TEACHING AND LEARNING

Professionalism

Lia Fluit and Sanneke Bolhuis

Module Authors Quality and Development of Medical Education Department
University Medical Centre Nijmegen
The Netherlands

Hans Flaatten, Bergen, Norway

With input/comments Zahid Khan, Birmingham, UK
from Gavin Lavery, Belfast, Northern Ireland
Jacques-André Romand, Geneva, Switzerland
and the following members of the PACT Steering Committee: Dermot Phelan and
Janice Zimmerman

Graham RAMSAY
Editor-in-Chief Chairman of the PACT Steering Committee
Medical Director, West Hertfordshire Hospitals NHS Trust, UK
Past President, European Society of Intensive Care Medicine

Dermot Phelan, Dublin, Ireland

Sub-Editor

António Carneiro, Porto, Portugal

Module Editor

Lia Fluit, Medical Education Training and Consultancy (METC), Nijmegen, the
Educational Editor Netherlands

Kathleen A Brown, Triwords Limited, Tayport, UK

Editorial Manager

Laurence Van den Bossche, ESICM, Brussels, Belgium

Editorial Secretary

Teaching and learning

Professionalism
LEARNING OBJECTIVES

After studying this module on Teaching and learning, you should be able to:

1. Understand how professionals learn

2. Use effective methods for teaching in the clinical setting and other venues
3. Choose appropriate methods to assess clinical competence
4. Discuss components of a curriculum plan
5. Describe the evaluation process for learning experiences
FACULTY DISCLOSURES

The authors of this module have not reported any disclosures.

DURATION

7 hours

Copyright©2007. European Society of Intensive Care Medicine. All rights reserved.

ISBN 13 978-92-9505-193-5 - Legal deposit D/2005/10.772/40

INTRODUCTION
In order to deliver good healthcare we need to train young physicians well. Our medical
education and training programmes should deliver well-motivated practitioners who
continually learn and develop throughout their careers. Throughout this process, the
teacher plays a crucial role by facilitating the learning process, giving feedback to trainees,
being a role model and assessing trainees.
Most medical teaching is an every day activity that has to compete with other priorities
including busy clinical commitments.

Although many physicians are involved in training and most regard teaching as an intrinsic
part of their occupation, few have had the opportunity to formally learn teaching
techniques. This is even more relevant nowadays because of new insights into learning
and teaching and the broadening spectrum of competencies involved in clinical care.

'It goes without saying that no man can teach successfully who is not at the same
time a student.'
Sir William Osler
This module will help you to understand how people learn in medical practice and how
training takes place. Most trainees are involved in some sort of teaching and therefore fulfil
trainee and trainer roles as indeed pertains to personnel at all levels of the healthcare
system.

1/ UNDERSTANDING HOW PROFESSIONALS LEARN

Becoming a specialist in intensive care medicine takes years of training. Most of a trainee's
and practitioner's learning and continuing professional development takes place in the
clinical setting ('on the job'), with the rest from 'off the job' courses, workshops, simulation
sessions, skills teaching and self study.
In order to organise an effective training programme it is important to understand how
adults learn in professional practice and what influences this learning in both positive and
negative ways. As clinical teachers, we may ask ourselves what kind of learning we would
like to see in (newly qualified as well as experienced) physicians in medical practice. How
can we influence learning and the formation of learning habits in professional practice?

How do professionals learn?

Learning in practice is not like school learning

Learning in practice, as an adult, is different from learning in school, as a child Non scholae sed vitae
or student. Adults have amassed knowledge, skills and experience. Their discimus (we do not learn
motives and need to learn are often related to the competencies they need for for school but for life)
their daily work. They learn while pursuing goals at work. Seneca

Childhood/school learning is mostly individual, explicit, intentional, and organised learning,

whereas learning in practice differs in that:
 Daily social interaction plays an important role.
 Learning often happens implicitly and spontaneously.
 Intentions may not be directed to learning, but to activities (to getting a job
done, to becoming a physician, to prove oneself, to survival).
 Learning is not organised, but happens all the time – when no one is paying
attention, and as a side-effect of participation in the context of professional
practice (or life).
Two important aspects of learning in practice are spontaneous learning from experience
(experiential learning) and planned learning. These are summarised in the following table
and discussed in more detail below.

Spontaneous experiential learning

T HINK What do you remember of your 'first time' as an intern, resident, or new start in a hospital
department? What happened to you? What were your positive and negative impressions?

By immersion

Trainees who start working in the intensive care unit (ICU) will not only learn how to solve
clinical problems, but will also learn what kind of organisation it is: what are the implicit
rules, what is and is not done, how do the staff behave, what kind of behaviour is expected
from trainees, and how staff interact with one another, newcomers, and with patients. This
is learning by immersion. Trainees learn by participating in the social context, by
observing and adapting to the habits of the 'model' practice. Trainees acquire the habits of
the department without much explicit thought. Two important characteristics of this type of
learning are that 1) behaviour and performance become easier by routine; so that no extra
learning effort is needed and 2) the learning effects become deeply ingrained.

By doing

Trainees learn from their own direct experience in performing tasks. Although trainees may
learn much from their own problem solving, some of this learning may be rather by trial
and error, hopefully without adverse consequences. The tasks are not just the concern of
trainees, but part of the activities in the ICU. Intensive care practice is a social practice.
The staff may comment on the performance of newcomers, and discuss what they are
doing. For more information see the PACT modules on Organisation and
management and Communication skills .

Role modelling

Trainees will have many opportunities to observe how more experienced 'Junior doctors do not
colleagues perform their tasks. This is called model learning or observational simply learn from
learning. Who serves as a model depends on who a trainee considers consultants, but learn to be
competent, attractive, powerful, and trustworthy. Models can be positive or like the consultants they
negative. Trainees may copy less desirable behaviour from a negative model. It admire and respect'
is very difficult to learn alternative better behaviour in the absence of a good Alan Bleakley (2002)
model. When suboptimal behaviour is accepted as the norm (probably more
likely in a small unit or institution), newcomers will adapt to the norm most of
the time.

Social interaction

What it means to be a physician and how to become one, becomes clearer to trainee
physicians while participating in medical practice. Trainees learn from experienced
physicians but also from social interaction with and between patients, nurses,
administrative and paramedical professional staff, ambulance personnel etc. The daily
interaction teaches the trainee what it is to be a physician in that location, and the
respective positions of other participants.

Every participant in professional practice is learning spontaneously; it happens all the time,
NOTE
whether desired or not, and whether or not you are conscious of it. The results from
spontaneous learning in practice are quite marked, and have a direct and pervasive effect on
practice.

Spontaneous learning and its effects on practice, tend to be overlooked. The advantages
and disadvantages are listed in the table below.
 Spontaneous
learning in
practice

Socialisation and individual differences

The word socialisation is often used to refer to the spontaneous learning by which
newcomers learn to adapt to a new environment. It is not a one-way process – what
trainees learn spontaneously from experience in your department also depends on what
they bring to the situation: their prior knowledge of medical practice, self-awareness,
preferred ways of learning, expectations, hopes and fears. Trainees learn from their own
perspective, or frame of reference. Thus, socialisation is mediated by the individual
frame of reference.

Trainees may differ in several ways. What differences do you think are important in their learning?
What is the importance?

Deliberate learning in practice

The recognition of the power and nature of spontaneous learning is a starting point for
stimulating learning in practice in a more conscious and deliberate way. Deliberate
learning builds on spontaneous learning, but asks questions and provides clarification. The
implicit nature of spontaneous experiential learning becomes subject to explicit
questioning, discussion and reflection in order to improve one's clinical competence. Are
we doing the things the way we say we are doing them? And are we doing the right
things? Can we improve?
First of all, you have to think about whether your department and hospital offers the
optimal medical practice, for patients as well as for trainees and other participants. What
kind of medical practice is offered as a learning environment? Are trainees immersed in
the best practice possible? Do trainees have the best opportunities for observational
learning? What do trainees observe? What kind of social interaction is taking place? In
what kind of everyday conversations are your trainees expected to participate?

