Thank you for viewing this document.

We would like to remind you that this material is the property of the author. It is provided to you by the ERS for your personal use only, as submitted by the author. 2012 by the author
ERS Annual Congress Vienna
15 September 2012

Postgraduate Course 20 European spirometry train-the-trainer programme

Saturday, 1 September 2012 08:4517:30 Room: C8

Principles of teaching and learning in the clinical workplace

Dr. Jamiu O. Busari Dept of Educational Development and Research Faculty of Health Medicine and Life Sciences Maastricht The Netherlands j.busari@atriummc.nl Summary
The goal of teaching is to facilitate learning and to ensure that learners achieve the desired goals of the educational process i.e. knowledge and/or skill acquisition. For this reason, the process of designing instructional methods has become an increasingly important and valuable activity. This is because it involves the identification of the nature of learning that is intended to take place, the development of the approach to teaching that would facilitate learning, the selection of the instructional methods that would cause learning, as well as, the provision of some form of assessment that would reflect that the outcome of the intended learning has been achieved. When the emphasis of any teaching process is on the content of the subject and the one teaching it, the teaching is classified as teacher-centred and content-oriented. The teacher is the key person in this session and is concerned, primarily, with the transmission of information. When the focus of teaching is not about transmitting information or imparting knowledge, but about facilitating student learning, then the teaching is considered to be student-centred and learning-oriented. The adult learning model [1] actively illustrates the latter approach where the responsibility for learning is placed in the hand of the learners, who are exposed to situations or stimuli that rouses prior knowledge and experiences. This teaching process involves stimulating the learners to learn, through being dealt with respectfully and being acknowledged as adults. The passive role of the teachers in this process also motivates and induces the readiness to learn and equally acknowledges learners as adult learners. The purpose of any instructional method should therefore be to facilitate an effective balance between content oriented and learning oriented instruction. This balance is a sliding scale, where the responsibility for choosing the amount of instructional focus is shared between the instructor and the learner.

Instructional methods in postgraduate medical training

It was almost 50 years ago, that Bloom first suggested that learning the content of any concept could occur at many levels of expertise from simple recitation of information that we do not really understand to knowing information so well that we can list it, discuss it, analyse it, use it in a variety of situations and extrapolate it to other similar problems [2]. Hence, if we expect our learners to master the clinical material they are being taught and also use the information appropriately in the clinical setting, then we need to give them the opportunities to practice them, and not just expect them to know the facts about a topic. The instructional methods that are chosen to achieve this often depend on who is being taught, for example whether it is the novice learner, such as a third-year medical student or a group of learners with multiple levels of training experience e.g. from preclinical students to senior residents and fellows during grand rounds. The methods used to create meaningful learning experiences for multilevel learners can also differ from those used for a uniform group. For example, the learners in a uniform group are more likely to have similar backgrounds and experiences with the material to be presented, as opposed to the mixed group whose participants may range from students with no prior experience to fellows with vast experience, thus creating an extra challenge for instructors. Clinical instructors should therefore know that different instructional methods work better in particular circumstances such as the classroom or lecture hall, the inpatient setting, operating theatres and the ambulatory or outpatient clinic setting. With the increasing need for students to be taught at sites remote from the main campus, it is also important to be aware of the educational strategies used for distance learning.

29

Lastly, when deciding on which instructional method to use in any educational process, it is helpful to define what the specific learning outcomes of the curriculum would be. These specific learning outcomes otherwise called intended learning outcomes form the building blocks of any curriculum and the choice of the method to be used depends on what we want to teach the learner (content), whom we are teaching (learner), the level of competence prior to the educational encounter (prior or antecedent knowledge) and the level of competence expected to be achieved after the educational encounter (intended learning outcome).

Intended learning outcomes

Identifying the nature of the learning outcomes is a key aspect of the instructional design process. If the intended learning outcomes are not clearly identified, it is unlikely that worthwhile learning will occur. The aim of the instructional methods should therefore be to enable the learner to construct their own knowledge, building on existing knowledge bases, and finding relevance and meaning in the process. Relevance and meaning are found through trying to make connections between the ideas that are being encountered and the real world of the practice of medicine. Hence, it is important that the learning outcomes reflect the knowledge (cognitions), skills, attitudes and/or behaviours that should be learnt and that are relevant for clinical practice. These elements form the cornerstones of competency, which is the combination of these attributes with other resources and the willingness to use these - in the performance of a professional task [3]. Competencies arise from the areas of competence that can be identified in an analysis of the roles and functions of a doctor. Analysis of the areas of competence leads to identification of the specific competencies, and analysis of the competencies leads, in turn, to identification of the underpinning attributes i.e. knowledge, skills and attitudes and/or behaviour (see table 1.) When knowledge is being taught, a variety of methods can be employed with the ultimate goal of getting the learner to actively engage in learning the material. When skills are being taught on the other hand, it is important that important aspects of what should be learnt is demonstrated and/or pointed out and that the learners doing the skill are supervised or talked through the process Finally, when teaching attitudes and behaviours, it is essential that methods are used that require the application of the attitude or behaviour in context relevant situations. These concepts, as they occur in the clinical learning environment and in relation to the physicians professional roles, can therefore be described as: 1. The ideas and concepts that are expected to be learnt (Cognitions) 2. The ability to utilize the learnt ideas or concepts when faced with a problem in practice (Cognitive skills) 3. The ability to exhibit certain behaviours that reflect specific desired attitudes or behaviours (Affective skills). 4. The physical or perceptual competencies trainees are expected to possess after the training. (Technical/Psychomotor-perceptual skills) In summary, the intended learning outcomes are in fact pre-defined measurable outcomes of the curriculum while the instructional methods are the instruments that are required to achieve these outcomes.

