Making good doctors good teachers: Supporting clinicians in improving their teaching skills

Transcription

1 Making good doctors good teachers: Supporting clinicians in improving their teaching skills Dr Kirsty Foster, Senior Lecturer in Medical Education Northern Clinical School and Office of Post-Graduate Medical Education, University of Sydney. Dr Rodger Laurent, Senior Staff Specialist, Royal North Shore Hospital and Clinical Senior Lecturer, University of Sydney. No bubble is so iridescent or floats longer than that blown by a successful teacher Sir William Osler ( ) 24 Institute for Teaching and Learning

2 Introduction Doctors have always been expected to teach and traditionally, medical knowledge and skills were passed on in a one-to-one relationship in which young doctors learned their craft through working with an experienced clinician over a long period of time. Nowadays this apprenticeship model is rarely possible (De Vita 2007). There is pressure on clinical teachers because of increasing numbers of medical students requiring tuition and supervision in clinical settings. However, time for doctors to learn about how to teach and support in developing and practising their teaching skills is often lacking in busy teaching hospitals where patient care takes priority. After qualification junior doctors, now part of the medical workforce, continue in training positions as they progress in their chosen area of practice. This can be in either primary or hospital care. They work through attachments in several different units with different health care teams or in general practice to ensure a breadth and adequacy of suitable experience before they become appropriately qualified. This means that twentyfirst century clinical teachers must not only be able to teach at several levels simultaneously but also to provide adequate and appropriate supervision and feedback to juniors as they progress towards autonomy as practitioners. Increased student numbers also means that doctors must also be skilled in effective lecturing and group teaching. It is therefore essential that current and prospective clinical teachers receive adequate assistance in developing their teaching skills and learning about the theories underpinning the principles of adult education. There are several studies in the medical education literature which show that courses for teachers improve teaching skills of the participants (Brown & Wall, 2003, Godfrey et al., 2004, Huggett et al., 2008, Kujumdshiev et al., 2008, McLeod et al, 2008, Witkowska-Stabel et al., 2008). Demonstrated improvements include increased teaching confidence and better feedback to the learners. A teaching course can increase the effectiveness of the teaching as evidenced by improved learner performance in examinations (Stern et al., 2000). The content of the courses reported varies. Some are focused on specific aspects of teaching, history taking and physical examination skills (Kujumdshiev et al., 2008), or educational theory (McLeod et al., 2008) and others cover a broad range of the different elements of teaching. The common topics are giving constructive feedback, assessing the trainee, creating a good educational climate and providing specific information about different teaching methods (Wall & McAleer, 2000). Some courses also include assessment, regarded as important by the participants. Most of the reported courses were run over two to three days. Consultants are interested in learning about basic educational theory and attending a course which included this topic has a positive effect on the participants teaching (McLeod et al, 2008). The Challenge As most clinical teachers have a primary responsibility to patient care, a major challenge in developing and supporting their teaching skills is providing accessible, appropriate and relevant education in a way which is reasonably manageable to busy, working clinicians. This paper reports on the development, delivery and evaluation of a Short Course for Clinical Teachers which was developed in response to a demand for formal tuition on how to teach by clinical teachers at Northern Clinical School (NCS). For these clinicians attendance at a university campusbased course was not feasible because of the necessary time commitment for study and distance from workplace. Aim Our aim was to develop a teaching course relevant for working clinical teachers and deliver it locally to the workplace so as to improve the standard of teaching, enhance knowledge of education theory and promote the scholarship of teaching. The objectives of the course were to cover aspects of teaching that were relevant to clinicians who already had some teaching experience. In planning the course we focused on the specific aspects of teaching relevant to medical students. Methods Course Development The course was set up in 2005 by one of the authors (RL) who was the Director of Clinical Training at Royal North Shore Hospital, and the Associate Dean at Northern Clinical School (NCS), Professor Michael Field. In 2007 the other author (KF), who was a new appointee at the School in a fulltime medical education academic position, took over from Professor Field as co-organiser of the course. Thus, there was from the outset, collaboration between Area Health Service and University in taking joint responsibility for delivery of good clinical education. In a University of Sydney teaching hospital there are several different modes of teaching, which include lectures, problem based learning, small group teaching and bedside tutorials, clinical skills sessions, ethics discussions and supervision of clinical attachments. The topics included in the NCS Short Course for Clinical Teachers course were determined by discussion with a selection of clinical teachers at the hospital and clinical school. It initially consisted of four modules, with a fifth module added in 2007 when the teaching of clinical reasoning was highlighted in the Sydney Medical School curriculum review process. The five modules of the Northern Clinical School Short Course for Clinical Teachers cover the practical aspects of teaching in clinical settings and are: 1. Bedside teaching 2. Effective supervision and feedback 3. Teaching physical examination and procedures 4. Presentation skills and giving effective lectures synergy ISSUE 29, November