Spontaneous learning happens when no one is aware or paying attention. Deliberate attention
is needed to go further – hence the term deliberate learning.
The concept of experiential learning is often used with the suggestion of a learning cycle
moving from experience to concept formation, evaluation, and testing hypotheses in
intentional experimentation. Experiential, spontaneous learning in itself does not
necessarily, let alone automatically, include conscious concept formation, or testing of
these concepts in subsequent actions. However, learning does not automatically happen
that way! Explicit efforts are needed to progress from experiential learning to reflective
learning.

The best clinical practice is also the best environment in which to learn clinical practice.
NOTE

You may stimulate deliberate learning in practice by providing:

 The best medical practice for spontaneous learning
 Good role models, who explain the rationale behind what can be observed,
and who help novices to notice what there is to observe
 Tasks that are challenging enough to learn from (but safe enough), so that the
novice may progress from relatively simple and partial tasks to full
responsibility
 Observation and feedback, tailored to the individual trainee and based on fair
and clear evaluative criteria
 Questions to assess trainees' present levels of competence in all relevant
domains.

When trainees go to different hospitals during their training, they may learn more consciously and
reflectively from their experiences in these different hospitals. Explain why training in different places
could counter possible disadvantages of only experiential learning, and stimulate more reflective
learning?

2/ HOW TO STIMULATE PROFESSIONAL LEARNING

Clinical teachers serve a dual role: they provide patient care and they teach. The challenge
of clinical teaching is how to balance patient care responsibilities with teaching
responsibilities. As a clinical teacher, you stimulate and evaluate trainees' learning.

Teaching in the clinical setting

Being taught in the clinical setting is essential to becoming a fully qualified physician. It
offers the potential for attaining skills in clinical history taking, patient examination and
diagnosis, management, and skills in collaboration, organisation, communication and
professional attitude.
Stimulating learning in the clinical setting includes: role modelling, organising trainees'
participation and feedback, planning your teaching and using clinical events to benefit your
trainees. Below, we discuss these aspects of teaching 'on the job' in clinical practice.

Role modelling

Whether you want it or not, trainees learn much from you as a role model (see 'Example is not the main
Task 1 ). Thus, conscious role modelling is an important method for helping thing in influencing others,
trainees acquire the knowledge and skills, as well as the values, attitudes and it is the only thing.'
behaviour associated with professionalism, humanitarianism and ethical Albert Schweitzer
practice.

Characteristics of positive role models include personal qualities (such as

compassion, a sense of humour, integrity), clinical skills (such as proficiency as
a diagnostician and effective interaction with patients and their relatives), and
teaching skills (such as ability to explain difficult subjects and a non-
threatening style).

Experienced physicians who have been identified by trainees as positive role

models are those who spend more time on teaching, participate more often in
faculty development programmes, emphasise interactions between patients and
physicians and the psychosocial aspects of medicine, give more in-depth
specific feedback to learners and last but not least, they enjoyed teaching.

Give examples on how to make role modelling explicit to your trainees.

Organising participation and providing feedback

Trainees learn from participating in the clinical setting (see Task 1 ). Traineeship
involves moving from peripheral to full participation in practice. When trainees start they
are relative outsiders who are not yet fully part of what is going on. They need to learn
what it is to be a responsible physician in this particular setting. The task of the trainer is
therefore to assist this process, by introducing trainees as incoming colleagues, by
assigning meaningful tasks with increasing responsibility, and by providing constructive
feedback.

Imagine how your clinical practice looks to newcomers, and think of what and who trainees
need to know, and how do they get acquainted as soon as possible? Who and what can be of
help? You may want to write an introductory manual for new trainees.

Level of competence

Before assigning tasks to trainees you need to know their level of competency. Even if
known, it is advisable to discuss with your trainees what you want them to do and why, so
that they may give their views about what they need to learn. The golden rule is 'balance
between safety and challenge'. When you assign tasks which are too difficult, you are
threatening the safety – not only of your patients, but also the necessary safety for
trainees' learning.
When tasks are too difficult, trainees may learn to take risks which are too great, or they
may get discouraged and start thinking about another career choice. When tasks are too
easy, trainees stop learning. Of course, tasks still need to be done, but as a clinical
teacher you need to make sure that trainees have sufficient tasks to learn from. This also
implies that in the course of time you go from easier (and/or partial) to more complex (and
complete) assignments for your trainees.
To guide the learning process it is essential that trainees receive feedback. The purpose
of feedback is to inform them about what is good in their professional behaviour and what
needs improvement, why and how. In order to be able to provide feedback it is necessary
for the teacher to know about a trainee's performance. This may sometimes be based on
what you hear from others. However, as a responsible teacher you also need to create
opportunities to observe trainees yourself.

Providing feedback

When providing feedback, keep the following in mind:

 It is about specific, observed performance (and does not include statements
about the person, unchecked assumptions or vague statements)
 It informs about which performance is good (reinforcement, so that this
behaviour will be maintained)
 It informs which performance shows weaknesses, mistakes, omissions,
including why, and what is the desirable behaviour
 It is individual – adapted to the competency level and to the personal
characteristics of your trainees. For example, you may want to encourage
trainees who are doing fine but feeling insecure, and you may want to be more
strict with trainees who overestimate their competency
 Invite trainees to self-assess (an important professional competency).
Anybody may provide feedback (subconsciously), just by their reactions to [Link]
NOTE
instance, nurses, physiotherapists, paramedics and patients give informal feedback, verbal
and non-verbal (e.g. body language). In giving your trainees educational feedback you may
want to think about the informal feedback that they have already received in practice.

For more information see the PACT module on Communication skills .

When delivering feedback to your trainees or students, the following structure Tell your trainees what they
can be helpful in making the feedback meaningful, recognisable and by creating need to know
a safe environment.
Step 1. Ask the trainees what was good in their professional behaviour.
Step 2. Provide your feedback.
Step 3. Ask the trainees what could be improved concerning their professional
behaviour.
Step 4. Provide your feedback.
Step 5. Let the trainees think of alternative behaviours, ask for a summary and
what they will do in a subsequent situation. In that way you can check if your
trainees did understand the message.
 Positive feedback is easily confused with only saying good things about a trainee such as 'you
did well and you were nice to that patient'. But feedback should focus on the trainee's specific
actions and what you observed.

Examples: 'when the patient said he was afraid he was going to die you stopped your
examination and asked him where that fear came from. That made me conclude you really
listened to the patient'. Or 'when the family was very upset and agitated, you stayed very
calm, you spoke very calmly and clearly and told them you respected their feelings. At that
point the family relaxed a little'.

Use the five steps described above to deliver feedback to your trainees or colleagues. Analyse
how the method works: can you say what has to be said? Do trainees accept the feedback? Do
they improve after the feedback session? What do trainees think about this way of delivering
feedback? (A good way to analyse a feedback session is by videotaping it and then watching it,
alone or with colleagues or peers).

Planning teaching moments and strategies

Trainees expect clinical teachers to: take time to teach, give feedback, tailor the teaching
to the learner, and use opportunities to teach. This means that, if you want to teach in an
effective way, you have to
 Prepare for clinical teaching by planning when and how to teach (planning)
 Use a variety of teaching methods to involve your learners actively and serve
individual needs (adapting teaching strategies)
 Evaluate and reflect after teaching (evaluating and reflecting).
T HINK How often do you keep the above points in mind when teaching?

Planning

The first and most important point in planning is that you start to recognise opportunities
for teaching in practice. Ask yourself which moments and events are most valuable for
your trainees to learn from, and plan to use them. Planning helps to sharpen expectations,
clarify roles and responsibilities, allocate time for instruction and feedback, and focus
learners on important priorities and tasks.

Sharpen expectations

At the beginning of each rotation or clinic, it is important to communicate clearly the

expectations. Introduce people to each other, formulate learning goals, ask trainees to
formulate personal goals and clarify responsibilities and expectations of both the learner
and the teacher. You might plan which patients you want your trainees to discuss and ask
them to prepare accordingly. And/or you think in advance which questions you will ask
them and what special points to explain.