30

Table 1. Relationship between physician professional roles, attributes and competencies

Attributes DESIRED PROFESSIONAL ROLES OF Knowledge (i.e. Cognitions) (Areas of competence) Clinical Skills (i.e. Cognitive, Technical, Psychomotor perceptual skills) Attitudes & Behaviour (i.e. Cognitions, affective skills) Principles of Teaching and learning in the clinical workplace

Competency Scholar Medical expert Scholar Medical Expert Communicator Manager Professional Health advocate Communicator Collaborator Manager

During teaching and learning in complex learning environments e.g. the clinical workplace, it is important that the trainees have access to the relevant educational materials and clinical experiences that would facilitate their individual learning. In this context, educational materials refer to the various sources of basic medical and clinical knowledge (e.g. Textbooks, (digital) scientific journals, podcasts, etc.), the necessary medical instruments, apparatus and hospital infrastructure that is required for learning to take place. The clinical experience on the other hand, is the conceptual learning that occurs from engagement in the different learning activities as well as from the various interactions with the different instructors in the clinical workplace. In order to achieve the optimal clinical experience therefore, the instructors should be equipped with certain basic competencies, that include; 1. The knowledge of how to teach (i.e. didactic knowledge), 2. The knowledge of the general principles of education and 3. Proficiency in domain-specific knowledge/competencies. A lot of research has been conducted on how expert clinician educators apply their knowledge in clinical practice and in their teaching. These findings show that they regularly make use of compiled (encapsulated) knowledge in their thought processes [4]. These compiled forms of knowledge are called Illness scripts, and have been described as clinical scenarios associated with mental problemsolving strategies. Expert physicians apply these illness scripts in solving clinical problems and in there teachings. Generated after (previous) patient encounters, illness scripts are committed to memory and are retrieved when the expert physician is faced with similar clinical problems in new patients. The moment a patients problem fails to match the stored illness scripts, however, the expert clinical teacher switches to the conventional method of analytic reasoning to solve the problem. The way trainees (i.e. medical students and junior physicians) apply their knowledge in clinical practice is different because they are mostly novices and possess a sparse store of illness scripts compared to the expert physicians. As a large number of the trainees are in the initials stages of developing and cultivating their own networks of information, the learning process occurs predominantly through analytical reasoning that is associated with solving clinical problems. The different experiences, contexts and problem-solving strategies that the learners acquire in the process of developing these knowledge networks is what they subsequently store as their own easily retrievable illness scripts, similar to what the expert physicians utilize in clinical practice and teaching.

PHYSICIANS

31

Creating the conditions for learning in the clinical setting

In the process of designing an educational program, it is important to identify the nature of the desired learning outcome as well as the kind of teaching or instructional methods that would be used to achieve the learning outcomes. As mentioned earlier, instructional methods are the means or methods used to educate or teach material to learners. They are the vehicles for providing information and the required interactions that enhance the learning process. Furthermore, it is important that the context and the principles of teaching and learning are clearly understood in order to guarantee that the educational process itself is effective. A prerequisite for this however, is that the content of what has to be learnt (Syllabus) and how it would be taught and assessed (Curriculum) should be clearly defined.

Curriculum versus syllabus

The curriculum is the complete set of material (intended to be) taught in an educational system. It is prescriptive (as opposed to the descriptive syllabus), and is a guiding document that helps teachers to understand the standards that the learner needs to achieve at the end of a developmental stage. The curriculum document indicates what to teach, how it should be taught and whether the material is being taught as expected. The Curriculum is developed keeping in mind the standards students should achieve from well-researched best practices taking into consideration the objectives, the content, and methods chosen to achieve those objectives. It could/should also contain a consideration of the kind of assessment one will use to check progress. The syllabus on the other hand is the content i.e. the list of topics/concepts to be taught. Simply put, it is a focused outline and time line of a particular course. A syllabus typically gives a brief overview of the course objectives, course expectations, a list of reading assignments, homework deadlines, and exam dates. It is typically available on the first day of a college course, and a student is expected to know what is in the syllabus throughout the course. Its purpose is to allow the student to work their schedule for their own maximum efficiency and effectiveness. It helps to avoid conflicts with other courses, and it prevents someone from accusing a professor of unfairly adding assignments. Finally, while the curriculum prescribes the objectives of the system, the syllabus describes the means to achieve them.