3 5. Facilitating development of clinical reasoning skills Educational theory was interwoven throughout the course and underpinned the design and delivery of each module. Up to date medical education papers were used to consolidate each session and to stimulate an interest in the theoretical basis of adult education. Format of the Course The course is conducted in five 90 minute modules run over a period of 6-8 weeks. The best continuous attendance was gained by holding sessions on the same day each week. Module length is set at 90 minutes to optimise engagement of participants as the course is run at the end of a working day. Light refreshments are served at the start of each session. The teaching methods used were small group discussions, short interactive presentations, video recordings of teaching scenarios and role-play using defined scenarios. Attention was given to creating a supportive atmosphere for discussion, debate and learning. The course tutors were the course convenors with additional expert tutors involved in some sessions. Participants all had at least some experience in clinical teaching making interaction crucial from an early stage to identify particular learning needs. The way in which the sessions are run form a key part of the education, highlighting such factors as the effect of different teaching styles, seating arrangements and group dynamics. For example, setting the room up with chairs in a circle one week and in rows the next demonstrated that discussion among participants was inhibited in the traditional classroom style arrangement. Giving them the experience of being in the situation themselves was more powerful than simply being given the information in a talk. Participants Consultants and Advanced Trainees were the target audience because they are responsible for the bulk of formal clinical teaching of medical students. The number of participants was capped at twenty in order to maintain a reasonable group size to promote interaction and an informal collaborative atmosphere. An invitation was sent to three hundred doctors involved in clinical teaching and supervision of medical students in the School s teaching hospitals. The low participant rate may be due to the fact that most clinicians receive no remuneration for teaching and are reluctant to spend extra time in attending teaching courses. Our strategy was to focus on those keen to take part in the course as champions in clinical teaching. Evaluation Participants were asked to complete evaluation forms at the end of each module. These included a five point Likert scale assessing four key components of the session: content and format perceived relevance to participant s own teaching level of interaction tutor support and feedback Participants also gave an overall rating and were asked for free text comments in answer to open ended questions about the most useful and least useful aspects and suggestions on how the course could be improved. Results The short course has been run annually since 2005 and in this time a total of 81 clinicians have taken part in at least one session of the course. The majority were doctors including hospital specialists, general practitioners and senior registrars. Two physiotherapists and a hospital scientist have also taken part. Table 1: Overall participant rating of sessions Session topic % very good or excellent The response to the course was very positive, which is not surprising as there are few practical teaching courses provided for working clinicians. The rating of the sessions is shown in Table 1. Most of the participants rated the sessions as very good or excellent. Comments from the participants are used to improve the course the following year. Comments written on the evaluation forms indicated that participants highly valued the level of interaction, the practical nature of the course and the opportunity to discuss and practice their teaching skills. They also enjoyed being stimulated to think about educational issues. Typical comments written under the Most useful aspects of the session included: I enjoyed the whole evening, gave a lot of food for thought with teaching skills Practical example to utilize concepts introduced Interactive teaching There were fewer responses when asked about Least useful aspects but representative examples are: Actually, all of it was useful Role playing scenarios. Suggestions for improvement were also canvassed and included: Starting and finishing on time More interaction Less role play From participants were asked to complete a brief survey prior to starting the course and again on % average % below average or poor Bedside teaching Effective supervision & feedback Examination and procedural skills Teaching clinical reasoning Giving effective lectures Institute for Teaching and Learning

