The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students

INTRODUCTION: Much of undergraduate clinical teaching is provided by residents. An earlier study showed the attitude of residents towards teaching to be generally positive. Little is known, however, about attending doctors' views on their own and residents' roles as teachers of medical students. OBJECTIVES: To examine attending doctors' perceptions of the (dis)advantages of resident teaching, their own teaching abilities and the need for a teacher training programme for residents. METHOD: A questionnaire survey of 76 attending doctors was carried out in the Departments of Obstetrics & Gynaecology and Paediatrics at the teaching hospitals of the Universities of Maastricht and Amsterdam, the Netherlands. RESULTS: Attending doctors perceive teaching by residents to be beneficial for students and residents alike. Although they consider themselves to be better suited than residents to teach medical students, they see teaching as an integral part of residency training and feel it should be recognised as such by departments and medical schools. Attending doctors are in favour of a teacher training programme for residents, which should include communication, clinical and teaching skills as well as skills such as time management and (self-) assessment. DISCUSSION: Despite the uneven distribution of participants between the departments, no significant differences were found between departments. It is interesting that attending doctors perceive teacher training as beneficial to residents' teaching skills, but provide more feedback on residents' attitudes than on their teaching. The results show that, in general, attending doctors share residents' views that teaching is an important component of residency and that a teacher training programme for residents is to be recommended.     

How medical residents perceive the quality of supervision provided by attending doctors in the clinical setting

INTRODUCTION: The supervision of medical residents is a key responsibility of attending doctors in the clinical setting. Most attending doctors, however, are unfamiliar with the principles of effective supervision. Although inconsistent, supervision has been shown to be both important and effective for the professional development of medical residents. OBJECTIVE: To examine how medical residents perceive the supervisory roles of attending doctors, in terms of what they perceive as poor supervision and what they characterise as good supervisory practice. METHOD: We carried out a questionnaire survey of 38 medical residents at the Department of Paediatrics at the teaching hospital of the University of Amsterdam, the Netherlands. Attending doctors directly involved with the supervision of medical residents participated in the study. The clinical settings where supervision occurred included the neonatal and paediatric intensive care units and the general paediatric wards. RESULTS: Medical residents rated the quality of supervision they received in all departments positively. A majority of the attending doctors were rated highly in 'overall supervision'. Creating pleasant learning environments and being stimulated to learn and function independently were aspects of supervision characterised positively. Coaching in clinical skills and procedures, effective communication skills and clinical decision making using principles of cost-appropriate care were aspects of supervision found to be deficient. DISCUSSION: This study shows that medical residents enjoy supervision from collaborative, understanding and patient attending doctors. Medical residents prefer to be treated as adult learners and enjoy feedback that is constructive, measured and adapted to their professional needs.     

Training clinical teachers in psychiatry to teach interviewing skills to medical students

To study the feasibility of training all clinical teachers in psychiatry to teach interviewing skills to medical students, 24 (unselected clinicians were assigned to one of four different training methods. They received either experiential or didactic instruction, and their initial teaching sessions were either supervised or unsupervised. A total of 287 medical students subsequently received feedback training from these teachers. While all students showed significant increases in skill after training, those taught by experientially trained teachers showed the greatest gains. Neither supervision nor the teachers' own interviewing skills exerted significant effects on students' performance. It is concluded that with only brief training unselected clinicians can become effective teachers of essential interviewing skills. Feedback training in such skills can, therefore, be incorporated into existing curricula without major disruption of other requirements.     

Clinical teachers and problem-based learning: a phenomenological study

AIM: To explore how clinicians perceive their roles in problem-based medical education, and how closely those perceptions link to the curriculum they teach. METHOD: All 14 general physicians in a teaching hospital took part in 6 semistructured discussions, which were analysed phenomenologically. RESULTS: Third year clinical teaching was described in terms that bore little relation to problem-based learning (PBL). Teachers placed great importance on the social dimension of professional learning. They expressed strongly positive affects towards learners and their learning that they found hard to express as PBL tutors. Their narratives of education were remarkably divorced from modern day clinical practice. CONCLUSIONS: Problem-based method lacked some important conditions for professional teaching and learning. Traditional apprenticeship is unsustainable under present day conditions of practice. There is a need for new educational methods that help the learner to build a professional identity through social interaction with practitioners.     