Choice of instructional methods

The choice of which instructional method to use in educating trainees in the clinical workplace is not limited to the contents of curriculum alone, but also to the context of the environment where the Learning takes place and in some case the size of the group. The instructional method could be the use of the Learning environment itself e.g. the patients bedside and/or a specific teaching strategy e.g. case presentation. In medical education, the most important Learning environments include the classroom or lecture hall, inpatient setting, Ambulatory or outpatient clinical setting, and remote Learning environment other than from a location the clinical setting. Furthermore, the setting where learning occurs within the different clinical environments has an influence on the choice of instructional methods. An overview of the learning settings within the different clinical environments as well as the suitable instructional methods is provided below (table 2).

32

Table 2. Overview of different learning environments and associated instructional methods

Learning Environment Inpatient/Hospital Outpatient/Ambulatory clinic Setting Wards Operating theater Grand rounds Morning rounds Patient handover rounds Bedside teachings Outpatient clinics

Suitable instructional methods Strategy Lectures Direct observation of procedural skills (DOPS) Case presentations Peer-based Learning Active Learning systems e.g. simulators One minute-preceptor Direct observation of consultation skills Letters- feedback on letters/SAIL Self-Directed Learning Peer-based Learning E-Learning/ Computer assisted instruction Letters - feedback on letters/SAIL Lecture Audience response systems Team based Learning Case methods/case based discussions Clinical demonstrations Active Learning systems Size Small group teaching: Focused discussion Problem based Learning Student led seminars Role play

Remote/Distance learning

Videoconferencing e.g. Skype Virtual Learning environment

Classroom

Lecture rooms Symposium Workshop Conferences

33

Inpatient and outpatient learning environments Direct observation in clinical practice

Direct observation of trainees or students by supervisory medical staff is vital for the instruction (and valid assessment) of clinical skills. Studies have shown that direct observation provides authentic patient-centred teaching environment and improves history-taking and physical examination skills [5 7]. In addition, direct observations are inherent in several assessment strategies used to rate trainees performance in the clinical setting and therefore, play an important role in the evaluation of clinical skills. Medical educators consider direct observation to be an important method for ensuring clinical competency. This is evidenced for example, by the requirements of the Liaison Committee on Medical Education in the United States, that faculties should provide ongoing assessment that assures that students have acquired (and can demonstrate on direct observation) the core clinical skills, behaviours, and attitudes that have been specified in the institution's educational objectives [8]. Direct observations in practice as instructional methods can be used for both educative and evaluative purposes. Examples of instructional methods that fall into these categories include direct observation of procedural skills (DOPS), teaching at the Bedside/Wards, outpatient clinics and in the operating theatre environments. Many medical institutions have reported the use of performance ratings based on direct observations of students in the assessment of clinical skills [9], yet, despite their wide use, the validity and reliability of these ratings have been challenged [10, 11]. The "long case" [12] and the "miniclinical-evaluation exercise" (mini-CEX) [13] are examples of DOPS used for evaluative purposes.

Self-directed learning
Self-directed learning in the broadest sense, describes a process in which individuals take the initiative with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying resources for learning, choosing and implementing learning strategies and evaluating learning outcomes [14]. There is evidence in medical educational literature that shows that learners, who demonstrate more initiative in learning, learn more and better than their counterparts who engage in passive learning through lectures. This is because self-directed learning (SDL) is in tune with the natural processes of psychological development; an essential aspect of maturing that involves developing the ability to take increased responsibility for ones self and become increasingly selfdirected. Furthermore, the ongoing reform in (medical) education has resulted in the shift of the initiative and responsibility for learning into the hands of the learners (active learning). The ongoing challenges and reform in healthcare delivery systems also require that learners should possess lifelong learning skills i.e. the ability to analyse problems, define what needs to be learnt, know how and where to access information, evaluate information, and be aware of the one's own limitations [15].

Peer assisted learning

Peer assisted learning is the development of knowledge and skill through active help and support among status equals or matched companions [16]. It is a situation in which people from similar social groupings who are not professional teachers help each other to learn and learn themselves by teaching [17]. Trainee benefits associated with PAL, include better performance in assessment tests [18, 19] reduction in the subjective distress during learning and enhanced course satisfaction through the establishment of a reciprocal social support system [20]. The advantages of PAL have also been identified among peer tutors who have been shown to benefit significantly from such learning environments [21]. In particular, peer tutors appear to demonstrate significantly greater cognitive gains than their peer learner counterparts [22, 23].