Create a positive learning climate

Learners are more likely to ask questions, pursue learning issues and contribute to the
group's learning if a safe and respectful learning environment is created. This can be
achieved by
 Demonstrating enthusiasm for teaching
 Knowing trainees / participants by name
 Asking for personal goals
 Encouraging interaction and discussion
 Showing respect to trainees and others.

Briefing participants / learners

When novice learners are left to their own devices, they often spend too much time with
the patient and don't elicit the important information required for patient care. Prepare
learners for an upcoming patient, for instance by asking what the most important
complications are or what information they need to differentiate competing diagnoses.
More advanced learners can be invited to discuss cases with the senior staff.

Why would it be important to explain in advance to novice learners what they can expect to see, for
instance during rounds or on the ward?

Adapting teaching methods

Excellent teachers have a repertoire of teaching strategies to involve trainees actively and
meet learners' needs. They can select the most appropriate method for the learner. Some
examples:

Select clinical cases according to trainees' level

Novice learners should be assigned to evaluate patients with more straightforward, typical
problems. Advanced learners should be challenged with more complicated cases.
Stimulate trainees to learn more about the diagnosed disease(s), such as pathophysiology
and aetiology. A good way to achieve deeper understanding is to ask them to prepare a
short presentation for the following day or week. In this way you can also check their
understanding.

Adapt feedback to individual learner

When you know the trainees you are aware what kind of learners they are, and you adapt
feedback accordingly. Are they good scientists, but forget to communicate what they are
doing? Provide feedback on both aspects and explain why it is important to share. Are they
very friendly and communicative, but sometimes neglectful? Provide feedback on both
aspects, and stress the danger of being neglectful. Are they lacking self-confidence?
Focus on positive feedback (things they do well) and provide reassurance.

Use questions to 'diagnose' learners and to stimulate active learning

Questioning is a key strategy for both effective patient care and teaching. As a physician
you use questioning every day with your patients. With your patients you want to learn
what is bothering them, what is going well, what they want to know about their condition,
and you want to check their understanding of the information you gave them. You can also
use these skills when teaching trainees.
As an expert you may tend to ask long, complex questions. Try to realise what the
underlying questions are. For example, you want to ask your trainees which of several
patients they would treat first. This implies underlying questions about each patient (What
do you see? What does it indicate? What else do you need to know and why? How do you
find out? Is it life threatening?) and necessitates a comparison of the answers to decide
which patient needs treatment first.
With appropriate questioning you find out what your trainees do (not) know sufficiently well,
what hinders their professional development, and what they think of your teaching. By
asking questions you can trigger reasoning, problem solving, and other higher cognitive
skills.

When asking questions, it can be helpful to have different purposes and levels of questions in mind.
What purposes and levels of questions can you distinguish? Give examples.

Read more about questioning and listening skills in the following reference and in the
PACT module on Communication skills

Utilisation of clinical practice

Teaching at the bedside

Bedside teaching includes any teaching done in the presence of the patient, Good clinical practice is at
regardless of the setting. Certain situations require bedside teaching such as the heart of good clinical
demonstrating and practising physical diagnosis, communication and procedural teaching!
skills. Besides educational advantages, such as the possibility to directly Prideaux et al (2000)
observe clinical skills, there is evidence that patients favour bedside teaching
and report better understanding of their illness. Of course this excludes using
patients for extensive skills teaching which should be done in simulated or
virtual situations. It also excludes the type of clinical teaching where the
patient's role is to demonstrate the teacher's superiority and importance!

An effective strategy for bedside teaching includes: attending to patient

comfort, using focused teaching methods and managing group dynamics. The
latter refers to making sure every trainee profits, stimulating interaction
between patient and trainee and between you and the trainees.
Clinical rounds

Clinical rounds are well known for their importance in postgraduate professional
development. If well prepared, they provide very valuable learning experiences for both
trainer and trainee. A distinction can be made between teaching rounds and business
rounds.

Teaching rounds

Teaching rounds can be clinical rounds where time is reserved explicitly for teaching. It
could also be a more formal session where a single case or several cases are selected for
examination and discussion. The latter fits well in undergraduate and early postgraduate
training. The disease process is a central theme, with clinical assessment (history taking
and physical examination) as the starting point from which discussion can develop.
Consider the following points:
 Treat the patient with respect, even when the patient is unconscious. When
possible involve the patient. Ask permission in advance; explain the purpose;
during the teaching don't only talk about but firstly with the patient
 Choose clear goals that are appropriate to the trainee, the setting and patients'
problems
 Adapt the teaching strategies to the existing needs, capabilities and
experience of the learners
 Actively involve learners, e.g. by asking them to perform (parts of) the
investigation, asking them to explain what they are doing, and what their
opinion is
 Give feedback on their performance afterwards (not in the presence of the
patients)
 Summarise at the end or ask your trainee to summarise.

Business rounds

These rounds are more part of everyday working in the hospital. In this type of round, the
patient, their treatment and progress are the central focus. You are role modelling in this
work situation. Junior staff can take the opportunity to safely display their diagnostic
competency, proposed treatment and follow-up capabilities. The outcome of clinical
interventions on a disease process in severely ill patients provides instant feedback on the
problem-solving and decision-making skills of those involved. This provides excellent
motivation to learn further, not only on the round, but also in other associated formal
teaching activities.
More information can be found in

Morning report

During the morning report one party accounts for patient care (diagnostic and therapeutic
actions) during the previous night, and the other party is taking over. If these sessions are
conducted in an interesting and active way, they can be a valuable learning experience
and offer a good opportunity to assess the progress of trainees. The following areas can
be practised and assessed during the morning report: prioritising a patient's problems;
making clear distinctions between sick and less sick; recognising the need for actions;
requests for additional investigations are well thought out and based on a good differential
diagnosis; and formulating a clear conclusion.
Tips:
 Use a simple format for the presentation of the patient
 Actively involve the trainees in choosing which patients are discussed
 Ask questions to clarify, motivate etc
 Choose a chairperson who is responsible for structure and time
 After trainees have seen senior staff model the morning report, ask trainees to
chair sessions (taking turns)
 Start and end on time
 Remember how tired the person who is presenting is relative to those starting
work!
Analyse the morning report in your department. How is it organised? Can it be improved in
terms of a learning event for participants? What does it take to make these improvements?
Who do you need to make these changes?

Teaching 'off the job'

Teaching 'off the job' comprises quite different formats such as lecturing, small group
teaching, and skills training. However, any planned teaching session can be broken down
into three key elements:
 Set
 Dialogue
 Closure
Set During the set it must be clear for trainees
 What they will learn (objectives)
 Why it is important (motivation)
 How the content is related to other parts (e.g. of a course) or practice
 What is expected of the trainees and the trainer (e.g. should trainees listen, or
should they be practising, can they ask questions).
Dialogue is the crucial part of a planned session which involves the interaction of the
trainees and the trainer. It includes elaboration on the main messages of the session (in
lectures), or working on an assignment to reach the learning objectives (in small group
teaching, workshops, and skills training).

When preparing a teaching session always try to focus on the key message: what should your
NOTE
learner never forget after this teaching session.

Closure has three elements

 Review (ask for questions; check if objectives have been reached)
 Summarising (by trainer or participant)
 Terminate the session.
 What is the benefit of asking for questions before the summary and termination of a teaching session?

Lecturing

Large group teaching has long been seen as a method of teaching in medical education.
But over the past decades the role has been questioned. Adults learn more effectively
through active participation and lectures are criticised for being too passive a learning
experience. However, a good lecturer activates the audience in a variety of ways.
A lecture is appropriate when the aim is to:
 Deliver information that is not available in another way
 Stimulate interest, raise curiosity, motivate
 Adapt information to the level of the audience
 Underline specific information
And/or
 Provide the learners with the overall picture
 Ensure shared knowledge (e.g. within a team).
T HINK about the lectures you enjoyed immensely in your medical career and lectures that you thought were
really bad. What made these lectures so good or so bad? What did the lecturer do?

