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.     

Pre-registration rotations into general practice: the concerns of pre-registration house officers and the views of hospital consultants

AIMS: To explore the concerns of pre-registration house officers (PRHOs) and the views of hospital consultants in relation to pre-registration rotations with a general practice component. METHOD: As part of a larger qualitative study evaluating how a group of 24 PRHOs learn in hospital and primary care settings, face-to-face semistructured interviews were conducted with the PRHOs, and semistructured telephone interviews with the PRHOs' educational supervisors were carried out. RESULTS: The interviews with the PRHOs highlighted their concerns about how consultants might view PRHO rotations into general practice. However, the majority of consultants interviewed recognized and valued specific aspects of the experience to be gained by PRHOs in general practice, including the relationship between primary and secondary care; communications skills; specific clinical skills, and an understanding of the natural course of illnesses. The experience was seen as valuable for PRHOs considering either a general practice or a hospital career. Of the 17 consultants, 10 were also confident that 4-month placements in surgery and medicine would give PRHOs adequate experience in either specialty, providing the placements were sufficiently busy. CONCLUSIONS: Medical school deans and medical students considering PRHO rotations with a general practice component can be encouraged by the fact that, in this small study, the majority of hospital consultants interviewed valued the specific experience offered by these rotations, and felt that adequate medical and surgical experience could be gained in busy 4-month hospital placements.     

A system for maintaining the educational and training standards of junior doctors

The development of junior doctors' competence is complex because the hospital environment in which doctors work places many demands on them. The need for quality education and training and personal development may be in direct conflict with the service commitments required from hospitals. This paper describes the methods by which the Postgraduate Medical Council of New South Wales, Australia, addresses the needs of junior doctors in the state in order to improve the quality of their education. Key elements of the Council's function include the provision of hospital clinical supervisors who oversee junior doctor education and training, and central involvement in supplying the junior doctor workforce to all state hospitals who must meet defined accreditation standards. This paper also provides data on evaluation of those methods and some educational outcomes.     

The Medical Skills Centre at the University of Calgary Medical School

The aim of the Medical Skills Centre at the University of Calgary is to provide a predictable learning environment and standardized teaching methods in the area of clinical skills teaching. The centre uses volunteer patients and trained actors for all levels of medical education and evaluation. A computer database enables easy access to groups of patients and varying medical issues. This article describes the organization and operation of the Medical Skills Centre and notes a variety of courses which use the unique facilities of the centre.     

Accreditation of Undergraduate and Graduate Medical Education: How do the Standards Contribute to Quality?

Accreditation organizations such as the Liaison Committee for Medical Education (LCME), the Royal College of Physicians and Surgeons of Canada (RCPSC), and the Accreditation Council for Graduate Medical Education (ACGME) are charged with the difficult task of evaluating the educational quality of medical education programs in North America. Traditionally accreditation includes a more quantitative rather than qualitative judgment of the educational facilities, resources and teaching provided by the programs. The focus is on the educational process but the contributions of these to the outcomes are not at all clear. As medical education moves toward outcome-based education related to a broad and context-based concept of competence, the accreditation paradigm should change accordingly.     

Evaluating primary care as a base for medical education: the report of the Cambridge Community-based Clinical Course

BACKGROUND: Medical students receive increasing amounts of their clinical education in a primary care setting. The educational possibilities of such attachments are still being explored. AIM: To report the evaluation of a small, radical innovation to provide students with a long-term community attachment which integrated with hospital-based education. METHOD: Between 1993 and 1998, 13 medical students completed 15-month attachments with a single general practice in England. The course offered them experience in the major clinical specialties throughout this period. Students were exposed to specialist as well as generalist education in the context of patients with whom they could establish a continuing relationship. The innovation was evaluated by its feasibility, by students' examination results, by analysis of clinical experience, through formal student feedback and by cost. RESULTS: The course was practicable in a particular setting with academic leadership. The students all passed their exams. They had wide, appropriate clinical experience even though the attachment was to a single practice. When they returned to the hospital environment, students did not feel themselves at a disadvantage compared with traditional students. The costs of the course are controversial: placement costs were higher than in the hospital, but those for facilities were lower. CONCLUSION: It is possible to run a course like this successfully. It remains the most radical attempt to share clinical education in the UK between primary and secondary/tertiary care. Further research is required into providing long-term clinical attachments in NHS primary care settings.     

