training, this is a complex and time consuming activity. Only a few of
you will be involved in such a task, but most of you will be confronted with the
outcome – the curriculum itself – either as a trainee, a trainer or supervisor.
An excellent summary of the elements of a curriculum is as follows.
A curriculum description
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Profile of the specialist
What kind of work? What is essential? What are future developments:
threats and opportunities?
Competencies
What should trainees be able to do by the end of the programme? This,
of course, is closely related to the profile of the specialist.
Learning goals/objectives Based on what a specialist does during his
work, what knowledge, skills and attitudes do trainees need to acquire
the desired competencies?
Philosophy on teaching, learning and assessment
How do trainees learn, what are the goals of assessment, is it based on
educational theory?
Structure
How is the programme built up, e.g., training periods, what is the order
of learning goals, what is mandatory, what is elective, one or more
hospitals?
Assessment programme
How are trainees assessed? What methods are used, etc?
Teaching formats
How is practice used for learning? What is the format for training
courses, skills teaching and simulations? How many, when etc?
Quality care
How is the programme evaluated? How is quality improvement
addressed?
How is your own training programme built up? Are all elements described? How
is it evaluated? Do you see things that can be improved? How do you
communicate this?
Creating a stimulating learning environment
In addition to being an environment in which excellence in patient care is the
foundation for learning, the intensive care environment should be an intensivistdirected, collaborative multi-professional team model of patient-centred care for all
ICU patients. This environment includes
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Strong dedicated physician and nursing leadership committed to quality
process, care and practice improvement
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All ICU personnel share a common vision regarding delivery of care
and clinical practice improvement that is focused on what is best for the
patient
Evidence-based protocols, clinical practice guidelines and standards
are routinely used and regularly reviewed to optimise patient care
Processes and outcomes are routinely measured to continuously
monitor the quality of care
Physicians, nurses, clinical pharmacists, therapists and others
collaborate as colleagues both in the care of patients and in the
practice improvement process
Dialogues around the best way to care for patients and current protocol
issues are common encounters, and challenges to process of care are
welcomed and respected
A process for practice improvement, in which problems are recognised
and dealt with at the front line by all members of the multi-professional
team, is emphasised and easily identified
Patients, families, and surrogate decision makers are kept well
informed about care plans, alternatives, and responses to therapy, and
their values are solicited and incorporated into the care plans.
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Level of expertise and supervision
During a training programme, trainees will acquire the competencies in a certain
order. Some competencies will be acquired early in specialist training at a level of
independent practice, other competencies will or can only be reached at the end
of the whole training programme. Unless otherwise indicated, by the end of
specialist training, competencies should be performed at a level of independent
practice (this may include the capacity to supervise others or direct a team) with
indirect supervision provided by a trainer. For intensive care training, three levels
of practice are distinguished within the CoBaTrICE project. These indicate the
minimum standard, and in many instances a higher level of expertise (i.e. a lower
level of supervision) is required. See figure 2 in the reference below.
Developing a course
Much of the teaching outside daily practice takes place in (short) courses,
distance-learning programmes, skills training and simulation programmes.
Short courses
Short courses are commonly used by physicians to stay up-to-date and acquire
new knowledge and skills. Not all courses lead to the desired change. In order to
make courses as effective as possible the 12 tips of Lockyer et al. can be very
useful.
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Assess the clinical problem
What course is really needed within the target group? Who says so?
Are they also committed to make changed performance possible in
practice?
Determine learning outcomes
Formulate learning outcomes or end points to be achieved by the
learners. Define outcomes in specific goals and as competencies.

Use evidence-based medicine to develop content
Better outcomes can be achieved when educational programmes are
based on evidence of clinical effectiveness.
 Identify resources
Think of the teachers needed, space, materials, etc.
 Select teaching strategies for active learning
The teaching strategy depends on the learning goals, the content, the
participants and resources. Use a variety of strategies. Keep in mind
the principles of how professionals learn.