Classroom learning environment

Many, if not all, clinical clerkships or fellowships contain didactic sessions that are distinct from the clinical teaching that happens at the bedside, in clinic, or on rounds. For the sake of clarity, the classroom teaching setting can be defined as one in which 15 or more students meet together in the same physical space with a single instructor.

34

The lecture
This is probably the most widely used type of formal instructional method. The lecture has been described as more or less, a continuous exposition by a speaker who wants his/her audience to learn something and its use is not restricted to formal educational settings alone, but also in arenas such as politics (speeches) and religion (sermons) [24]. Noting that lecture has its etymological roots in the Latin participle lectus (to read), it has been suggested that the academic lecture developed prior to the printing press as the only way that the knowledge stored in books could be transmitted to a large number of students. A lecture can be used to provide a broad-brush overview or introduction of a topic, particularly where the educational goal is for the learner to acquire a background familiarity with the subject, as opposed to a working knowledge. For learners who have a general knowledge of a topic, a lecture can provide an explication of the material, a cognitive framework for organizing the material, or a re-structuring of the material to make it more relevant to the situation at hand. Lectures are much less effective at changing attitudes, developing other learning skills (e.g. analysis, evaluation, teamwork, etc.) or helping learners apply knowledge to working situations.

Audience response systems

The audience response system (ARS) is a technology that can provide additional ways for the instructor and learners to interact during a presentation. ARS promotes attention to task, and possibly active learning, by requesting the learners to respond to questions embedded in the presentation. Typically conceptualized for use in large lecture settings (e.g. 100 or more) it has been used in a clerkship setting with far fewer students [25, 26]. ARS consists of an individual input device given to each audience member (e.g. proprietary keypads, PDA, or laptop software) that communicates an anonymous response (usually wirelessly) to a central lecture computer, which can quickly display the pooled results on the projected screen. The lecturer poses the question, the audience responds, and the results are promptly available for the lecturer and class to examine or discuss. Well-designed ARS questions can provide an immediate assessment of student learning, allowing the instructor to clarify points, modify a presentation as it is being given, and personalize it to the students at the time of lecture. It can also promote problem solving in class, extending a lecture beyond the simple providing of information.

Team-based learning
Team-Based Learning (TBL) is an educational method that bridges a large group (i.e. classroom) and small group approaches. Developed in the 1970s by Michaelson at the University of Oklahoma, it has spread into medical education since 2001 [2730]. TBL combines in-class activity with out-of-class preparation. A large class is divided into a number of student teams and preparatory homework assignments are given. The subsequent sessions, conducted with all the students in the large classroom, are highly structured and include the following components: individual and group quizzes that are immediately scored to foster accountability; discussion of quiz results; presenting a problem designed to be solved by the teams simultaneously during class; and subsequent open grading and discussion of the teams separate solutions. TBL is a method suitable for an entire course or multiple sessions within a course, and not to a single classroom experience. The educational goals can include the development of professionalism and teamwork competencies as well as problem solving and critical thinking that are much more difficult to achieve through the traditional lecture. TBL requires a skillful instructor as well as educating students about the method itself and how to perform the structured tasks.

Case method
The Case Method was developed at Harvard Business School in the 1970s by Barnes and Christensen, and it remains a widely used method today in business, law, and education [31]. However, it has not been widely adopted in medical education, as other instructional methods such as team-based and problem-based learning [32, 33]. The Case Method is predicated on the assumption that the real world is chaotic and that there are many variables that can be considered in managing real problems. The learners are given a complex task, the case, to work on outside of class. The case

35

is aligned with the learning objectives of the course and is usually designed such that there is more than one correct answer, and different reasonable approaches or solutions. Working outside of class, each person or team is expected to evaluate the case and research any necessary information. In the class session that follows, the facilitator comes prepared with questions that probe and challenge the reasoning and solutions engaging the learners to consider different conditions under which certain evaluation and management strategies might be used and when they might be inappropriate. The facilitator encourages the use of the knowledge each student has about the content to analyse, synthesize, critique, and build new conditional knowledge. At the end, the facilitator should consider some summary of what was learned from the session. The Case Method is notable for promoting critical thinking and discussion on topics about which reasonable persons can disagree. Case method teaching has been used very effectively to teach students topics in ethics and cultural competency and to discuss values and attitudes. It may be less successful at presenting information. The instructor must be a skilled discussion leader and come to the class prepared with questions that are designed to promote critical discussion of the issues raised by the case. The cases need to be sufficiently complex to allow for discussion and should address one or more learning goals. They should be as close to real situations as possible.