Standards for medical educators

Context In the current UK socio‐political climate of mounting regulation of professional practice, a debate on the topic of standards amongst medical teachers seems timely. The role of teacher is increasingly recognised as a core professional activity for all doctors and one that cannot be left to chance, aptitude or inclination. As a consequence, faculties have developed a plethora of teacher training programmes for medical teachers. But what is good medical teaching? Unless we know what it is, how can we develop it? One possible approach is to develop clear and comprehensive standards, defining what we mean by competent or effective clinical teaching. Methods In this article we have evaluated and compared two models of standards for clinical educators. The first is the outcome‐based approach developed at Dundee Medical School and the second is the scholarship model devised initially by Boyer and then elaborated by Glassick and Fincher et al. The key features of both models are briefly described and their comparative strengths and problematic aspects explored. Conclusion Both models offer interesting and stimulating ideas and together they provide an instructive contrast. They make a valuable contribution to the ongoing process of improving the provision of medical education.     

The first batch of graduates of a new medical curriculum in Asia: how their teachers see them

OBJECTIVE: To examine teachers' views of the first batch of graduates of a revised medical curriculum in Asia. METHODS: A cross-sectional study using a structured questionnaire was carried out to obtain the views of all the clinical teachers involved in teaching final year students of the old curriculum in 2000-01 and the new curriculum in 2001-02 at the University of Hong Kong, which commenced curricular reform in 1997. RESULTS: Nearly 62% of respondents felt that better graduates were being produced with the new curriculum. The majority of them rated the new curriculum students better in nearly all the major goals of the new curriculum, such as self-directed learning initiative, problem solving skills, interpersonal skills and clinical performance in patient care. However, the core knowledge of the new curriculum students was of concern to some teachers. CONCLUSION: This study focused on the first complete cycle of a revised medical curriculum in Asia. Teachers' views of the new curriculum students were highly positive and they felt that better graduates were being produced.     

A framework for developing excellence as a clinical educator

The current emphasis on providing quality undergraduate and postgraduate medical education has focused attention on the educational responsibilities of all doctors. There is a greater awareness of the need to train doctors as educators and courses have been set up to satisfy this need. Some courses, such as those on how to conduct appraisal, are specific to one task facing a medical educator. Other courses take a broader view and relate educational theory to practice. In this paper we describe an outcome-based approach in which competence in teaching is defined in terms of 12 learning outcomes. The framework provides a holistic approach to the roles of the teacher and supports the professionalism of teaching. Such a framework provides the basis for the development of a curriculum for teaching excellence. It helps to define important competences for different categories of teachers, communicate the areas to be addressed in a course, identify gaps in course provision, evaluate courses, assist in staff planning and allow individuals to assess their personal learning needs. The framework is presented to encourage wider debate.     

Factors influencing prescribing: an intern's perspective

OBJECTIVES: To examine the self-reported influences on intern prescribing practice. DESIGN: Qualitative interviews with a cross-sectional cohort. PARTICIPANTS AND SETTING: Ten interns practising in two urban teaching hospitals in New South Wales, Australia. RESULTS: The interns identified a number of factors that improve their confidence and perceived competence and allow them to extend their existing skills. These were approachable, available and up-to-date teachers (most often registrars and subspecialty nurses and pharmacists); timely, relevant and practical teaching (such as interactive bedside teaching); concise and widely accepted resources (such as prescribing pocket guides); and a constructive manner on the part of senior staff for dealing with prescribing errors. Interns also identified influences that are detrimental to confidence, conflict with their perceptions of appropriate prescribing and inhibit learning and skills acquisition. These were unapproachable, physically and mentally remote teachers (most often consultants); theoretical, inconsistent and irrelevant teaching (such as grand rounds or didactic education sessions); inconsistent and inaccessible resources; and a confrontational and accusatory way of dealing with prescribing errors. The added pressures of time, hospital hierarchies and the indirect influence of drug company promotion also impeded acquisition of good prescribing habits. CONCLUSIONS: At a critical time in skills development, interns encounter many forces that can potentially impact on prescribing practices in both positive and negative ways. Our data contribute to the understanding of the multifaceted learning environment of interns and may be useful in providing a foundation for prescriber education programmes tailored to the specific needs of junior doctors.     

