Clinical teaching: maintaining an educational role for doctors in the new health care environment

Student views on the effective teaching of physical examination skills: a qualitative study

OBJECTIVES

The lack of published studies into effective skills teaching in clinical skills centres inspired this study of student views of the teaching behaviours of skills teachers.

METHODS

We organised focus group discussions with students from Years 1-3 of a 6-year undergraduate medical curriculum. A total of 30 randomly selected students, divided into three groups, took part in two sessions. They discussed what teaching skills helped them to acquire physical examination skills.

RESULTS

Students' opinions related to didactic skills, interpersonal and communication skills and preconditions. Students appreciated didactic skills that stimulate deep and active learning. Another significant set of findings referred to teachers' attitudes towards students. Students wanted teachers to be considerate and to take them seriously. This was reflected in student descriptions of positive behaviours, such as: 'responding to students' questions'; 'not exposing students' weaknesses in front of the group', and '[not] putting students in an embarrassing position in skill demonstrations'. They also appreciated enthusiasm in teachers. Important preconditions included: the integration of skills training with basic science teaching; linking of skills training to clinical practice; the presence of clear goals and well-structured sessions; good time management; consistency of teaching, and the appropriate personal appearance of teachers and students.

CONCLUSIONS

The teaching skills and behaviours that most facilitate student acquisition of physical examination skills are interpersonal and communication skills, followed by a number of didactic interventions, embedded in several preconditions. Findings related to interpersonal and communication skills are comparable with findings pertaining to the teaching roles of tutors and clinical teachers; however, the didactic skills merit separate attention as teaching skills for use in skills laboratories. The results of this study should be complemented by a study performed in a larger population and a study exploring teachers' views.

Factors determining students' global satisfaction with clerkships: an analysis of a two year students' ratings database

Clerkships would benefit from teachers' improved understanding of the didactic aspects of their task. The purpose of this study is to identify factors that determine the teaching quality of clerkships and to examine the predictive value of these factors for students' global satisfaction. Thus, results would be further reflected to clinical teachers' tasks. These factors could then be taken into account in future clinical teaching. In this paper, a medical faculty's 2 year data set of student feedback from a systematic programme evaluation project was used. A factor analysis was performed on 11,780 student questionnaires. Factor loads, and the Cronbach's alpha coefficients of the questionnaire and factors were calculated. In order to examine the contributions of the factors to the students' global satisfaction, the study included a multivariate stepwise regression analysis. The analysis revealed four factors, which together explained 60.24% of the variance: Structure & Process (44.66%); Time (5.8 %); Outcome (5.35%) and Input (4.39%). The Structure & Process factor was found to be the best predictor of students' global satisfaction (R2 =( ).537). Our conclusion is that "efforts to improve clerkship quality should focus on students' learning processes and clerkship structure".

Development of a framework of medical undergraduate teaching activities

CONTEXT

The need for a comprehensive framework of teaching activities in undergraduate medical education was identified by colleagues involved in teacher training at the University of Edinburgh, UK and Karolinska Institutet, Sweden. Such a framework could be used to develop training programmes for medical teachers, to help experienced teachers to reflect upon and communicate with others about their practice, and as a focus for further research on medical teaching.

METHODS

A provisional framework of medical teaching activities and a model illustrating how these activities are situated within the wider context of learning and teaching were developed iteratively using the literature and pilot studies. The provisional framework and model were then methodically tested using journal analysis, brainstorming sessions and focus group sessions with medical teachers and teacher trainers in both institutions. Data gathered from this research were analysed and used to further develop the framework and model.

RESULTS

Many of the provisional teaching activities in the framework were further developed in response to the research data and some new activities were added. Teaching activities seemed to cluster into three domains: 'Facilitating', 'Managing', and 'Learning and Community Building'. Specific tasks were identified relating to planning, administering, resourcing, implementing and evaluating each teaching activity. Participants found the model of learning and teaching helpful and felt it adequately represented the place of teaching activities within the wider context of undergraduate medical education. The framework and model are now being used by the authors in faculty development, undergraduate teaching and further research.