Demonstrations
Classroom demonstrations can be very valuable to teach and critique many skills and examine attitudes and values. Videotapes and pictures can show rashes, limps, murmurs, deformities, and intonation that cannot be described verbally. The shift in classroom dynamic draws the learners attention. The use of other senses increases what is remembered. Seeing a patient who describes and demonstrates his problem to the group enhances learning in ways that no words can ever do. Watching and critiquing a live interview can improve interviewing skills and mental flexibility.

Active learning systems

Many games and quizzes have become available for use in classroom settings. For example, Jeopardy, Name that Rash and others games are available as proprietary products and individuals have constructed similar games for use in the classroom. The learners are often separated into teams and competitions are held to see which team can answer the most questions correctly. These activities foster active learning and can interest and motivate students in areas that are not inherently interesting to them.

Small group teaching methods

Small group teaching is defined by the size of the group of learners (usually 6 to 10 participants), and the fact that the focus of the method is on active learning and communication between members of the group [34]. These sessions can occur in a conference room, an administrative or clinical office, or even at the bedside of a patient. It is important that the educational setting is large enough for everyone to be able to sit and make eye contact. Tutorials, seminars, and attending rounds are traditional models of small group instruction in the clerkships. Small group teaching has been described as being able to offer learners an opportunity to discuss and refine their understanding of complex issues, to problem solve and apply their knowledge to new situations, and to reflect on their attitudes and feelings [35]. This method also provides an opportunity for integration of domains such as professionalism, humanism, communication skills, and self-directed learning into the formal curriculum of the clinical years. Finally, small group teaching allows for much closer contact with faculty than the traditional lecture approach. Examples of categories of small group teaching methods include the focused discussion, problem-based learning, student-led seminars, and role-play [34].

Focused discussions
In focused discussions, a faculty member usually presents a case or a problem and then leads a discussion with the rest of the group. The cases used should be relevant to the learners antecedent knowledge, address defined learning objectives, and contain teaching points that can be applied to other situations [36]. Cases can be prepared in advance by the faculty member to capture real life

36

situations in which a professional (representing the students who are training to adopt similar professions) confronts a dilemma common to the discipline [37]. It is also possible for students to prepare their own cases following a memorable or relevant clerkship experience. The discussion is usually led by the faculty member, but can be assigned to the student. One can also consider using video clips, handouts, or study guides to stimulate discussion, reflection, and learning in the small group setting [35].

Problem-based learning (PBL)

This technique is similar to the focused, case-based discussions, but encourages increased learner independence. PBL traditionally has been used for teaching in the first 2 years of medical school, but can also be an effective teaching strategy in the clerkship years. As part of a small group (ideally 46 members), students are first presented with a clinical problem that unfolds over 2 to 3 sessions with progressive disclosure of historical information, physical exam, laboratory data, etc. Students define the facts, develop hypotheses based on these facts, and then develop their own learning objectives and plan for solving the clinical problem. At the beginning of each session, students self-assign their roles in the session, as Leader (moderator), Reader, Scribe, or Participant. These roles will rotate with subsequent sessions, ensuring maximum active participation from all members in the group. Learning objectives are researched between sessions by students and presented back to the group for discussion. This type of small group fosters self-directed learning and teamwork among participants. The faculty members role in PBL is to facilitate this process, rather than to direct and lead it.

Student-led Seminars
In these seminars, the student is charged with presenting a topic to the rest of the group. The nature of the topics is usually negotiated within the small group. A topic may be chosen to complement a previous discussion or clinical experience, or a new topic may be presented. The presentation is usually followed by a focused discussion. Expectations for length of presentation use of handouts, or audio-visual material should be clearly stated in advance.

Role play
Role-play is an excellent technique for building clinical skills in the safety of the small group setting. It is particularly effective for practicing communication skills. Role-plays can be based on previously scripted written scenarios or on a real case that may have been presented to the group. Clear instructions must to be given regarding the nature of the roles, timing, and specific objectives. The role-play may be enacted in groups of two, with one student playing the physician and another playing the patient. Role- play can also take place in groups of three, with an observer added to the group. The observer should be given a checklist to facilitate observation and feedback. A debriefing and an opportunity for self-assessment and feedback should always follow the role- play.

Remote or distance learning environment E-learning

The use of virtual or digital learning environments has been proven to be an effective and fast growing method of instruction especially for students far from the main campus or teaching institution. Elearning is the use of Internet technologies to enhance knowledge and performance. Historically, this form of learning has been represented by two common e-learning modes: distance learning and computer-assisted instruction. Distance learning uses information technologies to deliver instruction to learners who are at remote locations from a central site. Computer-assisted instruction (also called computer-based learning and computer-based training) uses computers to aid in the delivery of standalone multimedia packages for learning and teaching [38]. These two educational modes have now been merged into e-learning as the Internet becomes the integrating technology. E-learning technologies offer learners control over content, learning sequence, pace of learning, time, and often media, allowing them to tailor their experiences to meet their personal learning objectives. In diverse medical education contexts, e-learning appears to be at least as effective as traditional instructor-led methods such as lectures. Learners do not see e-learning as replacing traditional instructor-led training but as a complement to it, forming part of a blended-learning strategy.