 Select teaching strategies that facilitate reflection
Reflection is essential for learning by professionals. It can lead to new
understanding, synthesis of old and new insights, finding of new
solutions etc.
 Create an individual needs assessment or pre-course
assessment
Let participants think in some way about their personal knowledge,
skills behaviour, attitudes in relation to the course goals. This can
stimulate their motivation to come and learn.
 Prepare teachers
This is a crucial element for successful courses. A committed team of
teachers that want to realise shared goals is maybe as important as
the content of the course.
 Commitment to change
Let participants think or formulate intentions for their own practice.
What are you going to do with what you have learned next week or
month? Let them think about what and/or who can help them and what
or who can hinder them?
 Provide post course reflection
Ask participants, after a sufficient period, to reflect on what they have
done so far with what they have learned during the course.
 Use evaluation data to improve your course
Learn from what participants formulate at the end of a course, the post
course evaluation and what they have done with the course content.
All this information can give you clues for the further improvement of
your course. Discuss this information with the teacher team.
Distance-learning programmes
Distance education, including PACT, is playing an increasing role in medical
education, particularly in postgraduate training and continuing professional
development.
Developing distance-learning programmes is time consuming and requires
additional skills to those required for writing book chapters or journal articles. For
the PACT programme, the editing team provided the authors with a short
introduction to the educational strategies to be adopted, the template for the
design of the programme and the educational format.
In designing a distance-learning programme, the following key areas need to be
addressed
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Educational need of the learners
Design of the materials
Support mechanisms for learners.
When developing a distance-learning programme, the so-called 'CRISIS' criteria
(Convenience, Relevance, Individualisation, Self-assessment, Interest,
Speculation and Systematic approach) can be of value. The initial criteria allow
the programme to grab the reader's attention and be functional; the latter allow
self-assessment and provoke reflection.
This meets the principles of adult learning which are characterised as needing
meaning and relevance, clear goals and objectives and the active involvement of
the participant but with a capacity for feedback and reflection.
5/ EVALUATION AND RESEARCH
Without evaluation, it will be difficult to make changes to improve the quality of
any programme. Because quality of care is related to the quality of education, we
need to be informed about the quality of our educational programmes. But what
is a good educational programme?
Classifying learning outcomes
To classify and analyse outcomes of any educational intervention, the modified
Kirkpatrick model of educational outcomes is very useful. The model describes
four levels of outcome
Level 1 Learners' reactions to the educational experience (satisfaction)
Level 2 Learning – which refers to change in attitudes, knowledge and skills
Level 3 Behaviour – which refers to changes in practice and the application of
learning into practice
Level 4 Results – which refer to change at the level of the system, the
organisational practice of learners or improved outcomes for patients.
Very often, evaluations focus on the first level. The level 2 evaluation is strongly
related to the assessment of trainees after courses etc. The level 3 evaluation is
becoming more frequent due to changes in the assessment of trainees as direct
observation and assessment becomes a more regular part of the assessment
programme. Level 4 evaluation would be ideal but is very difficult or even
impossible to measure because many factors will influence patient safety.
The quality circle
Educational experiences can be evaluated using a set of audit principles called
the quality circle. This is well illustrated in the PACT module on Quality
assurance and cost-effectiveness
Planning an evaluation
As in the assessment of trainees (see Task 3
) one can ask the same
questions when evaluating an educational programme, course, curriculum, or
workshop.
Why and When? The only certainty about any course or curriculum is that to
maintain relevance, it has to evolve with experience. To obtain appropriate
information and to act on it, participants at all management levels must accept
evaluation. Evaluation should take place before, during and after the programme.
Always ask yourself why you want to know certain information and at what
moment you need it.
What and Who? The entire design, piloting and implementation of a training
programme may be evaluated. Always ask yourself what you can or will do with
the outcomes? Can it lead to actions? Who is evaluated or evaluating depends
on why you evaluate, what you want to know, when you evaluate and what
instruments you choose. Make sure you ask the right group for the right
information.