Preparation

Structure your lecture according to the three main components identified above. The secret to giving an
You may want to divide the second part (dialogue) into several steps, depending effective presentation is in its
on your goals. preparation
Important points
 Think of a good start. Try to imagine what would grab the
attention of your audience – and focus their attention on
what you want to say. A story? A strange-looking slide?
Part of a movie? A statement? Tip: observe how
advertisements try to capture your attention and think of
possibilities to do the same
 Limit your messages. Don't cram your lecture with too
many goals. It is better to get across one main point than
to drown your audience in your expertise. Keep it simple
 Use examples for each of your messages. Start with an
example (from practice) and use it during the more general
explanation to illustrate what you want to convey (theory).
Don't restrict your message to abstract theory.

Preparation includes being aware of the setting and preparing the use of material such as
slides. When preparing the set you should think about the environment. What does the
room look like, how does the lighting work, is there a laptop available etc. Be as familiar
with the environment as possible.
Be clear about the role of the audience. Can they interrupt you? If so, prepare to tell them
and to invite them to do so. Also think of how you may want to stop the audience
participating if you anticipate time problems. You may have to choose between audience
participation and completing your lecture.

Use of slides or other audiovisual materials

Here is a short guide to presentation and effective use of slides.

During your presentation

When conducting a teaching session, you always deliver your message in more than one
way. As well as content, learning is also dependent on how you deliver your message and
what your body language is saying.

A confident start forms the basis of a successful presentation

NOTE

Helpful tips to make your presentation even more effective:

 Be prepared and focus on your role as lecturer.
 Maintain eye contact; in a large room this requires looking around (from left to
right, front to back, and vice versa).
 Don't stand like a statue – but don't move around too much either.
 Avoid distracting the audience e.g. by playing with keys or coins, fiddling (e.g.
fingers through your hair, rubbing your nose).
 Speak clearly and loudly – exaggerate as if you were an actor.
 Use a microphone if necessary (check if the audience can hear you clearly).
 Speak slower than you normally do, for your audience needs time to think (at
least when you tell them something that they do not know already).
 Avoid turning your back (don't speak to your slides).

Slides and visual material

Their value should not be underestimated. It helps people to remember your message, it
can help them to make sense of complex ideas and it can help to keep their attention. You
may also use slides as your notes, your backbone of the presentation.
Beware of:
 Too many words. Think 'bullet points' and avoid textual sentences.
 Too many slides e.g. use one slide per minute (rule of thumb).
 Unnecessary information on the slides (e.g. logos, names, numbers). No need
to give full references for example, just enough to allow the listener to look up
the reference on pubmed afterwards.
 Misspelling and too many typefaces.
 The use of green, red or other difficult to read colours for text.
 Insufficient contrast between background and text.
 Too many visual effects. These make the file large and hard to carry on a
'memory stick' and the lecture venue may not have the software to 'play'
videos etc.
Useful information about how to deliver a lecture can also be found in
 How much do people remember from several activities?
NOTE
Although no more than a rule of thumb, the National Training Laboratories, Virginia USA
say (as a percentage)

T HINK about how you learn from teaching your trainees. If teaching is such an excellent way to learn, what
does it mean for teaching? Can you think of ways to turn your trainees into teachers?

Small group teaching

Small group teaching may take different forms, for instance workshops and discussion
groups. It has some advantages over lecturing in that it actively involves learners. Well
organised small group teaching
 Allows learners to develop generic skills like problem-solving, interpersonal,
presentational and communication skills
 Allows learners to question and challenge assumptions and to develop deeper
understanding of a topic through discussion. A deeper understanding will
facilitate the application of what is learned in the future and in new situations
 Allows learners to develop skills and attitudes for team work
 Requires active involvement which tends to stimulate motivation and a positive
attitude towards what is learned
The key to successful learning in a small group lies with the teacher.

Describe two major roles of a teacher in small group teaching.

You can read more about small group teaching techniques and the role of the teacher in
Practical skills teaching

The traditional approach of learning psychomotor skills by practising on patients has

obvious drawbacks, especially with novice learners. Today, patient safety requires skills
training off the job as much as possible, e.g. in so-called skills centres. Here students,
residents and specialists can be trained in new skills using (dead) animals, manikins,
simulators, virtual technology and standardised patients.
Most skills training is based on several stages including demonstration, explanation, and
practise with feedback.
 Expert demonstration of the skill can be done live by a trainer or virtually, and
is necessary to provide the novice with a picture of the different elements as
well as the whole event
 To understand the skill, trainees need an explanation of what they see: why is
it done this way? Should it always be done this way or may (part of) the skill
be done in another way? In what cases? What are risks of changing (part of)
the activities?
 Next, trainees need to practise the specific psychomotor skills. Sometimes a
skill needs to be subdivided if it is complex
 When practising, trainees need feedback to inform them about their progress
 In the end an integrated, fluent application is required: automation is reached
by sufficient practice.

A teaching model, very well appreciated by surgical skills training, is the so-called four-
stage model
Stage 1 Demonstration: instructors demonstrate the skill
Stage 2 Verbalisation: instructors demonstrate the skill and explain what they are doing
Stage 3 Formulation: instructors perform the skill while learners tell them what to do
Stage 4 Practice: learners perform the skills and say what they are doing.
Here, you can see a video of the ATLS fourstage model.

The four-stage model mainly focuses on acquiring a specific skill and therefore on the first
phase of skill learning. It does not include repeated practice and feedback. The
explanation is focused on the activity and not so much on understanding the background
and context.
Other teaching models may vary in specifying stages, in providing extra steps, or repeating
earlier stages. In practice, you may vary the model because of your trainees' level of
competence, their speed of learning and what skills you want your trainees to acquire.
When you think of learning to perform an operation, a whole range of skills may be
involved that can be learned separately, but need to become a whole in the end.
 Although skills training usually starts in isolation from clinical practice, it should be followed
by guided practice in real life. In real life, inform your trainees beforehand which part they
are expected to do, so that you don't need to interrupt unexpectedly, leaving your trainees
wondering what they did wrong.

Simulation

Simulation and virtual reality are becoming widely established and have the advantage of
offering learner-centred education, away from clinical responsibilities at any convenient
time.
High-fidelity simulation can accurately recreate the conditions of an ICU and generate a
high degree of realism. Crisis management, team working and communication can be
taught alongside skills and procedures.
The most important features of high-fidelity simulations are
 Feedback is provided during the learning experience
 Learners can practise repeatedly
 The simulator is integrated into the curriculum
 There are increasing levels of difficulty for learners to practise
 The simulator is adaptable to multiple learning strategies
 The simulator can represent a wide variety of patient problems.

At present, high-fidelity simulations are being developed using the Patient Challenges from
the PACT modules. These simulations are being developed by the SAINT (Simulation
Applied to Intensive Care Medicine and Nurse Training) group within the ESICM.
A video of a simulation and the debriefing is currently under development.

Dealing with difficult situations

What if your audience is more experienced than you?

This may seem quite threatening. Two points to think about. Firstly: who is your target
audience? In reality, only a few people in the audience may be more skilled or specialised.
When you are asked to teach, your target audience does not consist of the more
experienced and more educated colleagues. Think of the learning goals you have set for
your lecture or group work. These goals are meant for your trainees, and they rightfully
expect you to be oriented towards them. A lecture, explanation, assignment or whatever
you prepare should not be filled with specialised details. They would only distract and
confuse your audience. So, maintain your message.
Secondly, if some people in the audience know more than you do, use them. Ask if they
can describe examples from their rich experience. When you get a difficult question, ask
them to help you. Recognise their contribution. Show that you are happy with their help.
There is nothing wrong with not knowing everything. If, however, experts get carried away
with their superb specialised knowledge, you may have to remind them to keep the target
audience in mind! Finally, of course it is always important to be well prepared for your
teaching.

