An introduction to teaching and learning in medicine
Foreword by
David M Irby
Ronald M Harden
Jennifer M Laidlaw
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ESSENTIAL SKILLS FOR A MEDICAL TEACHER
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ESSENTIAL SKILLS FOR A MEDICAL TEACHER
An introduction to teaching and learning in medicine
Third Edition
Ronald M Harden OBE MD FRCP (Glas) FRCPC FRCS (Ed)
Professor Emeritus Medical Education, University of Dundee, UK
General Secretary, Association for Medical Education in Europe (AMEE)
Editor, Medical Teacher
Jennifer M Laidlaw DipEdTech MMEd
Formerly Assistant Director, Education Development Unit, Scottish Council for Postgraduate Medical and Dental Education at the University of Dundee, Dundee, UK
Foreword by David M Irby PhD MDiv
Professor Emeritus of Medicine, Education Scientist, Center for Faculty Educators, School of Medicine, University of California, San Francisco, USA
The right of Ronald Harden and Jennifer Laidlaw to be identified as authors of this work has been asserted by them in accordance with the Copyright, Designs and Patents Act 1988.
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This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).
Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or contributors for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.
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Foreword
My life has been repeatedly transformed by exceptional teachers. I vividly recall a presentation by an amazing teacher and researcher at a national meeting 30 years ago, which changed the trajectory of my research and career. I was so excited about the ideas he presented that I embarked on a quest to establish a whole new line of inquiry. I left the conference and immediately resigned my assistant deanship, took a sabbatical to get retooled in qualitative research methods, and embarked on a set of research studies on clinical teacher knowledge and reasoning. Great teaching can change everything.
Reflecting on that powerful experience, I am reminded that I also love to teach because I love to learn, and I derive a great deal of personal satisfaction in helping others. I find joy in preparing, teaching interactively, and reflecting on my instruction so that I can continually improve. And I am inspired by and celebrate the learning gains and accomplishments of my learners and mentees. I ask you, what could be better than this?
Yet, exceptional teaching doesn’t just happen. Teaching excellence emerges from hard work and deliberate practice. By deliberate practice I mean, the conscious and effortful work on one component or skill of teaching in order to improve it - before moving on to master additional components. In learning anything new, the best approach is to pick one thing to focus on, implement and automate it, before adding another new strategy. Thus, the way to read this book, Essential Skills for a Medical Teacher, is to select one chapter or skill to read about, try using it in your teaching, and then revise until it works for you. Then, select another skill, concept or chapter to read and experiment with it.
This book offers insights from practice and scholarship to improve the various roles teachers perform: teacher, mentor, curriculum developer, assessor, educational leader, and scholar. Both new and experienced teachers will find practical and tested strategies for each of these roles in this book. Some of the ideas and concepts can be readily implemented while others require more extensive effort, collaboration and planning. Since there are no simple answers or quick fixes for excellent teaching, the book should be viewed as a set of tools designed for continuous improvement.
There is an additional benefit to reading the book: learning the vocabulary and concepts of contemporary medical education. At a conceptual level, teachers benefit from understanding key learning theories and terms, curriculum development frameworks, assessment strategies, and leadership practices. This offers a common language and
an evidence-based approach to working in medical education. These concepts can expand understanding about the roles and responsibilities of teachers not only for direct instruction but for the broader learning environment as well.
The format of the book lends itself to being a guide on the side for educational knowledge and skills. It is written in a style that is easy to assimilate, is evidencebased, offers practical and inspiring ideas with selected references on each topic presented. In addition, the chapters offer insights into key contemporary concepts in education, such as adaptive expertise, EPAs, spiral and hidden curricula; as well as helpful memory devices for retention of key points. You might see if you can find the following mnemonics used to remember key concepts in the book: SPICES, FAIR, CRISIS, PHOG, P2P, PROFILE.
The chapter on learning environments describes an expanded view of where and how we learn and work. Learning environments include the social interactions, organizational culture and structures, physical and virtual spaces, and personal experiences, perceptions and learning. A positive learning climate is built on teacher enthusiasm and humility, welcoming and respectful relationships, and balancing challenge with support. Interactions among participants in learning environments have been associated with learners thriving, learning and providing excellent patient care and the opposite: contributing to burnout, depression, diminished learning and poorer quality patient care. As teachers, we need to attend to all of the components of the learning environment and advocate for their improvement in order to create joy filled and challenging learning experiences for students and residents.