What methods? Always ask yourself what method(s) is/are most efficient and
effective in terms of time, money and acceptance.
There are a number of available instruments to evaluate the learning
environment, the quality of the teacher and the quality of an educational
programme. The methods for evaluating the different elements of a curriculum
are shown below.
Educational Programme Methods of evaluation
Find out in your own department how education is evaluated? Are there any
questionnaires? How do results lead to actions and further improvements?
Information about some instruments to evaluate clinical education and clinical
teachers can be found in
Faculty development
The quality of every educational programme will depend on the quality of the
teachers and the healthcare system. Physicians are well prepared for their
clinician roles, but few are trained for their teaching role.
Faculty development can help provide clinicians with new knowledge and skills
about teaching and learning. This is becoming increasingly important.
A good overview is given in
Educational research
There is increasing activity in the field of research in medical education. Greater
numbers of physicians are involved in educational research in some way. For
physicians, sometimes this can be difficult in the beginning, especially with
respect to gathering data. In medical research, quantitative research is
predominant, whereas educational research is often based on qualitative
methods. In the past, qualitative research methods (in medical education) were
often regarded as subjective, not valid or unreliable. However, these views are
changing (see reference).
For those interested in medical education research, there is a good deal of
available information. A useful starting point and website (Best Evidence in
Medical Education) is
The number of research articles and medical education journals is steadily
growing. Below are details of the variety of resources available.
Medical education http://www.mededuc.com
Medical Teacher http://www.medicalteacher.org
Clinical teacher http://www.theclinicalteacher.com
Evaluations of the Health profession http://intl-ehp.sagepub.com
Academic medicine http://www.academicmedicine.ac.uk
Teaching and learning in medicine http://www.siumed.edu/tlm/
Advances in health science
education http://www.ovid.com/site/catalog/Journal/1430.jsp?top=2&mid=3&botto
m=7&subsection=12
There are a variety of articles published in the British Medical Journal on medical
education.http://journals.bmj.com
Interesting organisations for medical education are:
AMEE: Association of Medical Education in Europe: http://www.amee.org
ASME: Association of Schools of Medical Education: http://www.asme.org
International conferences on medical education that are of interest to clinical
teachers are:
AMEE conference: http://www.amee.org
Ottawa conference: http://www.asme.org
RIME conference: http://www.aamc.org
The ESICM's international congress on intensive care has an increasing number
of presentations on education and educational research. Also 'train the trainer'
programmes are incorporated in the programme.
CONCLUSION
There is growing interest in education and learning within medical education and
specialist training. Increasing numbers of physicians want to be involved in
developing new educational and assessment methods. Changes in society have
contributed to this growing interest. Firstly, patients' growing awareness about
quality of care makes them reluctant to be 'guinea pigs' for students and
residents. Secondly, the reduction in working hours has led to a reduced training
period and some employers resent training time being included within the
working day.
New techniques such as high-fidelity simulation and virtual reality give us new
opportunities to train our future physicians. To help clinical teachers to improve
their teaching skills, faculty development programmes are offered in many
hospitals and medical schools. In order to gather new insights into the way
physicians learn, it is important to conduct research in the field of education.
It is the collaboration of educationalists, clinical teachers and scientists that can
create new knowledge and insights leading to improvements in patient care!
PATIENT CHALLENGES
Two months ago, you started on the intensive care unit training programme
in the ICU of a large teaching hospital. Previously you had worked for 12
months in a regional ICU and prior to that had spent three years in internal
medicine. Before you joined this ICU, you had heard from colleagues that the
ICU staff were interested in education and devoted significant time to training and
supervising their trainees.
It is Wednesday afternoon and the Director of Intensive Care (your supervisor of
training) asks you to supervise a medical student for a month. The student is in
his last year of his undergraduate course and has chosen a one-month elective
clerkship in intensive care medicine. He will start next week.