3/ HOW TO ASSESS CLINICAL COMPETENCE

A NECDOTE A trainee in intensive care medicine was very skilled in performing tasks, but when observing him it
was noticed that he often forgot to communicate with other staff. Also, it was said that this trainee
made several near-mistakes. The supervisor decided to have a talk with him. She mentioned the
near-mistakes and suggested he go to a training course to practise the relevant skills. The trainee
objected and denied what the supervisor had been told.

This anecdote illustrates one important goal in assessing trainees; that is identifying the
'trainee in difficulty' and the reason for difficulty. For most trainees however, assessment
will (or should) be an opportunity for personal development and be relatively non-
threatening and positive.
Assessment of clinical competence is not easy. Competent clinical performance includes
many aspects such as interpersonal and management skills that go beyond the medical
knowledge or technical skills that are traditionally the focus of assessment. Also,
assessment needs to come as close as possible to measuring authentic performance in
practice. However, the responsible clinical teacher is not always around to observe
trainees' performance. In recent years, assessment methods have been developed to
include performance in practice, to involve others in assessment, and to combine different
forms of assessment as inputs for overall assessment.
The five w-questions about assessing clinical competence are discussed below: why,
when, what, who, what ways?

Why do you assess clinical competence?

Formative assessment

You may want to do formative assessments of your trainees' clinical competence, directed
at giving feedback. In that case your goal is to stimulate your trainees' learning. You want
to be as precise and concrete as possible about good and weak parts in their performance.
Make sure that trainees understand clearly what parts need improvement, why and how.
But don't forget to be explicit about their good performance as well. Recognition of good
performance is important to ensure they continue this good performance (reinforcement)!

Formative versus summative assessment

You may want to do summative assessments of clinical competence, directed at taking

decisions about your trainees position in the training programme. Are the trainees ready to
proceed to the next stage? Have they acquired all necessary competencies to be a more
senior colleague? A decision to pass or fail has serious consequences and must therefore
be based on adequate (valid and reliable) assessments.
Too often only summative assessment is done in an explicit way. However, formative
assessment provides an important educational tool: 'assessment drives learning'.
The quality of summative assessment may also improve when you pay more attention to
formative assessment, resulting in you being better informed about trainees' progress.
Identifying poor performance is an important goal of both formative and summative
assessment. In formative assessment you still have the opportunity to give extra attention
to a trainee in difficulty.
When you document your formative and summative assessments in trainees' portfolios,
you stand on firm ground if you have to take negative or positive decisions about the
trainees' progress. (See also the portfolio section ).

When do you assess clinical competence?

Formative, informal assessment should be done quite often in various situations.

Possibilities include immediately after patient discussions, debriefings, clinical rounds,
presentations. Keep the assessment short, don't try to be complete, address only one or
two points at a time.

T HINK of possibilities in your situation to give feedback, and turn this into a good clinical teaching habit.

For trainees, organise appointments with them at least twice a year, to discuss their
progress in a more comprehensive and formalised way, but still with the formative goal of
providing feedback.
Summative assessments take place whenever a formal decision needs to be taken about
a trainee's progress in the training programme: entering the next stage, completing the
programme, or stopping because of inadequate results. In a well-structured training
programme it should be clear when, about what, and with what consequences summative
assessments will be made e.g. once a year.

Analyse your training programme and identify when formative and summative assessments
take place. Are these sufficient? Are trainees well informed about the assessments? Is the
trainer sufficiently well informed to make decisions concerning the trainees?

What do you assess?

The attributes required of a physician are numerous and no single test can distinguish
between a 'bad' or a 'good' physician. Attributes include generic skills and attitudes, such
as communication and team-working, as well as specialised knowledge and skills relevant
to each specialty. Assessment increasingly focuses on actual performance and therefore
on the competencies of a trainee.
There are several models that describe these competencies. For training in intensive care
medicine, a competency-based programme is described within the CoBaTrICE project
(see ) and this forms the basis for the assessment.
In 1990, Miller devised his pyramid to illustrate the shortcomings of assessment in medical
education (see illustration on the next screen). Knowledge assessment is at the base of his
pyramid, not because it is most important, but because it is done the most: in written or
oral form we test what the student knows. Skills assessment is the next step of his
pyramid: students 'show how', e.g. in skills stations. This type of assessment is done quite
a lot, but less often than knowledge testing. Trainees' performance in clinical practice is not
assessed very often or adequately. And we hardly ever assess the top of the pyramid: the
actual performance of responsible physicians.
Miller's message was that we need far more assessment as we get higher up the pyramid.
As a consequence, the pyramid should become more like a chest of equally filled drawers.
By 2006, more ways of assessing clinical performance have been developed, although
more development and implementation are still needed.

Miller's Pyramid,
illustrating shortcomings in
the assessment of clinical
skills, with overlaid 'chest
of drawers'

Who is assessing?

The clinical teacher may not be the only person who does the assessment. Of course the
principal clinical teacher is responsible for assessments taking place, and has the final
responsibility for summative assessments. Other people that are or can be involved are
 Staff members of several departments (assessing parts of the programme)
 The trainees themselves (reflective self-assessment reports)
 Peers (when they have been working together or at least been able to observe
each other)
 Paramedical and allied healthcare professionals (e.g. nurses, paramedics,
physiotherapists, nurse practitioners, physician assistants)
 Patient evaluations (specific aspects of trainees' performance).
Self- and peer assessment are important ways to prepare for lifelong learning and to involve
NOTE
new physicians in team-learning.

Gathering information from different sources is called multi source or 360 degree
feedback. The different perspectives give special value to this information. Peers, other
healthcare professionals, and patients may note different things to the staff. A positive as
well as a negative assessment is made stronger when different sources are in agreement.
When sources are not in agreement it is important to find out what causes the differences
in evaluation, especially before it is used in a summative way.
It may happen that the assessment by different sources conflicts with trainees' self-
assessment. You may find those who overestimate and those who underestimate
themselves. In the first case you will need a firmer approach to make sure trainees
understand and accept the assessments, and are prepared to work on improvement.
When trainees underestimate themselves, you also need to make sure they understand
and accept the assessments – in this case so that they will be ready to move on to a next
level of competency with more self-confidence.

What ways of assessment do you use?

There is no one perfect way of assessing a trainee's competence and performance. You
need a mix of different methods and sources to arrive at an adequate assessment, just like
you use quantitative and qualitative information from different sources when you are
evaluating a patient's condition.
Methods of assessment off the job include ways to assess knowledge, such as
standardised oral exams, written and internet-based exams (multiple-choice questions like
the European Diploma in Intensive Care (EDIC) exam), and ways to assess technical or
communication and interpersonal skills, such as the Standardised Patient Examination
(SPE) or OSCEs (Objective Structured Clinical Examination).
Other methods are more appropriate to assess performance on the job, where
knowledge, skills and attitudes need to be integrated into behaviour. Such methods are
usually based on observation of performance in practice. It is useful to base assessment
on repeated observation of different situations by different observers, to make the
assessment more valid and reliable. (See below). Possible methods include the Mini-CEX
(Clinical Examination), patient presentation evaluation, short questionnaires (for multi
source feedback), critical appraisal of a topic (CAT), Objective Structured Assessment of
Technical skills (OSAT) and logbooks.

What would test medical competence better: open-ended questions or multiple-choice questions?
Give arguments.

Whatever instruments you choose for assessing trainees, they always should be valid,
reliable, feasible, provide feedback, and detect poor performance in time:
Validity Does the assessment measure what it purports to measure (content validity)? Do
the assessment tasks predict future performance accurately (predictive validity)?
Reliability If an assessment is repeated with the same trainees, they should get the same
results. Results should not be due to accidental circumstances or coincidence.
Feasibility Can the assessments be undertaken within time and staff constraints?
Assessments should fit well with the training programme and the working day.
Feedback Does the assessment encourage learning? Does the assessment help the
trainee identify strengths and weaknesses? There are strong positive links between
assessment, good feedback and further learning.
Early warning Does the assessment system detect poor performance early? Poor
performance may trigger closer supervision and further assessment or raise questions
about the training environment.