Attending doctors' perspectives on how residents learn

CONTEXT: Graduate medical education is currently facing major educational reforms. There is a lack of empirical evidence in the literature about the learning processes of residents in the clinical workplace. This qualitative study uses a 'grounded theory' approach to continue the development of a theoretical framework of learning in the clinical workplace by adding the perspective of attending doctors. METHODS: A total of 21 Dutch attending doctors involved in the training of residents in obstetrics and gynaecology participated in 1 of 3 focus group sessions. They discussed their perceptions of how residents learn and what factors influence residents' learning. A grounded theory approach was used to analyse the transcribed discussions. RESULTS: Three related themes emerged. The first concerned the central role of participation in work-related activities: according to attending doctors, residents learn by tackling the everyday challenges of clinical work. The second involved the ways in which attending doctors influence what residents learn from work-related activities. The final theme focused on attending doctors' views of the essential characteristics of residents and their development during residency. CONCLUSIONS: Attending doctors' perspectives complement current insights derived from similar research among residents and from related literature. As part of an ongoing effort to further develop understanding of how residents learn, this study adds several ways in which attending doctors strive to combine guidance in both patient care and resident training. Furthermore, attending doctors' perspectives draw attention to other aspects of learning in the clinical workplace, such as the role of confidence and the balance between supervision and independence.     

How clinical communication has become a core part of medical education in the UK

Context  This paper sets out to analyse and interpret the complex events of the last 20 years in order to understand how the teaching and learning of clinical communication has emerged as a core part of the modern undergraduate medical curriculum in most medical schools in the UK.
Methods  The paper analyses the effects of key political, sociological, historical and policy influences on clinical communication development.
Results  Political influences include: the effects of neo-liberalism on society and on the professions in general; the challenging of traditional notions of professionalism in medicine; the creation of an internal market within the National Health Service, and the disempowerment of the medical lobby. Sociological influences include: the effects of a 'marketised' society on medicine and subtle shifts in the doctor−patient relationship because of this; the emergence of globalised information through the Internet, and the influence of increased litigation against doctors. Historical influences include: the effects of a change in emphasis for medical education away from an inflated factual curriculum towards a curriculum that recognises the importance of student attitudes and the teaching and learning of clinical communication skills. Policy influences include the important effects of Tomorrow's Doctors and the Dearing Report on the modern medical curriculum.
Conclusions  The paper concludes with a developmental map that charts the complex influences on clinical communication teaching and learning and a brief commentary on the growing body of teachers who deliver and develop the subject today.     

Simulation in undergraduate medical education: bridging the gap between theory and practice

OBJECTIVE: To evaluate the use of simulation-based teaching in the medical undergraduate curriculum in the context of management of medical emergencies, using a medium fidelity simulator. DESIGN: Small groups of medical students attended a simulation workshop on management of medical emergencies. The workshop was evaluated in a post-course questionnaire. SUBJECTS: All Year 4 medical students allocated to the resuscitation rotation during the first half of 2002. MAIN OUTCOME MEASURES: Student perceptions of learning outcomes, the value of the simulation in the undergraduate curriculum and their self-assessed improved mastery of workshop material. RESULTS: A total of 33 students attended the workshop and all completed questionnaires. Students rated the workshop highly and found it a valuable learning experience. In all, 21 (64%) students identified teamwork skills as key learning points; 11 (33%) felt they had learnt how to approach a problem better, particularly in terms of using a systematic approach, and 12 (36%) felt they had learnt how to apply their theoretical knowledge in a clinical setting better. All 33 students were positive about the use of simulation in their training; 14 students wrote that simulation should be used more or should be mandatory in training; 5 students commented positively on the realism of the learning experience and a further 5 said they valued the opportunity to learn new skills in a safe environment. CONCLUSION: This study demonstrates that medical students value simulation-based learning highly. In particular, they value the opportunity to apply their theoretical knowledge in a safe and realistic setting, to develop teamwork skills and to develop a systematic approach to a problem. A medium fidelity simulator is a valuable educational tool in medical undergraduate education.     