37

Sheffield Assessment Instrument for Letters

The Sheffield Assessment Instrument for letters is a checklist of ideal items which should be included in a referral letter. This SAIL is used to assess referral letters to other practitioners and it consists of a list of features, which should be in an ideal letter that can be scored. There is also space for general comments. The overall score in this tool has been validated and found to be discriminating (i.e. it distinguishes between good and bad letters) and reproducible (i.e. the same letter will score the same with different scorers or at different times). Most of the value from this tool is gained from the discussion that arises from using the tool. The tool can be used to assess one letter, or several, to find out whether there is a pattern. It could be used on selected letters, or on letters chosen at random. A powerful way of using the tool would be to allow the registrar to score one of the supervisors letters as well, allowing role-modelling that can lead to improving the supervisors own practice.

Conclusion
Knowledge acquisition in postgraduate medical training is an active process and involves the processing of information through the interaction of existing knowledge with new knowledge. During this process, the learners prior knowledge is important for learning and the quality of what is learnt is dependent on the activation of prior knowledge, the degree of elaboration of the knowledge or skill being learnt and the effective transfer of the prior knowledge in the new learning context. Therefore, effective instructional methods and the knowledge of their strengths and weaknesses are crucial for effective learning in the clinical learning environment.

References
1. David, T.J. & Patel, L. Adult learning theory, problem based learning, and paediatrics. Archives of Disease in Childhood 1995; 73: 357-63 2. Bloom, B, Englehart, M, Furst, E, Hill, W, & Krathwohl, D. Taxonomy of educational objectives: The classification of educational goals. Handbook I: Cognitive domain. New York: Longmans, Green; 1956 3. Gonczi, A., Hager, P., & Athanasou, J. The development of competency-based assessment strategies strategies for the professions. National Office of Overseas Skills Recognition Research Paper no. 8. Australian Government Publishing Service: Canberra 1993 4. Schmidt HG, Norman GR, Boshuizen HPA. A cognitive perspective on medical expertise: Theory and implications. Academic Medicine, 1990; 65(10): 611-21 5. Cooper D, Beswick W, Whelan G. Intensive bedside teaching of physical examination to medical undergraduates: evaluation including the effect of group size. Med Educ. 1983;17:311-5. 6. Morgan WL. Bedside teaching. Trans Am Clin Climatol Assoc. 1981; 93:164-71. 7. Reischman F, Browning FE, Hinshaw JR. Observation of undergraduate clinic teaching in action. J Med Educ. 1964; 39:147-63. 8. Functions and structure of a medical school http://www.lcme.org/standard.htm#current. Accessed 28 July 2009. Liaison Committee on Medical Education, Washington, DC. 9. Mavis BE, Cole BL, Hoppe RB. A survey of student assessment in the U. S. medical schools: the balance of breadth versus fidelity. Teach Learn Med. 2001; 13:74-9. 10. Borowitz SM, Saulsbury FT, Wilson WG. Information collected during the residency match process does not predict clinical performance. Arch Pediatr Adolesc Med. 2000; 54:256-60. 11. Carline JD, Paauw DS, Thiede KW, Ramsey PG. Factors affecting the reliability of ratings of students clinical skills in a medicine clerkship. J Gen Intern Med. 1992; 7:506-10. 12. Norman G. The long case versus objective structured clinical examinations. BMJ 2002; 324:748-749. 13. Norcini JJ, Blank LL, Duffy FD, Fortna GS. The mini-CEX: a method for assessing clinical skills. Ann Intern Med 2003; 138:476-481. 14. Knowles, M. S. (1975) Self-directed learning: A guide for learners and teachers, Prentice Hall, Englewood Cliffs, New Jersey.