Portfolio and personal learning plans

A portfolio is a collection of evidence which, when taken together, demonstrates

competence and expertise. In addition to the formal acquisition of competencies which
form the core of the CoBaTrICE programme, there are many other aspects of clinical
practice and professional development which can be included, such as research and audit
activities, teaching received or delivered, courses attended, work-place based
assessments, case summaries, log books, personal reflections or letters from patients and
relatives. CoBaTrICE has produced the CoBaFolio template as a means of enabling
trainees to collate evidence of competence. The trainee is the owner of the portfolio.
You may ask your trainees to write a personal learning plan. Such plans can be made to
cover parts of the programme (module, placement). The trainee describes 1) learning
needs, 2) learning activities, and 3) evidence of learning that will be put into the portfolio.
You discuss and agree on the plan with your trainee. This learning agreement is part of the
portfolio.
A portfolio is also a suitable way to organise your assessment programme (overall
formative and summative assessments). Trainees are asked to write self-evaluation
reports, in which they summarise the results of the various assessments and reflect on
these assessment data. Formative discussions with your trainees result in plans for
learning in the period ahead. You agree on what activities they will undertake and what
assessments will be carried out. For summative purposes, you evaluate the data and self-
evaluation in order to make your decision.
For examples of a portfolio, learning agreement and personal learning plan for trainees in
intensive care medicine, see

Why do you think it is important to ask your trainee to write a self-evaluation and discuss this with
you?

Finally, when evaluating trainees, it is very important to have clear criteria. Make sure you
discuss your criteria regularly with colleagues and other staff who are taking part in the
assessment. It is very common for different clinical teachers and staff members to have
different ideas about what is inadequate, sufficient, or excellent. Formulating criteria can
best be done for stages (e.g. years) in the training programme, so that you assess trainees
according to what you expect at a certain stage of the programme. It is important to make
the evaluation criteria as explicit as possible to your trainees. When they know what you
look for, they know what they need to learn. Assessment drives learning!

What measures can you take to make the assessment within your department as valid and reliable as
possible?
Useful websites on
assessment [Link]
[Link]
[Link] [Assessment, Table of methods]
[Link]
[Link]

Dealing with difficult assessment situations

What can you expect from trainees?

When a new trainee starts, you need to ascertain their level of competency. You need to
discuss this issue with your trainee and you may find a portfolio helpful in this discussion.
(See Task 3 ). Take time to get to know your trainee, and to keep in touch with their
competency development. It is the basis for your responsibility as a teacher/supervisor.

What if your trainee lacks motivation?

When a trainee seems to lack motivation, do not react judgmentally. Find out why. Maybe
the trainee is just not such an extrovert as you'd expected? If motivation is indeed lacking,
is it temporary? What is the cause? Problems at home (partner, children, a move to a new
house)? Or is the trainee disappointed about the work? Are long hours exhausting your
trainee? Do they have doubts about their own abilities? Are they questioning the career
choice? Discussing the problem, recognising the difficult situation, and giving the trainee
some space to find solutions, may be enough to help the trainee back on track. If your
trainee has really lost motivation for intensive care medicine altogether, the best thing to
do may be to offer encouragement to think about an alternative.

There is no time for observation and feedback

Clinical teachers often complain about the time it takes to observe trainees and give them
feedback. And of course it is difficult to build in time for this in a very busy practice. Here
are some suggestions for finding ways to incorporate observation and feedback
 Discuss with colleagues and trainees opportunities within the daily practice
where observation and feedback can be easily incorporated
 Plan moments for observation
 It is not necessary to have very long observations. Often short observations
(e.g. five minutes) can give you enough information for feedback. It is more
helpful to give a little feedback rather than too much
 Feedback at the end of a round, a morning report or case presentation doesn't
cost observation time
 Convince staff and trainees of the importance of these observations and
feedback
 Use any available time together with your trainees (e.g. when walking through
the hall, while washing hands, taking off gloves) to ask questions, to listen, to
recall events and give feedback.
What to do with a trainee in difficulty

Characteristics of a trainee in difficulty may include reluctance to ask for help, poor
communication skills, lack of responsibility, frustration and anger, a disregard for
punctuality, or a failure to see that there is a problem. The underlying causes of difficulty
may be related to personal, environmental or adaptive factors.

During routine practice, incidents that give cause for concern about a trainee can be
considered as early warning signs.

To identify a trainee in difficulty and remediable causes, key questions to ask include
 Is this an isolated incident or is a trend/repetition evident?
 Does the trainee have the insight to recognise the problem?
 Can the incident be turned into a learning opportunity?
 What questions does the case raise about the learning environment?
 Do other colleagues have same experiences?
What can you do?
 Focus on patients' as well as the trainee's safety
 Ensure the trainee knows how, when and who to call for help
 Discuss the event with the trainee and reflect on how to handle such an event
in the future
 Make this incident a learning opportunity
 Communicate clearly with the trainee and document this carefully
 Increase formal and informal monitoring, supervision and review of the trainee
and the learning environment.

4/ HOW TO PLAN FOR LEARNING

The curriculum
Today, the definition of a curriculum includes all the planned learning Curriculum has its roots in the
experiences of a school, educational institution or postgraduate specialty Latin word for track or race
training: what should be learned (content), how it should be learned (teaching course. From there it came to
and learning strategies), how it should be assessed (assessment process) and mean course of study or
how the whole is evaluated. syllabus

Postgraduate specialist education is built on top of a long undergraduate

medical education and in some countries an additional internship. Postgraduate
training is primarily work-based and the learning environment is not a teaching
environment but a highly complex and busy work-based system whose primary
role is providing a service to patients.

Internationally, professional bodies are increasingly responding to society's

needs and various models specify the roles of future physicians and the
expected learning outcomes. In essence, these models are quite similar (see
Ringsted reference, below).

Some models which have been described are the outcome-based model, the
seven roles of the CanMEDS model, the six general competencies used in the
USA and (in the UK) the 12 generic aspects of the role as a consultant.

Competency-based curriculum

In developing a training programme for medical education, the competency approach has
become prominent at most stages of undergraduate and postgraduate medical training in
many countries.

Competencies are the ability to adequately carry out a professional activity in a specific
authentic context by integrating knowledge, skills and attitudes. Competencies are not
directly visible or measurable, but are demonstrated when performing tasks.
Competencies for the intensive care physician are defined within the CoBaTrICE project.
They define the minimum standard of knowledge, skills and attitudes required for a
physician to be identified as a specialist in intensive care medicine. They have been
developed with the intention of being internationally applicable but able to accommodate
national practices and local constraints. They comprise 102 competence statements
grouped into 12 domains.

Developing a curriculum

For specialty training, this is a complex and time consuming activity. Only a few of you will
be involved in such a task, but most of you will be confronted with the outcome – the
curriculum itself – either as a trainee, a trainer or supervisor.
An excellent summary of the elements of a curriculum is as follows.

A curriculum description
  Profile of the specialist
What kind of work? What is essential? What are future developments: threats
and opportunities?
 Competencies
What should trainees be able to do by the end of the programme? This, of
course, is closely related to the profile of the specialist.
 Learning goals/objectives Based on what a specialist does during his work,
what knowledge, skills and attitudes do trainees need to acquire the desired
competencies?
 Philosophy on teaching, learning and assessment
How do trainees learn, what are the goals of assessment, is it based on
educational theory?
 Structure
How is the programme built up, e.g., training periods, what is the order of
learning goals, what is mandatory, what is elective, one or more hospitals?
 Assessment programme
How are trainees assessed? What methods are used, etc?
 Teaching formats
How is practice used for learning? What is the format for training courses,
skills teaching and simulations? How many, when etc?
 Quality care
How is the programme evaluated? How is quality improvement addressed?
How is your own training programme built up? Are all elements described? How is it
evaluated? Do you see things that can be improved? How do you communicate this?