AMEE Guide no. 34: Teaching in the clinical environment

Teaching in the clinical environment is a demanding, complex and often frustrating task, a task many clinicians assume without adequate preparation or orientation. Twelve roles have previously been described for medical teachers, grouped into six major tasks: (1) the information provider; (2) the role model; (3) the facilitator; (4) the assessor; (5) the curriculum and course planner; and (6) the resource material creator (Harden & Crosby 2000). It is clear that many of these roles require a teacher to be more than a medical expert. In a pure educational setting, teachers may have limited roles, but the clinical teacher often plays many roles simultaneously, switching from one role to another during the same encounter. The large majority of clinical teachers around the world have received rigorous training in medical knowledge and skills but little to none in teaching. As physicians become ever busier in their own clinical practice, being effective teachers becomes more challenging in the context of expanding clinical responsibilities and shrinking time for teaching (Prideaux et al. 2000). Clinicians on the frontline are often unaware of educational mandates from licensing and accreditation bodies as well as medical schools and postgraduate training programmes and this has major implications for staff training. Institutions need to provide necessary orientation and training for their clinical teachers. This Guide looks at the many challenges for teachers in the clinical environment, application of relevant educational theories to the clinical context and practical teaching tips for clinical teachers. This guide will concentrate on the hospital setting as teaching within the community is the subject of another AMEE guide.

Clinical teaching in emergency medicine: the board round at Hope Hospital emergency department

This article discusses the educational value of the "board round", a clinical teaching forum introduced at Hope Hospital, Manchester, UK. At midday on weekdays all available consultants and middle grade doctors, and any other staff who can attend, meet to discuss a case selected from the patients currently in the department. As several experienced clinicians are available to discuss a clinical problem, the round allows a broad debate during which the merits of several management options are discussed. In addition, attending a board round addresses in part the concerns which senior clinicians may have about the balance of service delivery and protected teaching time. The paper describes several other advantages of this method of teaching, which has been adopted by other hospitals in the region.

Disentangling clinical learning experiences: an exploratory study on the dynamic tensions in internship

Clinical practice is an essential component of medical training, but not all internships yield the appropriate and expected learning results. We report on an exploratory study of the learning process during internship in undergraduate medical education. We hypothesised that learning experiences in clinical practice are determined by characteristics of the interns, characteristics of the training setting and the meaningful interactions between them. As the study focused on the perceptions and interpretations of both interns and their supervisors of interns' experiences in practical training, qualitative research methods were used for data collection and analysis. This consisted of student shadowing, complemented by informal and semistructured interviews with both interns and supervisors. Analysis revealed 5 components that constitute learning experiences in clinical internship. These components represent dynamics in the clinical environment that constantly require students to (re-)define and (re-)position themselves: the agenda of the internship (working versus learning); the attitude of the supervisor (evaluator versus coach); the culture of the training setting (work-orientated versus training-orientated); the intern's learning attitude (passive versus proactive), and the nature of the learning process (informal versus formal). The model of components and tensions offers a conceptual framework to analyse and understand students' learning during internship. It not only contributes to a grounded theoretical conceptualisation of clinical learning, but may also be used in efforts to improve the quality of learning during internship, as well as the level of support and supervision.

A South West regional survey to identify education staff development needs in clinical skills and practice

This paper reports tentative findings from a survey (undertaken in 2001) of education staff employed to teach nurses and midwives in four highereducation institutions in the South West of England, with specific focus on answers regarding clinical skills and practice within a wider aim of evaluating training needs. A 57 item self-administered postal questionnaire was sent out to 760 educators, 426 were returned with a response rate of 56%. The results were analysed using SPSS version 9, using descriptive statistics focusing on the responses of HE staff and lecturer practitioners on joint appointments. Findings suggest HE staff teach a limited range of (defined) clinical skills, they have varying and wide definitions of clinical skills, less confidence in teaching skills in practice, minimal experience in working in practice settings and difficulties in engagement in practice. They continue to experience role diversity and a wide variation in meeting clinical demands for clinical competence. Definitions of clinical practice and practice skill are explored in relation to the need for nurse teachers to have ‘recent and practical experience of nursing’. A range of education roles are explored.

Clinical teachers as role models: perceptions of interns and residents in a Lebanese medical school

OBJECTIVE

To identify the characteristics and learning impact of role models as perceived by interns and residents in an Arabic Middle Eastern country, Lebanon.

METHODS

A structured and self-administered questionnaire was sent to the cohort of interns (n = 34) and residents (n = 66) training in a Lebanese university hospital. The questionnaire contained pre-specified items related to professional and personal characteristics of positive and negative role models, as well as to the impact of these models on professional learning and career choices. Responders were asked to recognise and to rank-order the items associated to their identified models.

RESULTS

A total of 88 responders (97%) had positive role models and 87 responders (96%) had negative role models in their current training programme. Characteristics identified most frequently and ranked most highly by the trainees were related to clinical skills in positive role models and to inadequate humanistic and collaborative attitudes in negative models. Role modelling had a positive impact on the achievement of clinical skills for 55% of the responders, and on the acquisition of humanistic and collaborative attitudes for 30% of them. Thirty-eight per cent of the trainees were influenced by their role models in the choice of their specialities. Responses were generally comparable between levels of training and between medical and surgical specialities.

