Monthly Archives: September 2017

When to teach “how to teach”

The answer to this question is probably “when someone on the curriculum committee tells us to” or perhaps when it is mandated by a government who suddenly wake up to the fact there may not be enough willing teachers for the graduates being produced.

Today I went for a walk along the Foreshore. Half way along I realised I had left my phone behind.  I nearly turned back.  What is the point of walking that distance if your steps aren’t being formally counted by your pedometer and recorded?  This is how far I have descended into the tick-box culture!  Similarly, in the workplace, when documentation assumes such importance we are tempted to stop doing other things that are difficult to document.  This reminded me of an article I was alerted to two days ago in Medical Teacher Are Australian medical students being taught to teach?

This article noted the accepted line of the increased demand for teaching and supervision (because of growth in numbers) and the study aimed (via a 22 item questionnaire to 19 medical schools) to find out what there is in terms of programs for “teaching skills”. Not surprisingly there was a variety of compulsory and elective courses.

I guess a larger question is whether utilising all these busy, variably-trained students and doctors-in-training is the cheap solution policy makers are always looking for? Interestingly two schools reported that they did not offer peer-to-peer teaching opportunities because of time and staffing constraints but also the belief that the quality of expert teaching is superior.  Certainly this is an issue not to ignore and short and long-term feedback should be sought on peer and near-peer teaching.  As with many good ideas, the implementation makes the difference.  Post graduate colleges have also diligently added teaching skills to their requirements in the last couple of decades and, of course, several of the inter-related CanMEDS roles relate to this.

The upskilling of junior and senior hospital doctors in teaching skills has frequently been raised and courses such as Teaching on the Run have gone a way toward filling in the practical gaps here and competence to teach certainly gets a mention in the curricula for RACGP and ACRRM. Training organisations are entrusted with teaching these somewhat labyrinthine curricula but what does it mean to tick that particular box?  There can be a gap between curriculum, syllabus and what actually happens on the ground – even if they are written in terms of competency outcomes.  What is required in post-graduate training also raises the issue of what skills can be assumed to have been effectively acquired at undergraduate level.

The RACGP curriculum notes that GPs may teach both patients and other health professionals and that “All GPs have the capacity to inspire, to be teachers, mentors and leaders in the art of general practice to improve outcomes for their patients and for the broader community.” and they document specific outcomes such as:

CS4.3.1 Professional knowledge and skills are effectively shared with others  At the registrar level this includes:

CS4.3.1.1b Develop strategies to share recently acquired skills and knowledge with peers

CS4.3.1.2b Assist peers and colleagues to identify and prioritise areas of clinical knowledge and skill that are in need of development

CS4.3.1.3b Identify strategies to create an inclusive team-based approach to teaching and leadership

These outcomes are reasonably limited to the specific context but it may be a challenge to measure when outcomes are achieved and it is not very specific in terms of teaching skills.  Similarly, in ACRRM there is a Research and Teaching chapter and one of the essential skills is the ability to communicate scientific information effectively with patients and colleagues. There is an expectation that (6.12) doctors “Teach and clinically supervise health students, junior doctors and other health professionals” and there is some detailing of the sub-skills required for teaching and supervision under “definition of terms” (perhaps relevant to the skills and competencies that supervisors are utilising in teaching the trainees).

Thus, there is the curriculum and accountability approach but it is obviously difficult to find a balance between core and non-core skills in such an area and therefore difficult to simultaneously assure basic competencies and encourage excellence and expertise.  On the other hand, reflect on how you became interested in and enthused about teaching. For me it started decades back when I was a medical student in the first year of the Newcastle Medical School. It was the first school to implement Problem-Based Learning in Australia and it was impossible to be a learner in the system and not be aware of the commitment and enthusiasm of the staff to a philosophy of education. So while we were acquiring the “facts” we were also debating the “process” and many of us took this into later learning and teaching – without being told to do that.  The commitment of teachers and staff in a program is a crucial factor.

At this point I would just point out some practical questions worth asking from an educational point of view:

  • Is the transfer of these skills happening in your program? What is an effective rather than efficient approach? There are studies in the literature that address some of these individual questions and it would be nice to base practice on some evidence.
  • Is there a learning environment to facilitate it within the training system?
  • At what level of training is it best to learn how to teach – given that learning is optimal at the point of need (and other needs – such as passing exams – may be competing)?
  • Who is it best to teach – should it be a requirement for everyone or should energy be expended differentially on those who express interest and aptitude?
  • How do people get enthused about teaching?

The article started with the assumption that numbers are increasing and this also has implications for the organisation of teaching. Do we know what is the benefit of a huge number of learners completing an online module compared to, for instance, having a process of identifying and mentoring a smaller number of future educators?  Are there gradations of involvement that could be encouraged?

So if you are a medical educator teaching a class of 80 trainees how might you best enthuse and skill them for future teaching? If you are a supervisor in a practice with one or more trainees, how might you achieve similar outcomes in your own particular environment- which may actually be more conducive to this?  How can educators and supervisors work together toward this goal and how will a training program meaningfully evaluate their effectiveness in this area?  Do you know if your learners are finishing their training program keen to come back as teachers and supervisors? Because this is what is needed for sustainability.

It may be a waste of time to demand learners achieve goals about teaching skills when they are distracted by upcoming and high-stakes exams. It is probably both unfair and ineffective.  It may also be a waste of time if they do not get the chance to reinforce these skills during training.  At the post-graduate level their need to acquire knowledge and skills to treat patients is a powerful motivator (and competing factor).  You could take a more holistic approach where the educator unobtrusively conveys (but documents!) these skills through modelling, engagement and involvement and this may require more detailed planning of learning activities. . There is much evidence in the literature about the power of the role model in medical education (mentioned before in this blog) and it is often at this level that the supervisor has the most influence, along with a bit of nudging and supporting of the registrar to step up themselves (perhaps in a practice clinical meeting).  It is not unusual for learner feedback to comment when someone is “a great teacher”. As with other skills, they learn by observing and practising so repetition of the skills throughout training is preferable. Bear in mind that implementing a broader approach goes above and beyond usual requirements and therefore is less likely to be acknowledged. There are many worthwhile outcomes which are difficult to measure (and document) – just as lifting a few weights and going a really long walk with your phone in the wrong pocket will not look as impressive as it should; and struggling up an ancient spiral stone staircase to a scary rooftop is worth it for the exercise and the different perspective rather than the step count.

PS I have now worked out how to add steps to the ongoing tally on my phone – once I have already done the hard yards on the ground that is!  I guess this raises the issue of the temptation to document in an “optimistic” fashion!  But we won’t go there.