The Director tells you that this is her first request for a clerkship since she started
in post. Her predecessor had preferred an informal approach to training so there
is no existing programme for you to work to. You are keen to supervise the
student but you realise there will be time implications. When you mention that
others will need to take over some of the clinical tasks, you are told that there are
no extra resources for this training. Despite this, you accept the job and agree to
develop a programme for this student. You enthusiastically start thinking about a
possible programme.
Learning issues
Teaching in the clinical setting
Developing a learning programme
N OTE
In some jurisdictions / medical schools, medical students are not permitted to undertake
patient procedures for reasons such as insurance, liability etc. This may have a bearing on
what the student might achieve.
What do you first want to know before developing a programme for this student?
Learning issues
Learning goals
Learning in a clinical setting
Assessing students
The student is at the end of his undergraduate training and has successfully
completed all other mandatory clerkships. The goal of this ICU clerkship is to
experience working at the level of a newly-qualified physician and to deal with the
associated responsibilities.
The student has explained in a letter that he has always had an interest in
intensive care medicine and that he wants to find out if he would like to become
an intensivist.
How do you perceive your role as a teacher in this clinical setting and how do you relate this to
learning in a clinical environment?
Learning issues
Providing feedback
Observation and feedback (1)
Observation and feedback (2)
You have devised a programme for this student. During the first week, you think
he will learn most when shadowing and observing you while you are working.
During the second week, the student will have the opportunity to provide some
patient care while you are observing him. If you think he is competent enough,
you will give him two patients to take care of while you are supervising him during
the final two weeks.
You have received the assessment form from the Medical Faculty Office to
complete at the end of the clerkship.
Learning issues
Supervision
Level of competence
Tools for assessment
When and how do you use the assessment form?
Learning issues
Learning goals
Formative assessment
Summative assessment
N OTE
Assessment and learning objectives are closely related.
The following Monday the student arrives at the ICU at 8.00 a.m. You introduce
him to the department and explain the programme. He is eager and wants to start
immediately. You explain that you want him to observe you and that you will ask
him questions about the patients to test his knowledge.
The first week is busy for the student and for you. He wants to know everything
and constantly asks you to explain what you are doing. Although it takes you
extra time, you like his enthusiasm. On Friday you want to prepare him for the
coming week.
Learning issues
Introduction
Planning teaching moments
How do you prepare your student for the coming week?
During the second week you observe your student while he is examining a
patient. In his eagerness to start examining the patient, the student forgets to use
the chlorhexidine hand-wash. You notice that he omits parts of the examination
and forgets to ask the nurses about their observations. He seems very pleased
with himself. You decide to give him feedback after you finish your round.
What are you going to tell him? How do you conduct your feedback session?
Learning issues
Providing feedback
Adapting feedback to individual learners
Multi source feedback
Throughout the rest of the week he is doing fine and other colleagues who have
provided him with guidance are positive. You have asked the nurses about his
communication with them and they tell you that he has greatly improved.
During the clerkship you plan to teach him how to place a peripheral i.v. catheter.
There is an excellent videotape about this skill which you could use.
Learning issues
PACT module on Communication skills
How can you teach him this skill? What instructions do you give the student? What other
measures do you take?
Learning issues
Skills teaching
Four-stage model
How do you conduct formative assessment?
Learning issues
Formative assessment
During the final week you plan the assessment of your student. You are thinking
of letting him run a simple scenario on the Human Patient Simulator. Fortunately,
they have a space available and also a scenario that is suitable for his level of
competence.
Learning issues
High-fidelity simulation training
How would you prepare him for running a scenario?
How do you set up the debriefing?
Learning issues
Providing feedback
During the scenario your student does well. You had selected a fairly
uncomplicated scenario and concentrated on topics that he had practised and/or
discussed during his clerkship. He is communicating very well with the nurse. He
scores well in this assessment. You keep in mind the five steps for providing
feedback when starting the debriefing.