Creating a stimulating learning environment

In addition to being an environment in which excellence in patient care is the foundation for
learning, the intensive care environment should be an intensivist-directed, collaborative
multi-professional team model of patient-centred care for all ICU patients. This
environment includes
 Strong dedicated physician and nursing leadership committed to quality
process, care and practice improvement
 All ICU personnel share a common vision regarding delivery of care and
clinical practice improvement that is focused on what is best for the patient
 Evidence-based protocols, clinical practice guidelines and standards are
routinely used and regularly reviewed to optimise patient care
 Processes and outcomes are routinely measured to continuously monitor the
quality of care
 Physicians, nurses, clinical pharmacists, therapists and others collaborate as
colleagues both in the care of patients and in the practice improvement
process
 Dialogues around the best way to care for patients and current protocol issues
are common encounters, and challenges to process of care are welcomed and
respected
 A process for practice improvement, in which problems are recognised and
dealt with at the front line by all members of the multi-professional team, is
emphasised and easily identified
  Patients, families, and surrogate decision makers are kept well informed about
care plans, alternatives, and responses to therapy, and their values are
solicited and incorporated into the care plans.

Level of expertise and supervision

During a training programme, trainees will acquire the competencies in a certain order.
Some competencies will be acquired early in specialist training at a level of independent
practice, other competencies will or can only be reached at the end of the whole training
programme. Unless otherwise indicated, by the end of specialist training, competencies
should be performed at a level of independent practice (this may include the capacity to
supervise others or direct a team) with indirect supervision provided by a trainer. For
intensive care training, three levels of practice are distinguished within the CoBaTrICE
project. These indicate the minimum standard, and in many instances a higher level of
expertise (i.e. a lower level of supervision) is required. See figure 2 in the reference below.

Developing a course

Much of the teaching outside daily practice takes place in (short) courses, distance-
learning programmes, skills training and simulation programmes.

Short courses

Short courses are commonly used by physicians to stay up-to-date and acquire new
knowledge and skills. Not all courses lead to the desired change. In order to make courses
as effective as possible the 12 tips of Lockyer et al. can be very useful.
 Assess the clinical problem
What course is really needed within the target group? Who says so? Are they
also committed to make changed performance possible in practice?
 Determine learning outcomes
Formulate learning outcomes or end points to be achieved by the learners.
Define outcomes in specific goals and as competencies.
 Use evidence-based medicine to develop content
Better outcomes can be achieved when educational programmes are based
on evidence of clinical effectiveness.
 Identify resources
Think of the teachers needed, space, materials, etc.
 Select teaching strategies for active learning
The teaching strategy depends on the learning goals, the content, the
participants and resources. Use a variety of strategies. Keep in mind the
principles of how professionals learn.
  Select teaching strategies that facilitate reflection
Reflection is essential for learning by professionals. It can lead to new
understanding, synthesis of old and new insights, finding of new solutions etc.
 Create an individual needs assessment or pre-course assessment
Let participants think in some way about their personal knowledge, skills
behaviour, attitudes in relation to the course goals. This can stimulate their
motivation to come and learn.
 Prepare teachers
This is a crucial element for successful courses. A committed team of teachers
that want to realise shared goals is maybe as important as the content of the
course.
 Commitment to change
Let participants think or formulate intentions for their own practice. What are
you going to do with what you have learned next week or month? Let them
think about what and/or who can help them and what or who can hinder them?
 Provide post course reflection
Ask participants, after a sufficient period, to reflect on what they have done so
far with what they have learned during the course.
 Use evaluation data to improve your course
Learn from what participants formulate at the end of a course, the post course
evaluation and what they have done with the course content. All this
information can give you clues for the further improvement of your course.
Discuss this information with the teacher team.

Distance-learning programmes

Distance education, including PACT, is playing an increasing role in medical education,

particularly in postgraduate training and continuing professional development.
Developing distance-learning programmes is time consuming and requires additional skills
to those required for writing book chapters or journal articles. For the PACT programme,
the editing team provided the authors with a short introduction to the educational strategies
to be adopted, the template for the design of the programme and the educational format.
In designing a distance-learning programme, the following key areas need to be addressed
 Educational need of the learners
 Design of the materials
 Support mechanisms for learners.
When developing a distance-learning programme, the so-called 'CRISIS' criteria
(Convenience, Relevance, Individualisation, Self-assessment, Interest, Speculation and
Systematic approach) can be of value. The initial criteria allow the programme to grab the
reader's attention and be functional; the latter allow self-assessment and provoke
reflection.
This meets the principles of adult learning which are characterised as needing meaning
and relevance, clear goals and objectives and the active involvement of the participant but
with a capacity for feedback and reflection.
5/ EVALUATION AND RESEARCH
Without evaluation, it will be difficult to make changes to improve the quality of any
programme. Because quality of care is related to the quality of education, we need to be
informed about the quality of our educational programmes. But what is a good educational
programme?

Classifying learning outcomes

To classify and analyse outcomes of any educational intervention, the modified Kirkpatrick
model of educational outcomes is very useful. The model describes four levels of outcome
Level 1 Learners' reactions to the educational experience (satisfaction)
Level 2 Learning – which refers to change in attitudes, knowledge and skills
Level 3 Behaviour – which refers to changes in practice and the application of learning into
practice
Level 4 Results – which refer to change at the level of the system, the organisational
practice of learners or improved outcomes for patients.

Very often, evaluations focus on the first level. The level 2 evaluation is strongly related to
the assessment of trainees after courses etc. The level 3 evaluation is becoming more
frequent due to changes in the assessment of trainees as direct observation and
assessment becomes a more regular part of the assessment programme. Level 4
evaluation would be ideal but is very difficult or even impossible to measure because many
factors will influence patient safety.

The quality circle

Educational experiences can be evaluated using a set of audit principles called the quality
circle. This is well illustrated in the PACT module on Quality assurance and cost-
effectiveness

Planning an evaluation

As in the assessment of trainees (see Task 3 ) one can ask the same questions when
evaluating an educational programme, course, curriculum, or workshop.
Why and When? The only certainty about any course or curriculum is that to maintain
relevance, it has to evolve with experience. To obtain appropriate information and to act on
it, participants at all management levels must accept evaluation. Evaluation should take
place before, during and after the programme. Always ask yourself why you want to know
certain information and at what moment you need it.
What and Who? The entire design, piloting and implementation of a training programme
may be evaluated. Always ask yourself what you can or will do with the outcomes? Can it
lead to actions? Who is evaluated or evaluating depends on why you evaluate, what you
want to know, when you evaluate and what instruments you choose. Make sure you ask
the right group for the right information.
What methods? Always ask yourself what method(s) is/are most efficient and effective in
terms of time, money and acceptance.
There are a number of available instruments to evaluate the learning environment, the
quality of the teacher and the quality of an educational programme. The methods for
evaluating the different elements of a curriculum are shown below.

Educational Programme -
Methods of evaluation

Find out in your own department how education is evaluated? Are there any questionnaires?
How do results lead to actions and further improvements?

Information about some instruments to evaluate clinical education and clinical teachers
can be found in

Faculty development

The quality of every educational programme will depend on the quality of the teachers and
the healthcare system. Physicians are well prepared for their clinician roles, but few are
trained for their teaching role.
Faculty development can help provide clinicians with new knowledge and skills about
teaching and learning. This is becoming increasingly important.
A good overview is given in
Educational research

There is increasing activity in the field of research in medical education. Greater numbers
of physicians are involved in educational research in some way. For physicians,
sometimes this can be difficult in the beginning, especially with respect to gathering data.
In medical research, quantitative research is predominant, whereas educational research
is often based on qualitative methods. In the past, qualitative research methods (in medical
education) were often regarded as subjective, not valid or unreliable. However, these
views are changing (see reference).