Promoting effective teaching and learning: hospital consultants identify their needs

OBJECTIVES: The aim of this study was to help hospital consultants identify their needs in relation to teaching skills, leading to the development of a teacher training programme. DESIGN: The study was directed at all 869 consultants in the region and initially involved a postal questionnaire which had a 60.5% response rate. SETTING: Hospitals throughout Northern Ireland. SUBJECTS: Hospital consultants. RESULTS: Results from this questionnaire indicated that while the majority of respondents were interested teachers, only 34% had received any teacher training. The questionnaire was followed by a focus group study involving three groups of consultants drawn randomly from those who had responded to the questionnaire. Participants in these groups identified the following key areas of hospital education: qualities of hospital teachers; selection procedures; problems of teaching in hospitals; the need for teacher training and how it should be provided. CONCLUSION: The study highlighted that hospital teachers need to acquire and update their teaching skills through attending courses that should include basic teaching and assessment/appraisal skills. These courses should last 1 or 2 days and be provided at a regional or subregional level. As a result of this study, teacher training courses have been developed in this region.     

Development and validation of the Attitudes Towards the Homeless Questionnaire

CONTEXT: The homeless are a significant group within society, which is increasing in size. They have demonstrably greater physical and mental health needs than the housed, and yet often have difficulty accessing primary health care. Medical 'reluctance' to look after homeless people is increasingly suggested as part of the problem. Medical education may have a role in ameliorating this. OBJECTIVES: This paper reports on the development and validation of a questionnaire specifically developed to measure medical students' attitudes towards the homeless. METHOD AND RESULTS: The Attitudes Towards the Homeless Questionnaire, developed using the views of over 370 medical students, was shown to have a Pearson test-retest reliability correlation coefficient of 0.8 and a Cronbach's alpha coefficient of 0.74. CONCLUSIONS: The Attitudes Towards the Homeless Questionnaire appears to be a valid and reliable instrument, which can measure students' attitudes towards the homeless. It could be a useful tool in assessing the effectiveness of educational interventions.     

Challenges of educating for medical professionalism: who should step up to the line?

Context  The teaching of professionalism has recently become an important issue in medical education. Medical professionalism remains controversial, but several recently published institutional documents on professionalism seem to express an implicit, yet broad consensus on three points: that professionalism mainly consists of adherence to a specific set of professional attributes constitutive of medical role morality and readily identifiable as virtues of medical professionalism (VMP); that medical education needs to focus on the endowment of these attributes, and that medical ethicists should play a central role in assuming this educational responsibility.
Methods  This paper examines the assumption that the task of supporting the development of the VMP should primarily fall to medical ethicists. Considerations in favour of this position are weighted against a set of countervailing considerations. The latter include the charge that the VMP are too vague as educational guidelines, that they may not be teachable, and that the responsibility for their development must be shared across the medical faculty.
Conclusions  Medical ethics educators are right to embrace the professionalism agenda on four conditions: that the limitations of addressing the formation of professional attributes in university-based teaching are recognised; that there is clinical as well as university-based evaluation of professional attributes; that the development of the VMP as a process of professional socialisation is seen as an interdisciplinary educational project, and that the examination and explanation of the cognitive grounds of the VMP are the focus of medical educators' activities.     

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.     

Views of junior doctors on the specialist registrar (SpR) training scheme: qualitative study of UK medical graduates

OBJECTIVE: To report junior doctors' views on specialist registrar (SpR) training. DESIGN: In 1999, as part of ongoing studies of doctors' careers, we surveyed all doctors who had qualified from UK medical schools in 1993. Structured questions about recipients' careers were accompanied by a form inviting free text comments. Comments about the SpR scheme were extracted for analysis. RESULTS: Doctors commented that there were insufficient national training numbers (NTNs) for those who wanted them, and that more than the minimum entry requirements seemed necessary for shortlisting. Strengthening curricula vitae through research and published work could prolong the duration of training and did not guarantee success. Specialist registrar training was considered by some respondents to be narrow and inflexible, with service work taking priority over training needs. As a result, some respondents feared they would not be competent to practise as consultants. There was a perceived shortage of consultant vacancies and 6 months was considered insufficient time for obtaining a suitable post. DISCUSSION: It is inevitable that doctors may not necessarily be able to pursue their initially chosen career paths. Trainers need to provide realistic advice about career opportunities. Provision of information about NTN availability and formal career counselling could help to prevent delays in career progression. The shortened and more structured programme of training has reduced its flexibility in some doctors' experience. Improvements in educational content will need greater input from consultants, which may require an increase in consultant posts. Time will tell whether concerns about competence to practise as consultants and consultant post availability will be justified.     