CONCLUSION

Clinical teachers, practising in a non-occidental cultural and medical learning environment, are considered very frequently as role models by their interns and residents and have a positive impact on their professional learning and career choices. Strategies to reinforce role modelling are needed in Lebanon, in order to pass a broad spectrum of professional values to our students.

A comparison of medical students' perceptions of their initial basic clinical training placements in 'new' and established teaching hospitals

This study has examined students' perceptions of the factors influencing learning during initial hospital placements and whether differences in perceived experiences were evident between students attending new and established teaching hospitals. Five focus groups were conducted with Year III students at the University of Birmingham Medical School (UBMS): three with students attending three established teaching hospitals and two with students attached to a new teaching hospital (designated as part of the UBMS expansion programme). Extensive variation in student perception of hospital experiences was evident at the level of teaching hospital, teaching firm and individual teacher. Emergent themes were split into two main categories: 'students' perceptions of teaching and the teaching environment' and 'the new hospital learner'. Themes emerging that related to variation in student experience included the amount of structured teaching, enthusiasm of teachers, grade of teachers, specialty of designated firms and the number of students. The new teaching hospital was generally looked upon favourably by students in comparison to established teaching hospitals. Many of the factors influencing student experience relate to themes grouped under the 'new hospital learner', describing the period of adjustment experienced by students during their first encounter with this new learning environment. Interventions to improve student experience might be aimed at organisations and individuals delivering teaching. However, factors contributing to the student experience, such as the competing demand to teaching of heavy clinical workloads, are outside the scope of medical school intervention. In the absence of fundamental change, mechanisms to equip students with 'survival skills' as self-directed hospital learners should also be considered.

BEME systematic review: predictive values of measurements obtained in medical schools and future performance in medical practice

BACKGROUND

Effectiveness of medical education programs is most meaningfully measured as performance of its graduates.

OBJECTIVES

To assess the value of measurements obtained in medical schools in predicting future performance in medical practice.

METHODS

SEARCH STRATEGY

The English literature from 1955 to 2004 was searched using MEDLINE, Embase, Cochrane's EPOC (Effective Practice and Organization of Care Group), Controlled Trial databases, ERIC, British Education Index, Psych Info, Timelit, Web of Science and hand searching of medical education journals.

INCLUSION & EXCLUSIONS

Selected studies included students assessed or followed up to internship, residency and/or practice after postgraduate training. Assessment systems and instruments studied (Predictors) were the National Board Medical Examinations (NBME) I and II, preclinical and clerkship grade-point average, Observed Standardized Clinical Examination scores and Undergraduate Dean's rankings and honors society. Outcome measures were residency supervisor ratings, NBME III, residency in-training examinations, American Specialty Board examination scores, and on-the-job practice performance.

DATA EXTRACTION

Data were extracted by using a modification of the BEME data extraction form study objectives, design, sample variables, statistical analysis and results. All included studies are summarized in a tabular form. DATA ANALYSIS AND SYNTHESIS: Quantitative meta-analysis and qualitative approaches were used for data analysis and synthesis including the methodological quality of the studies included.

RESULTS

Of 569 studies retrieved with our search strategy, 175 full text studies were reviewed. A total of 38 studies met our inclusion criteria and 19 had sufficient data to be included in a meta-analysis of correlation coefficients. The highest correlation between predictor and outcome was NBME Part II and NBME Part III, r = 0.72, 95% CI 0.30-0.49 and the lowest between NBME I and supervisor rating during residency, r = 0.22, 95% CI 0.13-0.30. The approach to studying the predictive value of assessment tools varied widely between studies and no consistent approach could be identified. Overall, undergraduate grades and rankings were moderately correlated with internship and residency performance. Performance on similar instruments was more closely correlated. Studies assessing practice performance beyond postgraduate training programs were few.

CONCLUSIONS

There is a need for a more consistent and systematic approach to studies of the effectiveness of undergraduate assessment systems and tools and their predictive value. Although existing tools do appear to have low to moderate correlation with postgraduate training performance, little is known about their relationship to longer-term practice patterns and outcomes.

Consultant attitudes to undertaking undergraduate teaching duties: perspectives from hospitals serving a large medical school

OBJECTIVE

To explore attitudes among National Health Service consultants responsible for delivering basic clinical teaching to medical students.

DESIGN

Postal questionnaire.

SUBJECTS AND SETTING

A total of 308 acute hospital trust consultants working in 4 'new' and 4 'established' teaching hospitals in the West Midlands metropolitan area, and involved in the delivery of clinical teaching to Year 3 medical students at the University of Birmingham Medical School during 2002-03.