For those interested in medical education research, there is a good deal of available
information. A useful starting point and website (Best Evidence in Medical Education) is

The number of research articles and medical education journals is steadily growing. Below
are details of the variety of resources available.
Medical education [Link]
Medical Teacher [Link]
Clinical teacher [Link]
Evaluations of the Health profession [Link]
Academic medicine [Link]
Teaching and learning in medicine [Link]
Advances in health science
education [Link]
section=12
There are a variety of articles published in the British Medical Journal on medical
[Link]://[Link]
Interesting organisations for medical education are:
AMEE: Association of Medical Education in Europe: [Link]
ASME: Association of Schools of Medical Education: [Link]
International conferences on medical education that are of interest to clinical teachers are:
AMEE conference: [Link]
Ottawa conference: [Link]
RIME conference: [Link]
The ESICM's international congress on intensive care has an increasing number of
presentations on education and educational research. Also 'train the trainer' programmes
are incorporated in the programme.

CONCLUSION
There is growing interest in education and learning within medical education and specialist
training. Increasing numbers of physicians want to be involved in developing new
educational and assessment methods. Changes in society have contributed to this growing
interest. Firstly, patients' growing awareness about quality of care makes them reluctant to
be 'guinea pigs' for students and residents. Secondly, the reduction in working hours has
led to a reduced training period and some employers resent training time being included
within the working day.
New techniques such as high-fidelity simulation and virtual reality give us new
opportunities to train our future physicians. To help clinical teachers to improve their
teaching skills, faculty development programmes are offered in many hospitals and
medical schools. In order to gather new insights into the way physicians learn, it is
important to conduct research in the field of education.
It is the collaboration of educationalists, clinical teachers and scientists that can create new
knowledge and insights leading to improvements in patient care!

PATIENT CHALLENGES
Two months ago, you started on the intensive care unit training programme in
the ICU of a large teaching hospital. Previously you had worked for 12 months in a regional
ICU and prior to that had spent three years in internal medicine. Before you joined this ICU, you had
heard from colleagues that the ICU staff were interested in education and devoted significant time to
training and supervising their trainees.

It is Wednesday afternoon and the Director of Intensive Care (your supervisor of training) asks you to
supervise a medical student for a month. The student is in his last year of his undergraduate course and
has chosen a one-month elective clerkship in intensive care medicine. He will start next week.

The Director tells you that this is her first request for a clerkship since she started in post. Her
predecessor had preferred an informal approach to training so there is no existing programme for you to
work to. You are keen to supervise the student but you realise there will be time implications. When you
mention that others will need to take over some of the clinical tasks, you are told that there are no extra
resources for this training. Despite this, you accept the job and agree to develop a programme for this
student. You enthusiastically start thinking about a possible programme.
Learning issues

Teaching in the clinical setting

Developing a learning programme

In some jurisdictions / medical schools, medical students are not permitted to undertake
N OTE patient procedures for reasons such as insurance, liability etc. This may have a bearing on
what the student might achieve.

What do you first want to know before developing a programme for this student?
Learning issues

Learning goals

Learning in a clinical setting

Assessing students

The student is at the end of his undergraduate training and has successfully completed all other
mandatory clerkships. The goal of this ICU clerkship is to experience working at the level of a newly-
qualified physician and to deal with the associated responsibilities.

The student has explained in a letter that he has always had an interest in intensive care medicine and
that he wants to find out if he would like to become an intensivist.

How do you perceive your role as a teacher in this clinical setting and how do you relate this to learning in a
clinical environment?

Learning issues

Providing feedback

Observation and feedback (1)

Observation and feedback (2)

You have devised a programme for this student. During the first week, you think he will learn most when
shadowing and observing you while you are working. During the second week, the student will have the
opportunity to provide some patient care while you are observing him. If you think he is competent
enough, you will give him two patients to take care of while you are supervising him during the final two
weeks.

You have received the assessment form from the Medical Faculty Office to complete at the end of the
clerkship.
Learning issues

Supervision

Level of competence

Tools for assessment

When and how do you use the assessment form?

Learning issues

Learning goals
 Formative assessment

Summative assessment

Assessment and learning objectives are closely related.

N OTE

The following Monday the student arrives at the ICU at 8.00 a.m. You introduce him to the department
and explain the programme. He is eager and wants to start immediately. You explain that you want him
to observe you and that you will ask him questions about the patients to test his knowledge.

The first week is busy for the student and for you. He wants to know everything and constantly asks you
to explain what you are doing. Although it takes you extra time, you like his enthusiasm. On Friday you
want to prepare him for the coming week.
Learning issues

Introduction

Planning teaching moments

How do you prepare your student for the coming week?

During the second week you observe your student while he is examining a patient. In his eagerness to
start examining the patient, the student forgets to use the chlorhexidine hand-wash. You notice that he
omits parts of the examination and forgets to ask the nurses about their observations. He seems very
pleased with himself. You decide to give him feedback after you finish your round.

What are you going to tell him? How do you conduct your feedback session?

Learning issues

Providing feedback
Adapting feedback to individual learners
Multi source feedback

Throughout the rest of the week he is doing fine and other colleagues who have provided him with
guidance are positive. You have asked the nurses about his communication with them and they tell you
that he has greatly improved.

During the clerkship you plan to teach him how to place a peripheral i.v. catheter. There is an excellent
videotape about this skill which you could use.
Learning issues

PACT module on Communication skills

 How can you teach him this skill? What instructions do you give the student? What other measures do you
take?

Learning issues

Skills teaching

Four-stage model

How do you conduct formative assessment?

Learning issues

Formative assessment

During the final week you plan the assessment of your student. You are thinking of letting him run a
simple scenario on the Human Patient Simulator. Fortunately, they have a space available and also a
scenario that is suitable for his level of competence.
Learning issues

High-fidelity simulation training

How would you prepare him for running a scenario?

How do you set up the debriefing?

Learning issues

Providing feedback

During the scenario your student does well. You had selected a fairly uncomplicated scenario and
concentrated on topics that he had practised and/or discussed during his clerkship. He is communicating
very well with the nurse. He scores well in this assessment. You keep in mind the five steps for providing
feedback when starting the debriefing.

You then ask the student to examine a patient who is being weaned from ventilation and evaluate the
factors holding up his progress. But the patient's daughter objects to 'a student practising' on her father
and wishes to speak to his supervisor.

How should the student respond?

You, as supervisor, first apologise to the patient's daughter that you had not adequately taken into
account the patient's autonomy. In addition, given that the patient was not in a position to interact with
the student or the other ICU staff, that you should have discussed the evaluation with her, as she was
present and supporting her father at the time.
Learning issues

PACT module on Ethics

You, as his supervisor, now ask the student to justify to the daughter his role in examining the patient. How
does he respond?

Learning issues

PACT module on Communication skills

The daughter asks the student how his examination of her father could possibly help. How does he reply?

The last thing to do is the summative assessment. It means you have to complete the assessment form
you received from the Medical faculty.
Learning issues

Summative assessment

How will the assessment relate to the content of the course?

The day before the final assessment you speak to the rest of the team about their impressions of the
student. You ask the Director of Intensive Care, who initially assigned you this task, whether she would
like to become involved in the summative assessment.

What is the advantage to requesting the Director's involvement?

Learning issues

Assessment validity
 How do you organise the assessment?

Although this student passed successfully, the Director is concerned that there is no formal evaluation of
the clerkship itself. When she asks the student his opinion about it, he is very complimentary about the
organisation of the clerkship and says that he has learned a great deal over the four weeks. He indicates
he has become very enthusiastic about intensive care medicine and is thinking about a career within this
specialty.

Following your discussions with the student, you start to think about the strengths and weaknesses of
the clerkship. You want to convey the key points to your own supervisor of training to help inform the
evolution of future clerkships.

points do you list in your evaluation in terms of strengths and improvements?

ng issues

luation of education

on, good clinical teaching and a good clinical environment complement each other. Think of what the
participant gets to see, what tasks he will perform and how the feedback is organised. Enthusiastic
are extremely important both to the healthcare environment and to the quality of the teaching. Clinical
is an integrated activity of the quality healthcare team. The better the learning environment, the better
hysicians are motivated towards lifelong, quality patient care and indeed towards a career in your specialty!