4 Table 2: Percentage of respondents from 2007, 2008 and 2009 strongly agreeing/agreeing with statements before and after course Statement Before After I feel confident teaching by the bedside 50% 80% I feel confident in teaching effectively on ward rounds 38% 87.5% I have the skills to give honest feedback to students and trainees 50% 80% I need more support in teaching in clinical settings 69% 10% I would like to learn more about educational theory 87.5% 80% completion. The results, shown in Table 2, demonstrate a change in confidence and perceived need for help in clinical teaching. They also demonstrate a clear desire to learn more about educational theory. Comments were sought from participants prior to the course about what they hoped to learn and afterwards about what they had learned. Analysis of these comments demonstrated a subtle shift from simply thinking about their own individual skills and confidence beforehand, towards a more reflective approach to the complexity of clinical teaching and their own place within a clinical teaching community on completion of the course. This shift in attitude to teaching is illustrated by examples of what participants said they wanted to learn before the course: A variety of teaching methods Tricks for focused teaching To gain more confidence in clinical teaching After the course examples of what participants said they had learned were: That teaching is an exact science One needs to learn medical education theory/methods to do it well. How medical education is changing it s great Some points in improving teaching and it was interesting to know how medical students learn How much is involved in the teaching process These comments with a more reflective approach to the course content suggest a good level of engagement with the course content. Discussion The course has been very successful and we continue to improve the content and teaching methods. The changes we have introduced are based on participants comments and changes in the medical school curriculum, in the light of published educational theory. We believe that our decision to run the course as five separate modules at weekly intervals rather than as a two or three day course has maximised participant numbers. It is difficult for practicing clinicians to take this length of time of work and it was much easier for them to attend at the end of the working day. It also meant that the course had to be sufficiently interesting and interactive for them to learn at this time of the day. Although there are not sufficient numbers yet studied for statistical significance there are clear trends in the data. The most important outcome is the increase in confidence of the participants in their teaching. This includes bedside and ward round teaching. They now do not require the same support for their teaching. They also feel more confident in their ability to give honest feedback to students and junior medical staff. This is an important aspect of education that is generally poorly managed (Walsh et al.; 2009). It is interesting that role play made the participants uncomfortable, even though there were guidelines for each of the roles. As a result we produced videos illustrating different aspects of bedside teaching and feedback which were discussed. Live role play remaining in the course was acted out by the course tutors and invited tutors. Participants preferred this method of teaching and we will increase the number of videos for next year s course. Videos have the advantage in that they can be carefully scripted to reliably demonstrate specific points. We have also found that they are excellent starters for discussion. The interactive format was greatly appreciated by the participants. They also had good ideas which were appreciated by the other participants. Educational theory was incorporated throughout the session rather than being given as a formal talk or lecture. The educational basis for the different aspects was discussed so that the participants could understand educational theory and its application at the same time. There was evidence from comments that this was helpful. I was enthusiastic to teach but didn t know how or what; I was doing random, rather inappropriate stuff. So this session was fantastic. Almost all the participants who have taken part in the course remain actively involved in clinical teaching at Northern Clinical School and many have increased their teaching commitment since attending the course. They are also influential in recruiting new clinical teachers to the schools tutor database. The course required few resources and did not require specific funding. It was free to participants. It is the type of course that could be easily instituted in any clinical school. All that is required are keen tutors with qualifications and experience in medical education. In contrast to published courses, we did not include assessment in our course. We considered it to be a separate issue because whereas many clinicians are required to teach, only a small number are involved in assessment. This has not been commented on by any of our participants. However, it could be synergy ISSUE 29, November

5 given as a single stand alone module for those involved in assessment. Conclusion Universities responsible for educating doctors and other health professionals must ensure that students and trainees receive good clinical teaching. Clinicians require support in developing their teaching skills and increasing their knowledge about relevant basic educational theory and effective educational strategies. A flexible approach, responsive to the needs of busy clinicians, in the provision of training courses must be taken to ensure the wide uptake necessary. We have demonstrated one way of providing a relevant course in clinical teaching which is accessible and acceptable to clinical tutors and which sparks their interest and enthusiasm in further improving their knowledge and skills in medical education. Sydney Medical School s new policy to locate a medical education academic at each of the teaching hospital campuses has facilitated this process. A collaboration between academic and senior clinical staff in delivery of such a course is an important element in fostering an ethos of education and learning within a teaching hospital. References Brown N, W. Teaching the consultant teachers in psychiatry: Experience in Birmingham. Medical Teacher 2003;25: De Vita MA. Simulation and the prognosis for the apprenticeship model of health care education. Journal of Intensive Care Medicine. 2007:22(5) Godfrey J, Dennick R, & Welsh C. Training the trainers: Do teaching courses develop teaching skills? Medical Education 2004;38: Huggett KN, Kavan MG, Jeffries WB. The summer initiative for teaching excellence (SITE) in the health sciences. Kujumdshiev S, Hamm K, Ochsendorf F, Schulze J, Braunbeck A, Wagner T. Implementation of a Trainthe-teacher workshop for a new curriculum for teaching clinical examination and history taking McLeod PJ, Brawer J, Steinert Y, Chalk C, McLeod A. A pilot study designed to acquaint medical educators with basic pedagogic principles. Medical Teacher 2008;30:92-93 Stern DT, Williams BC, Gill A, Gruppen LD, Wooliscroft JO, Grum CM. Is there a relationship between attending physicians and residents teaching skills and students examination scores? Acad Med 2000;75: Wall D, McAleer. Teaching the consultant teachers: identifying the core content. Medical Education 2000;34: Walsh AE, Armson H, Wakefield JG, Leadbetter W & Roder S. (2009) Using a novel small group approach to enhance feedback skills for community-based teachers. Teaching and Learning in Medicine, 21:1, Witkowska-Stabel M. Teach-theteacher training: What is applicable according to participants? 28 Institute for Teaching and Learning