MEDEV

School of Medical Sciences Education Development

Introduction

This short paper will be of particular interest to you if you have been involved in clinical teaching and learning facilitation at both undergraduate and postgraduate level.The principles expressed will serve as an aid to help support your role in training.

Approaches to Teaching

Historically, medicine has been taught didactically continuing the teacher-centred learning processes, common in primary and secondary levels of education, through university and into the years of clinical practice. This form of didactic teaching is comfortable for those learners who do not want to be challenged, and for those learners who believe knowledge is simply material to be memorised and retained.

It is also comfortable for teachers who were mainly taught in that way themselves. In the long term such didactic teaching, if relied on as the sole method of education, tends to lead to a state of dependency on the learner’s part, and it is not a good model for professional development.

An alternative to the didactic model is to adopt learner centred strategies. With this approach, instead of seeing the learners as receptacles for information they are encouraged to seek and reflect on new knowledge in the light of their own experience and to decide on the most effective way of integrating that knowledge into their own practice.

Research into learning in higher/professional education has demonstrated conclusively that when we are actively involved in our own learning we become more effective learners. The following illustrates this. We retain:

• 10% of what we read;
• 20% of what we hear;
• 30% of what we see;
• 50% of what we see and hear;
• 70% of what we say;
• 90% of what we say as we are doing something

(Montgomery 1993)

A more teacher-centred approach may be the most appropriate in the early phase of learning when the learner’s knowledge base is weak and skills are limited. Later, a more learner-centred approach should be adopted as experience builds.

There are a range of techniques which can be used in teaching, and part of the skill of the teacher is selecting the most appropriate techniques to teach a particular topic. The choice of technique will also be influenced by the type and range of your learners.

However, there should be one overriding reason in selecting a teaching technique – it should help and reinforce learners in their endeavour to become competent independent practitioners of lifelong learning.

The skill of the learner centred teacher lies in:

• identifying learning opportunities
• providing links and directions for the learner
• challenging the learners to reflect on both their own past experience and areas of new knowledge and practice skills
• acting as a resource for learners to test and discuss their new or revised knowledge and skills.

Actively Involving the Learners

So how can you be more learner centred in your teaching? There are a wide range of strategies available to you. Some examples are listed below, but you will find many more in the suggested readings at the end of this article. You can foster active learning by:

• Asking learners to teach the topic or skill they are learning. Learners learn most effectively when they are asked to teach another person. To be able to carry out this task effectively, they have to become fully involved in developing a clear understanding of a particular skill or body of knowledge.     
• This encourages them to think critically about the material: to anticipate difficult questions; to spend time concentrating on particularly difficult or challenging elements of the skill or area of knowledge; and to decide on the most effective way of communication their new found knowledge and skills to others (including their teachers).
• Chunking formal teaching into periods of no more than ten minutes duration, allowing questions and uncertainties to be raised. Lengthy expositions are a challenge to concentration and tend to reduce the learner to a passive role. Try to break up your teaching and think of how to involve the learners in an activity after each of your brief formal teaching slots. For example, you could ask the audience to consider a particular matter with their neighbour for a few minutes, then two or three of the pairs could be invited to offer the answer or their opinion to the whole group.
• Setting up tutorials/supervised sessions. But limit your personal contributions to an introduction of the topic and lines of approach and then act as a resources person, steering the direction of the discussion as little as possible.
• Asking your learners to write a report. Your role is to act as a resource and only take responsibility for leading in the opening stages, offering minimal direction.
• Ask your learner(s) to present a clinical case to yourself or a group. This creates the opportunity to discuss patient management and treatment planning or problem-solving, as well to practice and develop presentation skills. This can be done by individual learners but you can also divide your learners into small groups and ask each group to look at a different case and then feed back in plenary.
• In this way multiple perspectives are brought to play and a number of cases can be covered perhaps linked to a particular theme or condition. Admission of ignorance should be encouraged and valued as a means for clarification and learning for others. Most explanations should be offered by group members rather than by the teacher.
• Inviting learners to present at team meetings. Trainees might be asked to investigate some point of uncertainty and provide feedback to the next meeting. This has the added advantage of grounding the learning directly in real professional practice.
• Setting up a journal club. Each member has a journal article to review and present to the group. Other members should be encouraged to read the same article and independently criticise the paper. This helps the learners to engage with the relevant literature for themselves rather than relying on the knowledge being filtered through the teacher.
• Employ active strategies in grand rounds and other large scale lectures. There are a number of practical strategies for breaking up a grand round into manageable chunks. For example you can set a short task based on a case study and invite the audience to form into ‘buzz groups’ of two or three and briefly discuss the issues raised. One or two of the groups could give feedback. Many lecture theatres now have facilities for electronic feedback from the audience so you can set questions and ask for responses. These have the added advantage of enabling you to check whether the audience have understood the information given. You should also aim to encourage, questions or clarification during the presentation.
• Encourage your learners to find out for themselves through guided self study. Your role is to help the learner plan their learning and to agree clear outcomes. You can also provide guidance and support to the learner as he/she undertakes the agreed learning tasks. Clear learning outcomes and plans provide a focus and motivation for self study and empower the learner to become increasingly self sufficient.
• Asking your learners to talk through practical tasks as they perform them. Using video recording and providing immediate constructive feedback is also an invaluable tool in developing skills. When giving feedback avoid sarcasm or highly negative remarks. Seek to identify any positive aspects of a performance but be honest and clear about how the skill can be improved.
• In this model of teaching, the teacher becomes an active facilitator of learning. The teacher works with the learner on a wide variety of learning opportunities (both formal and informal) to maximise the effectiveness of the learning process. Teaching and learning becomes a dynamic interactive process – a partnership between teacher and learner – where the teacher is learning at the same time as the learner.

Further Reading

Bayley, T. and Drury, M. (Eds) 1998, Teaching and Training Techniques for Hospital Doctors, Oxford. Radcliffe Medical Press.

Brookfield S. Understanding and facilitating adult learning, ISBN:0335152260.

Cryer, P. (Ed) 1992, Enabling Active Learning in Small Groups, CVCP Universities Staff Development and Training Unit, Sheffield.

Montgomery, D. (1993), Fostering Learner Managed Learning in Teaching Education, in Graves, N. (ed), Learner Managed Learning, HEC. Leeds.

Payton, J. W. R. (Ed) 1998, Teaching and Learning in Medical Practice, London, Manticore.