MAIN OUTCOME MEASURE(S)

The questionnaire explored contractual requirements, actual teaching commitments and perceptions of medical students' knowledge and attitudes. Responses from doctors and surgeons and from respondents working in established and new teaching hospitals were compared.

RESULTS

A total of 249 responses were received (response rate 80.8%). Although many consultants enjoy teaching students, their enjoyment and their ability to deliver high standards of teaching are compromised by time and resource constraints. For many the situation is aggravated by the perceived inappropriate organisation of the clinical teaching curriculum and the inadequate preparation of students for clinical practice. Linking these themes is the overarching perception among teachers that neither service nor educational establishments afford teaching the levels of recognition and reward associated with clinical work or research.

CONCLUSION

To overcome barriers to teaching requires more reciprocal links between hospital staff and medical schools, opportunities for consultants to understand and to comment on curricular and timetable developments, and, perhaps most importantly, recognition (in contractual, financial, managerial and personal terms) of the importance of undergraduate teaching in the competing triad of service, research and education.

Validation of a checklist to assess ward round performance in internal medicine

BACKGROUND

Ward rounds are an essential responsibility for doctors in hospital settings. Tools for guiding and assessing trainees' performance of ward rounds are needed. A checklist was developed for that purpose for use with trainees in internal medicine.

OBJECTIVE

To assess the content and construct validity of the task-specific checklist.

METHODS

To determine content validity, a questionnaire was mailed to 295 internists. They were requested to give their opinion on the relevance of each item included on the checklist and to indicate the comprehensiveness of the checklist. To determine construct validity, an observer assessed 4 groups of doctors during performance of a complete ward round (n = 32). The nurse who accompanied the doctor on rounds made a global assessment of the performance.

RESULTS

The response rate to the questionnaire was 80.7%. The respondents found that all 10 items on the checklist were relevant to ward round performance and that the item collection was comprehensive. Checklist mean-item scores differed between levels of expertise: junior house officers 1.4 (1.0-1.9); senior house officers 2.0 (1.5-2.9); specialist trainees 2.5 (1.8-2.8), and specialists 2.7 (2.3-3.5); median (range) (P < 0.001). A significant correlation was found between global observer scores and nurse scores (r = 0.56, P < 0.001).

CONCLUSION

The checklist, developed for assessing trainees' performance of ward rounds in internal medicine, showed high content validity. Construct validity was supported by the higher scores of experienced doctors compared to those with less experience and the significant correlation between the observer's and nurses' global scores. The developed checklist should be valuable in guiding and assessing trainees on ward round performance.

Teaching and learning in the clinical setting: a qualitative study of the perceptions of students and teachers

OBJECTIVE

To describe the perceptions of medical students and clinical teachers of teaching and learning in the clinical setting.

DESIGN

Qualitative study of focus groups with undergraduate medical students and semistructured interviews with hospital consultant clinical teachers.

SETTING

The School of Medicine, University of Leeds and the Leeds Teaching Hospitals Trust, UK.

PARTICIPANTS

Fourth year medical students and consultant clinical teachers.

MAIN OUTCOME MEASURES

Analysis of narratives to identify students' perceptions of clinical teaching and consultants' views of their delivery of undergraduate clinical teaching.

RESULTS

Students believed in the importance of consultant teaching and saw consultants as role models. However, they perceived variability in the quality and reliability of teaching between physicians and surgeons. Some traditional teaching venues, especially theatre, are believed to be of little clinical importance. Generally, consultants enjoyed teaching but felt under severe pressure from other commitments. They taught in a range of settings and used various teaching strategies, not all of which were perceived to be 'teaching' by students.

CONCLUSIONS

While students and teachers are educational partners, they are not always in agreement about the quality, quantity, style or appropriate setting of clinical teaching. To enable teachers to provide more high quality teaching, there needs to be support, opportunities and incentives to understand curricular developments and acquire teaching skills.

Recent perspectives on clinical teaching

Clinical teaching is part of a doctor's professional life, whether it takes place in surgeries, clinics or in hospitals, with undergraduates, postgraduate trainees or colleagues. Learning to teach well means questioning the effectiveness of some of the old teaching methods, exploring new ideas and trying out new methods in different situations. It means collaborating more closely with colleagues and learners about developing and implementing new approaches to medical education. This paper is the first of an occasional series of articles about the practical aspects of clinical teaching. The articles have the following characteristics: they explore contemporary themes in medical and health care education; they use up-to-date references; they are a quick and easy resource for busy teachers; they explore new ideas about teaching and learning, and they provide a reference list of relevant papers. This article deals with recent ideas about clinical teachers' knowledge and roles, teaching and organizational strategies, and the measurement of teaching effectiveness.