You then ask the student to examine a patient who is being weaned from
ventilation and evaluate the factors holding up his progress. But the patient's
daughter objects to 'a student practising' on her father and wishes to speak to his
supervisor.
How should the student respond?
You, as supervisor, first apologise to the patient's daughter that you had not
adequately taken into account the patient's autonomy. In addition, given that the
patient was not in a position to interact with the student or the other ICU staff,
that you should have discussed the evaluation with her, as she was present and
supporting her father at the time.
Learning issues
PACT module on Ethics
You, as his supervisor, now ask the student to justify to the daughter his role in examining the
patient. How does he respond?
Learning issues
PACT module on Communication skills
The daughter asks the student how his examination of her father could possibly help. How does
he reply?
The last thing to do is the summative assessment. It means you have to
complete the assessment form you received from the Medical faculty.
Learning issues
Summative assessment
How will the assessment relate to the content of the course?
The day before the final assessment you speak to the rest of the team about their
impressions of the student. You ask the Director of Intensive Care, who initially
assigned you this task, whether she would like to become involved in the
summative assessment.
What is the advantage to requesting the Director's involvement?
Learning issues
Assessment validity
How do you organise the assessment?
Although this student passed successfully, the Director is concerned that there is
no formal evaluation of the clerkship itself. When she asks the student his opinion
about it, he is very complimentary about the organisation of the clerkship and
says that he has learned a great deal over the four weeks. He indicates he has
become very enthusiastic about intensive care medicine and is thinking about a
career within this specialty.
Following your discussions with the student, you start to think about the strengths
and weaknesses of the clerkship. You want to convey the key points to your own
supervisor of training to help inform the evolution of future clerkships.
What points do you list in your evaluation in terms of strengths and improvements?
Learning issues
Evaluation of education
On reflection, good clinical teaching and a good clinical environment
complement each other. Think of what the learner / participant gets to see, what
tasks he will perform and how the feedback is organised. Enthusiastic teachers
are extremely important both to the healthcare environment and to the quality of
the teaching. Clinical teaching is an integrated activity of the quality healthcare
team. The better the learning environment, the better young physicians are
motivated towards lifelong, quality patient care and indeed towards a career in
your specialty!
Q1. Factors that support effective supervision are
A. Personal friendship between supervisor and trainee
True
False
B. Trainee input into the format of the supervisory process
True
False
C. Sufficient time
True
False
D. Experience of the trainee
True
False
E. Supervisor's ability to provide adaptive feedback
True
False
A. Is solely dependent on relevant medical knowledge
True
False
B. Provides trainees with feedback during practice
True
False
C. Includes opportunities for observing the skills
True
False
D. Starts with practice on patients
True
False
E. Is realised by 'see one, do one, teach one'
True
False
Q2. Effective skills teaching
Q3. Validity of assessment of clinical competence is positively
affected by
A. Lack of pre-agreed assessment criteria between
examiners
True
False
B. Number of cases
True
False
C. Clear description of clinical competence
True
False
D. Training of the examiners
True
False
E. Assessment by the principal supervisor only
True
False
A. Happens when the clinical teacher tells the trainee to
observe him/her
True
False
B. Has always been the best way for trainees to learn
True
False
Q4. Learning from role modelling
C. Is the best way; even when models show wrong
behaviour, because trainees will decide to do it better
True
False
D. Is a very strong way of learning, with significant impact
True
False
E. Needs reflection and discussion
True
False
A. Can be realised best with assigned teaching
responsibilities
True
False
B. Should focus primarily on teaching opportunities outside
of the clinical area
True
False
C. Includes time to spend with house staff on teaching
matters
True
False
D. Has no secrets for the specialist who is academically most
knowledgeable
True
False
E. Is more effective if it is accorded seniority in the
organisation
True
False
Q5. The supervisor's role