In the chapter on passion for teaching, there are helpful tips on how to be a passionate teacher and how to avoid burnout. Passion for teaching and the topic of instruction is essential to motivate learning. I learned from my earliest research on clinical teaching that enthusiasm (and a passion for teaching and for one’s profession) is the highest correlate of overall teaching effectiveness as rated by students and residents. Sharing excitement for teaching and patient care activates, energizes and focuses learning.
I have devoted my career to helping teachers improve through faculty development and educational scholarship. In the process, I have discovered numerous resources that can help teachers in their continuing quest for excellence. This book is one of them. It helps shift our thinking away from teaching obligations toward the joy of teaching that can inspire learners and shape the future. I commend this book to you.
David M. Irby PhD MDiv Professor Emeritus of Medicine
Education Scientist, Center for Faculty Educators, School of Medicine
University of California San Francisco San Francisco, CA USA
Preface
Welcome to the third edition of Essential Skills for a Medical Teacher. If you are new to teaching and training you will find that the text describes what you should know about curriculum planning, about teaching and learning methods, and about assessment. For those more experienced, it provides an update on developments in medical education and an opportunity to critique your own teaching in the light of best education practice. The text has been prepared as a practical resource that will assist you to create meaningful learning opportunities for your students or trainees. At the same time it introduces some key principles that will help you to reflect on the recommendations provided and on your own teaching.
The chapters in the book have been revised and updated to take account of the developments in medical education since the second edition was published. New chapters have been added addressing entrustable professional activities, the selection of the most appropriate teaching method, your approach to assessment using the assessment PROFILE, self-assessment, bringing about change, and the future of medical education.
The book provides a concise summary of practical issues and what is required of a teacher, with bulleted lists to allow you to assimilate quickly the key elements. It was Albert Einstein who said that ‘any intelligent fool can make things bigger and more complex’. We hope we have avoided doing so! At the end of each chapter we ask you to Think about issues raised and also Dig deeper in the published literature. In addition to references cited in the text, we have provided additional references should you wish to explore the topic in more depth.
We have divided the book into six sections. The first section introduces you to your roles as a teacher and the challenges you face. The second section addresses the key question you need to consider first – what should the student or trainee learn. This reflects the important move to outcome- or competency-based education. The next section looks at the different options for addressing these learning outcomes in a curriculum and the range of educational strategies available. Section four then considers how you can best facilitate the student’s learning and the tools available in your teacher’s toolkit. Section five describes how you can assess whether the learner has mastered the necessary outcomes and competencies and the power assessment has to assist the student’s learning. The final section considers how you
can review your own teaching, adopt an evidence-informed approach, and bring about change where this may be indicated. The book reflects the wind of change in medical education. The last chapter looks at what the education programme might look like in 5 or 10 years.
Whether your responsibilities are in undergraduate, postgraduate, or continuing education, your role as a teacher or trainer is of the greatest importance. We hope you will find this book both enjoyable and useful and that it will help you to respond to the current and changing demands in medical education.
About the authors
Ronald M Harden
Professor Ronald Harden graduated from the medical school in Glasgow, UK. He completed training and practised as an endocrinologist before moving full time to medical education. Professor Harden is editor of Medical Teacher and General Secretary and Treasurer of the Association for Medical Education in Europe (AMEE). He was formerly Professor of Medical Education, Teaching Dean and Director of the Centre for Medical Education at the University of Dundee, and Consultant Physician.
Professor Harden is recognised as one of the leading international authorities in medical education with unparalleled experience in undergraduate, postgraduate, and continuing medical education. He brings to medical education a unique blend of theoretical and practical experience. He is committed to developing new approaches to medical education, to curriculum planning, and to teaching and learning. Ideas which he has pioneered include the Objective Structured Clinical Examination (OSCE), which has been universally adopted as a standard approach to assessment of clinical competence. He has led work related to outcome-based education, curriculum mapping, and the application of new learning technologies. Professor Harden has written extensively in his areas of interest and has published more than 400 papers in leading journals. He is co-author of The Definitive Guide to the OSCE and The Eight Roles of the Medical Teacher and co-editor of A Practical Guide for Medical Teachers and the Routledge International Handbook of Medical Education
He has served as a consultant and visiting professor in Europe, North America, South America, the Middle East, Africa, India, and the Far East. His contributions to excellence in medical education have attracted numerous awards including an honorary fellowship of the Royal College of Physicians, Surgeons of Canada, the prestigious Hubbard Award by the National Board of Medical Examiners in the USA, and recognition by the Kellogg Foundation for his contributions to medical education in South America. He was awarded by the Queen the OBE for his services to medical education. He was presented in Singapore in February 2006 with the ‘Mentoring, Innovation and Leadership in Education Scholarship’ (MILES) award for ‘outstanding contributions to the advancement of global medical education and academic medicine’. In 2006, Professor Harden was the winner of the Karolinska
Institutet Prize for Research in Medical Education. The purpose of the prize is to recognise and stimulate high-quality research in medical education in order to promote long-term improvements of educational practices in medical training. It is often considered as the Nobel Prize for medical education. In 2009, he was awarded the ASME Richard Farrow Gold Medal, in recognition of the contributions he has made to medical education. In 2010, he was presented with the AMEE Lifetime Achievement Award for services to medical education. He received a Cura Personalis Award from Georgetown University Medical Center and honorary doctorates from the University of Lisbon and the University of Tampere. He was recently awarded the Gusi Peace Prize for services to medical education at a ceremony in Manila, and the Henry Fok Medal in Macau, China. He received in 2019 the degree of a Doctor of Laws honoris causa from the University of Dundee.