Teaching the consultant teachers: identifying the core content

OBJECTIVES: To determine the key themes for teaching hospital consultants how to teach. DESIGN: 1. In-depth interviews with a total of 19 experts, consultants and junior doctors to identify key topics. 2. Literature review from 1969 to obtain the main themes from the medical educational literature. 3. Analysis of the main themes in 11 'Teaching the teachers' courses. 4. Triangulation of interview data, literature themes and teaching courses content to generate 15 criteria for a questionnaire. 5. Questionnaire study to 593 senior and junior hospital doctors. SETTING: Hospitals in the West Midlands Region in England. SUBJECTS: Consultants and junior hospital doctors. RESULTS: Overall, 441 doctors replied (74% response rate). The top five themes were giving feedback constructively, keeping up to date as a teacher, building a good educational climate, assessing the trainee and assessing the trainee's learning needs. Results showed no statistically significant differences in the order of themes for all groups analysed, including seniority, gender, specialty, origin by medical school and consultants of different ages. CONCLUSIONS: Consultants need teaching in these topics. There are implications for funding and providing these courses for postgraduate deans, Royal Colleges and universities. Further research is needed to evaluate whether such an initiative does produce better teaching and learning, and a better educational climate in hospitals.     

How residents learn: qualitative evidence for the pivotal role of clinical activities

OBJECTIVES: Medical councils worldwide have outlined new standards for postgraduate medical education. This means that residency programmes will have to integrate modern educational views into the clinical workplace. Postgraduate medical education is often characterised as a process of learning from experience. However, empirical evidence regarding the learning processes of residents in the clinical workplace is lacking. This qualitative study sought insight into the intricate process of how residents learn in the clinical workplace. METHODS: We carried out a qualitative study using focus groups. A grounded theory approach was used to analyse the transcribed tape recordings. A total of 51 obstetrics and gynaecology residents from teaching hospitals and affiliated general hospitals participated in 7 focus group discussions. Participants discussed how they learn and what factors influence their learning. RESULTS: An underlying theoretical framework emerged from the data, which clarified what happens when residents learn by doing in the clinical workplace. This framework shows that work-related activities are the starting point for learning. The subsequent processes of 'interpretation' and 'construction of meaning' lead to refinement and expansion of residents' knowledge and skills. Interaction plays an important role in the learning process. This is in line with both cognitivist and sociocultural views on learning. CONCLUSIONS: The presented theoretical framework of residents' learning provides much needed empirical evidence for the actual learning processes of residents in the clinical workplace. The insights it offers can be used to exploit the full educational potential of the clinical workplace.     

Residents' perceptions of their teachers: facilitative behaviour and the learning value of rotations

Summary. Despite changes in modern medicine the role of the clinical teacher remains central to medical residents' education and rotations continue to be their dominant educational context. Residents have strong positive feelings for clinical teachers who are perceived as interested in teaching and for those rotations that provide a balance of educational opportunities and patient care responsibilities. Research in residency education has focused on teacher behaviours used to teach medical residents clinical information or patient care skills but has neglected teacher behaviours used to facilitate effective learning relationships with residents. To explore the impact of clinical teachers' use of facilitative behaviours on residents' educational experience, we use concepts stemming from the psychologist Carl Rogers' work previously shown to be associated with positive learning outcomes — empathy, unconditional positive regard, and congruence. These constructs are measured by the use of the four scales of the Barrett-Lennard Relationship Inventory (BLRI) — level of regard, unconditionality of regard, congruence and empathy. Our study measures the correlation between residents' perceptions of clinical teachers' use of facilitative behaviours and residents' evaluation of the learning value of rotations. Thirty-three residents completed the BLRI on a different clinical teacher for each of six monthly rotations. A total of 158 surveys were returned. There were strong positive correlations between three of the BLRI variables and residents' perception of the learning value of rotations. Potential uses of these findings are discussed.     