38

15. Shokar, G. S., Shokar, N.K., Romero, C.M. and Bulik ,R.J. (2003) Self-directed learning: looking at outcomes with medical students, Family Medicine, 35(6):445-6. 16. Topping KJ: The effectiveness of peer tutoring in further and higher education: A typology and review of the literature. Higher Education (Historical Archive) 1996, 32:321-345. 17. Topping KJ: The effectiveness of peer tutoring in further and higher education: A typology and review of the literature. In Mentoring and Tutoring by Students Edited by: Goodlad S. London, Kogan Page; 1998. 18. Trevino PM, Eiland DC: Evaluation of basic science, peer tutorial programme for first- and second-year medical students. Journal of Medical Education 1980, 55:952-953. 19. Ebbert MR, Morgan PM, Harris LB: A comprehensive student peer-teaching programme. Academic Medicine 1999, 74:583-584. 20. Fantuzzo JW, Dimeff LA, Fox SL: Reciprocal peer tutoring: A multimodal assessment of effectiveness with college students. Teaching of Psychology 1989, 16:133-135. 21. Fantuzzo JW: Effects of Reciprocal Peer Tutoring on Academic Achievement and Psychological Adjustment: A Component Analysis. Journal of Educational Psychology 1989, 81:173-177. 22. Lambiotte JG: Manipulating cooperative scripts for teaching and learning. Journal of Educational Psychology 1987, 79:424-430. 23. Annis LF: The processes and effects of peer tutoring. Human Learning: Journal of Practical Research & Applications 1983, 2:39-47. 24. Bligh DA. What's the use of lectures? San Francisco: Jossey-Bass; 2000. 25. Menon AS, Moffett S, Enriquez M, Martinez MM, Dev P, Grappone T. Audience response made easy: using personal digital assistants as a classroom polling tool. J Am Med Inform Assoc. 2004;11(3):217-20. 26. Uhari M, Renko M, Soini H. Experiences of using an interactive audience response system in lectures. BMC Med Educ. 2003;3(1):12. 27. Hunt DP, Haidet P, Coverdale JH, Richards B. The effect of using team learning in an evidence-based medicine course for medical students. Teach Learn Med. 2003;15(2):131-9. 28. Levine RE, O'Boyle M, Haidet P, Lynn DJ, Stone MM, Wolf DV, Paniagua FA. Transforming a clinical clerkship with team learning. Teach Learn Med. 2004;16(3):270- 5. 29. Michaelsen L, Richards B. Drawing conclusions from the team-learning literature in healthsciences education: a commentary. Teach Learn Med. 2005;17(1):85-8. 30. Nieder GL, Parmelee DX, Stolfi A, Hudes PD. Team-based learning in a medical gross anatomy and embryology course. Clin Anat. 2005;18(1):56-63. 31. Barnes LB, Christensen CR, Hansen AJ. Teaching and the case method. Boston: Harvard Business School Press; 1994. 32. Beech DJ, Domer FR. Utility of the case-method approach for the integration of clinical and basic science in surgical education. J Cancer Educ. 2002;17(3):161-4. 33. Goodenough DA. Changing ground: a medical school lecturer turns to discussion teaching. In: Christensen CR, Garvin DA, Sweet A, eds. Education for judgment: the artistry of discussion leadership. Boston: Harvard Business School Press; 1991. p 83- 98. 34. Dennick RG, Exley K. Teaching and learning in groups and teams. Biochemical Education. 1998; 26(2):111-5. 35. Steinert Y. Twelve tips for effective small group teaching in the health professions. Med Teach. 1996; 203-7. 36. Herreid CF. What makes a good case? J Coll Sci Teach. 1998; 27(3):163-5. 37. Armstrong E. Overview: Advantages of the case based approach. Pedicases.org. Boston: Harvard Medical School; 2004. [updated 2005 August 15; cited 2011 Mar 24]. Available from: http://www.pedicases.org/teaching/overview/approach.html. 38. Ward JP, Gordon J, Field MJ, Lehmann HP. Communication and information technology in medical education. Lancet. 2001;357: 79296

Further reading
1. Spencer J. ABC of learning and teaching in medicine: Learning and teaching in the clinical environment British Medical Journal 2003; 326:591-94

39

2. Cox K. Planning bedside teaching. (Parts 1 to 8.) Med J Australia 1993; 158:280-2, 355-7, 417-8, 493-5, 571-2, 607-8, 789-90, and 159:64-5. 3. Parsell G, Bligh J. Recent perspectives on clinical teaching. Med Educ 2001; 35:409-14. 4. Hargreaves DH, Southworth GW, Stanley P,Ward SJ. On-the-job learning for physicians. London: Royal Society of Medicine, 1997. 5. Ross, Michael T. and Cameron, Helen S. 'Peer assisted learning: a planning and implementation framework: AMEE Guide no. 30', Medical Teacher, 29: 6, 2007, 527-45 6. Durning, Steven J. and Cate, Olle Th. J. ten 'Peer teaching in medical education', Medical Teacher, 29: 6, 2007, 523 524

40

UNDERSTANDING THE PRINCIPLES OF TEACHING AND LEARNING IN THE CLINICAL WORKPLACE

Dr. Jamiu O. Busari MD, MHPE, PHD Dept. of Pediatrics, Atrium Medical Center/University of Maastricht, Educational development & research dept.