Identifying core skills for the medical curriculum

A survey was undertaken at the University of Sheffield Medical School to identify clinical and other professional skills which are required on graduation and to assess whether and when these skills have been acquired. The purpose of the survey was to identify core practical skills, defined as skills which the majority of clinical firms require and which, in addition, were used by the majority of Pre-registration house officers (PRHOs). The survey was conducted by questionnaires which were circulated to the following four sample groups (number in sample: % response rate): (1) consultants in clinical firms taking undergraduates and post-graduates from Sheffield Medical School (63: 75%); (2) house officers starting their pre-registration year (118: 52%); (3) house officers ending their pre-registration year (120: 43%); and (4) undergraduates starting their final year (110: 65%). The questionnaire contained a stimulus list of 31 clinical and four personal skills with an opportunity for respondents to list other skills they felt to be important. Of the 35 skills listed on the questionnaire, 26 were identified as core practical skills. Fifteen of the core skills had been acquired by the majority of students by the time they graduated, 13 of which were acquired prior to the final undergraduate year. Core skills not acquired as an undergraduate were acquired as a PRHO. The survey acted as a quality control mechanism for teaching at both undergraduate and post graduate levels and provided the basis of a medical school core of practical skills on the basic medical education continuum.     

The medical school as a social organization: the sources of resistance to change

Medical schools vary by nation and by culture but, for students, the experience appears to be very similar. Also, despite a half-century of radical changes in medical practice, education as a process of socialization for the profession is relatively unchanged. At the same time, medical educators have frequently instituted curricular reforms. To analyse this history of reform without change, this paper first establishes what the content and structure of medical education is, and how it came to be that way; second it traces a process whereby the scientific mission of academic medicine has crowded out its social responsibility to train for society's most basic health-care delivery needs. The main argument is that medical education's manifest humanistic mission is little more than a screen for the research mission that is the major thrust of the institution's social structure.     

The current status of senior house officer postgraduate education in a single region

OBJECTIVE: To assess postgraduate education (PGE) for paediatric senior house officers (SHOs) in a single region. METHODS: A survey of all paediatric SHOs in the region was undertaken in the form of a questionnaire and telephone contact. The standard set by the Committee of Postgraduate Medical Deans for SHO education formed the basis for the questionnaire; there should be (i) a designated educational supervisor for each SHO, (ii) regular work appraisal and counselling and (iii) 4 h protected teaching per week. Supplementary questions were asked regarding methods of teaching and study leave. RESULTS: There was a 92% response rate from SHOs and 90% of SHOs contacted had a named educational supervisor. The mean time for protected teaching per week was 2.14 h, although this varied widely between centres. There were many different teaching methods used and 82% of SHOs had no difficulty in obtaining study leave. There was a particular problem for those who were working shifts or cross-covering. CONCLUSIONS: Our study has shown that paediatric SHOs in Wales are reasonably satisfied with their postgraduate education, although there is considerable variation between different units. Several areas have been highlighted which need to be improved if we are to provide SHOs with adequate preparation for the specialist registrar training grade.     

The value of marginality in a medical school: general practice and curriculum change

OBJECTIVE: To report the process of introduction, development and sustenance of a curriculum for a department of general practice in the context of changing curricula required by the General Medical Council. SETTING AND CONTEXT: Tayside Centre for General Practice, the Department of General Practice within Dundee University Medical School. METHODS: Use of action research methodology common in educational and sociological research. Action research utilizes a range of data collection techniques which allow the participants in the research full opportunities to reflect on the data as it emerges and make developments accordingly. ANALYSIS: This took place as part of the process of the 5-year project. The analysis used as its starting point the sociological theory of the social construction of power within institutions. It offers the thesis that marginality seems to be a prerequisite in confronting institutional conservatism. CONCLUSIONS: Use of an action research model facilitated more effective change by providing a supportive atmosphere in which to tackle changes. The marginal status of the general practice group in relation to the medical school allowed creative negotiation of alliances within the medical school. Other groups within the medical school who are introducing new curricula can learn from this report.     