Integrating the teaching role into one’s identity: a qualitative study of beginning undergraduate medical teachers

Beginning medical teachers often see themselves as doctors or researchers rather than as teachers. Using both figured worlds theory and dialogical self theory, this study explores how beginning teachers in the field of undergraduate medical education integrate the teacher role into their identity. A qualitative study was performed, involving 18 beginning medical teachers at a Dutch medical school. The teachers were interviewed twice and kept a logbook over a period of 7 months. The study shows that the integration of the teacher role into the teachers’ identity was hampered by the idea that teaching is perceived by others as a low status occupation. Some teachers experienced significant tension because of this, while others showed resilience in resisting the negative associations that were thought to exist regarding teaching. The teachers used five different identity narratives in order to integrate the teacher role into their identity, in which the positions of teacher and doctor or researcher were found to be combined, adopted or rejected in diverse ways. The five identity narratives were: (1) coalition between the I-position of teacher and other I-positions; (2) no integration of the I-position of teacher: holding on to other I-positions; (3) construction of the I-position of teacher and other I-positions as opposites; (4) coalition between the I-position of teacher and a third position of coordinator; and (5) meta-position: trivialising the importance of status. These identity narratives offer starting points for supporting undergraduate teachers during their early professional years.     

Linking assessment to learning: a new route to quality assurance in medical practice

BACKGROUND: If continuing professional development is to work and be sensible, an understanding of clinical practice is needed, based on the daily experiences of doctors within the multiple factors that determine the nature and quality of practice. Moreover, there must be a way to link performance and assessment to ensure that ongoing learning and continuing competence are, in reality, connected. Current understanding of learning no longer holds that a doctor enters practice thoroughly trained with a lifetime's storehouse of knowledge. Rather a doctor's ongoing learning is a 'journey' across a practice lifetime, which involves the doctor as a person, interacting with their patients, other health professionals and the larger societal and community issues. OBJECTIVES: In this paper, we describe a model of learning and practice that proposes how change occurs, and how assessment links practice performance and learning. We describe how doctors define desired performance, compare actual with desired performance, define educational need and initiate educational action. METHOD: To illustrate the model, we describe how doctor performance varies over time for any one condition, and across conditions. We discuss how doctors perceive and respond to these variations in their performance. The model is also used to illustrate different formative and summative approaches to assessment, and to highlight the aspects of performance these can assess. CONCLUSIONS: We conclude by exploring the implications of this model for integrated medical services, highlighting the actions and directions that would be required of doctors, medical and professional organisations, universities and other continuing education providers, credentialling bodies and governments.     

Characteristics of doctors and nurses as perceived by students entering medical school: implications for shared teaching

INTRODUCTION: Debate continues with respect to when to introduce interprofessional education for maximal potential benefit. One perspective is that interprofessional education should be introduced early in the undergraduate curriculum before students develop stereotyped impressions of other professional groups. However, it may be that students at entry to medical school have already developed these stereotypical impressions. This study examines perceived professional characteristics of doctors and nurses by students entering medical school. METHODOLOGY: Year 1 medical students in 4 consecutive years completed a questionnaire on their perceptions of the characteristics and backgrounds of nurses and doctors and on their attitudes to shared teaching. RESULTS: Year 1 medical students were found to perceive the characteristics of doctors and nurses differently. They considered nurses to be more caring and doctors to be more arrogant. They considered nurses to have lower academic ability, competence and status, although comparable life experience. They were generally very positive about beginning shared learning at an early stage of training. DISCUSSION: Whilst it is encouraging that medical students are positive about shared teaching, it is of concern that they have a poor perception of the academic ability, status in society and professional competence of the nurse at entry to medical school. These perceived impressions, which may reflect societal misconceptions regarding the roles and responsibilities of nurses within a modern health care system, may have an impact on the success of early interprofessional teaching initiatives in undergraduate curricula.