GOAL

Deepen our insight on:

Basic health professions education Education in the clinical workplace

WORKPLACE LEARNING

learning by doing on the job training job-embedded learning

41

LEARNING STYLE

The way an individual is used to learning new concepts or tasks

Different among individuals Habitual or behavioural On its own neither good nor bad influenced by context, subculture

THEORIES ON (WORKPLACE) LEARNING PHASES OF THE LEARNING PROCESS

concrete experience starts by experiencing: activists reflective observation Reserved, tests the water: reflector abstract conceptualising Explanation, models, concepts: theoretists active experimenting Tests theory in practice: pragmatist
Kolb

42

THEORIES ON (WORKPLACE) LEARNING PHASES OF THE LEARNING PROCESS

concrete experiencing reflective observation abstract conceptualising active experimentation activist reflector theoretist pragmatist

Not always in the same order Not in the same degree/intensity Extent of acquisition related to preferred activity Origin of the typical thinker and doer

INFLUENCE OF CONTEXT, SUBCULTURES

FUNCTIONAL LEARNING VS DIRECTIVE LEARNING (VERMUNT)

Focus on reproducing facts (rote learning) Memorising, focused on tests, classroom learning Exam scores Focus on understanding/meaning (holistic learning) Major highlights, standpoints, conclusions, critical Personal interest Focus on application (apprenticeship) Relevance, opportunities for application, concrete information Vocation

43

EFFECTIVE LEARNING & EDUCATIONAL PRINCIPLES

The human mind is not an archive The human mind is organized as a network Memory is dynamic

EFFECTIVE LEARNING FACTORS THAT INFLUENCE LEARNING

Meaning

EFFECTIVE LEARNING FACTORS THAT INFLUENCE LEARNING

The procedure is actually quite simple. First you arrange items into different groups. Of course, one pile may be sufficient depending on how much there is to do. If you have to go somewhere else due to lack of facilities that is the next step; otherwise, you are pretty well set. It is important not to overdo things. That is, it is better to do too few things at once than too many. In the short run this may not seem important, but complications can easily arise. A mistake can be expensive as well. At first, the whole procedure may seem complicated. Soon, however, it will become just another facet of life. After the procedure is completed, one arranges the materials into different groups again. Then they can be put into their appropriate places. Eventually they will be used once more and the whole cycle will then have to be repeated. However, that is part of life.

44

EFFECTIVE LEARNING FACTORS THAT INFLUENCE LEARNING

What did you retain from this text? Mention a few relevant aspects ..

EFFECTIVE LEARNING FACTORS THAT INFLUENCE LEARNING

Washing Clothes
The procedure is actually quite simple. First you arrange items into different groups. Of course, one pile may be sufficient depending on how much there is to do. If you have to go somewhere else due to lack of facilities that is the next step; otherwise, you are pretty well set. It is important not to overdo things. That is, it is better to do too few things at once than too many. In the short run this may not seem important, but complications can easily arise. A mistake can be expensive as well. At first, the whole procedure may seem complicated. Soon, however, it will become just another facet of life. After the procedure is completed, one arranges the materials into different groups again. Then they can be put into their appropriate places. Eventually they will be used once more and the whole cycle will then have to be repeated. However, that is part of life.

EFFECTIVE LEARNING FACTORS THAT INFLUENCE LEARNING

Meaning Context specificity

Specific relations, mnemonics (Nursery rhymes)

Encodingspecificity
The way certain things are learnt (encoded) determines whether and/or how the knowledge is retrievable for use (weekdays)

45

LEARNING OUTPUT WHICH ACTIVITIES CONTRIBUTE MOST TO LEARNING?

Studying

average retention rate

Teaching

National Training Laboratories, Bethel,Maine

EFFECTIVE LEARNING FACTORS THAT INFLUENCE LEARNING

Meaning Context specificity Encoding specificity Approach to learning

Deep vs Superficial Holistic vs Atomistic

46

INTEGRATING KNOWLEDGE

Novice

versus

Expert

Busari et al., 2004, JPGM

47

COMPETENCY: OPERATIONAL DEFINITION

COMPETENCY DEVELOPMENT DynamicProcess

does shows how knows how knows

Miller 1990

COMPETENCY DEVELOPMENT
Dynamic process

does

knows
Miller 1990

48

COMPETENCY DEVELOPMENT
Dynamic process

does

does shows how knows how

knows knows
Miller 1990

ENDPOINTS OF THE EDUCATIONAL PROCESS

Stage 4 Stage 3 Stage 2 Stage1

unaware aware aware unaware

competent competent incompetent incompetent

ENDPOINTS OF COMPETENCE
Levels of competency

competence

does shows how knows how knows

Independent
distant supervision close supervision

knowledgeable Miller 1990

49

CONCLUDING REMARKS Teaching is an inherent aspect of the medical profession

There is a need for effective transfer of knowledge among medical professionals

50