Promoting professional knowledge, experiential learning and critical thinking for medical students

It has been recognized internationally that undergraduate medical education must adapt to changing needs, as illustrated by the Tomorrow's Doctors recommendations from the General Medical Council. This paper aims to relate contemporary educational theory to under-graduate medical educational requirements, specifically highlighting conditions (e.g. experiential learning) for: professional knowledge acquisition; critical thinking, problem-solving and clinical problem-solving; and lifelong professional learning. Furthermore, problem-based learning (PBL) is highlighted as potentially providing such conditions. There are lessons from contemporary educational theory for the reform of undergraduate medical education. These include valuing prior knowledge and experience; promoting learner responsibility through facilitating rather than directing learning; encouraging learners to test out and apply new knowledge, and using small-group work to foster explicitly the elusive skills of critical thinking and reflection. Contemporary educational theory contributes valuable insights, but cannot dictate the ultimate 'mix'; at best it provides some principles for reflective analysis of the learning experiences created for tomorrow's doctors.     

Elaborated learning in undergraduate medical education

Southampton Medical School holds its major examination of basic knowledge after rather than before students enter their first clinical attachments. An interview survey investigated its educational effects, and found that students adopt one of four revision approaches. The most successful, not just in terms of examination grade but more particularly in students' subsequent ability to retrieve and use the knowledge gained, occurred when students related their preclinical revision to their clinical experiences. One of these approaches, an elaboration of knowledge, is considered to be essential for effective clinical thinking yet is probably rare elsewhere in medical education since it appears to be a consequence of a particular curricular arrangement. An explanation is given in terms of current thinking in cognitive psychology, and this challenges the theoretical assumptions on which other research in medical education has been uncritically based. Some implications for medical education and further research are discussed.     

Medical education and medical education research and development activities in modern China

The development of medical education in China occurred quite differently to medical education in the rest of the world. A review of the literature has been presented regarding the historical development and the evolution of medical education research and development (MERAD) units in modern China. The history of medical education in modern China has been divided into three periods: (1) the 17 years before the 'Cultural Revolution' (1949-1966); (2) the period of the 'Cultural Revolution' (1966-1976); (3) the post 'Cultural Revolution' period (1976 onwards). Although a number of MERAD activities had existed on China's medical campuses since 1949, there was no formal organizational structure for MERAD before 1978. The change of the political situation in 1978 led China to seek modernization, with education as its basis. In the process of health care system modernization, medical education was given priority, and the Western model of establishing MERAD units as a means of improving the training of health professionals was introduced. The evolution of medical education research and development in modern China appears to be following the Western pattern due to the multitude of Western consultants and fellowships in Western countries provided to Chinese medical education leaders. A group of people from medicine is gathering in the MERAD field and MERAD units are beginning to take shape in modern China.     

Training in assessment and appraisal: who needs it?

The aim of this project was to develop a training programme to help consultants supervising postgraduate medical trainees to fulfil their role as Educational Supervisors. A training needs analysis was conducted which revealed that consultants did not appreciate the importance of some of their new duties. This was mainly because of the lack of clear perception of their new roles. Hence training needs to be provided.     

Learning together in medical and nursing training: aspirations and activity

CONTEXT: Policy documents about service innovation, education priorities and professional development exhort professions to learn together and work collaboratively. However, the literature suggests that the existence of shared learning in medical and nursing pre-qualifying education is patchy. AIM: This paper does not claim to be research. It sets out to reflect on the trends and tensions in key policy directions, relating these to aspirations and a mapping of current intiatives in the sphere of medical and nursing pre-qualifying education. APPROACH: A limited national information gathering exercise was conducted during the planning phase of seminars hosted by the Centre for the Advancement of Interprofessional Education (CAIPE) in 1996 and 1997. This involved directly contacting all medical schools and departments of nursing and midwifery in geographical proximity, or with an institutional relationship. Information was sought on current or planned activity in shared learning, defined as medical and nursing students and/or working together. EMERGING THEMES: There were a few examples of shared learning identified by the mapping exercise. The paper discusses these and draws on the consensus that emerged from the seminars on objectives and topics for shared learning. It concludes with a discussion of what makes for success or failure in such ventures with suggestions for future educational policy development.