Jennifer M Laidlaw
Jennifer Laidlaw joined the University of Dundee’s Centre for Medical Education in 1975, having previously been a media resource officer for the Royal Bank of Scotland and an innovator of their first distance learning programmes for bank staff.
At the University of Dundee, she initially taught on a Diploma in Medical Education course attended by WHO fellows from the Eastern Mediterranean Region (EMRO). For over 20 years she planned, organised, and led courses on medical education both in Dundee and overseas.
She has acted as a medical education consultant for the World Health Organisation, the British Council, medical schools, and colleges. She has run workshops in Malaysia, the United Arab Emirates, Australia, Egypt, Kuwait, Thailand, Bangladesh, Hungary, and Romania.
She provided the educational design for the Centre’s distance learning programmes, which were distributed to over 50,000 healthcare professionals, including general practitioners, surgeons, pharmacists, dentists, nurses, and physiotherapists. Her postgraduate experience was with junior doctors, designing and teaching on induction courses.
She initiated the Twelve Tips series, which continues to be produced by the journal Medical Teacher, and provided the educational design for the series Developing the Teaching Instinct produced by the Education Development Unit of the Scottish Council for Postgraduate Medical and Dental Education.
In her teaching, whether it be face-to-face or at a distance, she has applied the FAIR principles that are highlighted in this book. The approach has certainly worked for her.
Acknowledgements
As we have recorded in previous editions, the understanding and experiences in medical education which we describe in this book have been gained and made immeasurably richer through our association with former colleagues. We are also grateful to all who have shared their experiences and views on medical education with us at conferences, through papers we have read, and in schools we have visited.
We have learned a lot working with the excellent facilitators on our Essential Skills in Medical Education (ESME) courses and from the participants who have shared their thoughts with us. Medical education is an applied discipline and only by seeing and experiencing at first-hand what works and what does not work have we been able to distil what we believe to be helpful advice.
We would like to thank everyone who supported us in the preparation of this book, including Jacob Thorn for work on the preparation of the manuscript, Jim Glenn, whose cartoons we hope will entertain the reader, and David Irby, who has written the Foreword. Finally, we would like to thank the team from Elsevier, including Laurence Hunter, Carole McMurray, and Elyse O’Grady, without whose support and assistance this book would not have been possible.
Ronald M Harden
Jennifer M Laidlaw
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SECTION 1 Challenges you face as a teacher
(Teaching responsibilities)
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What is expected of you as a teacher at a time of change
1
What would the learner miss if you were not there as a teacher? You have a critical role to play in the education programme.
The teacher is important
More than half a century ago in 1963, Sir Derrick Dunlop wrote in ‘The Future of Medical Education in Scotland’,
‘It is important to remember that the actual details of the curriculum matter little in comparison to the selection of students and teachers. If these are good any system will work pretty well; if they are indifferent the most perfect curriculum will fail to produce results.’
This is equally true today. If you are a teacher, a trainer, a clinical supervisor, someone with responsibility for a section of a course, or a dean, you can make a difference to the quality of your students’ or trainees’ learning experience. Teachers in fact are a key ingredient in the education programme and the medical school or postgraduate body’s greatest asset. The teacher is critical to the success or failure of the education programme with regard to the planning and delivery of the curriculum, to the methods adopted to support teaching and learning, and to the assessment of the student’s progress and achievement of the specified learning outcomes. As we discuss in Chapter 21, there are no bad lectures only bad lecturers. Acknowledging the importance of the teacher, Lawrence Stenhouse (1975), an education guru, suggested that there could be no such thing as curriculum development without teacher development.
Thomas Good (2010), reviewing research on teaching, illustrated the importance of the teachers, using the analogy of how a chicken dinner with salad, wine, and an apple can be a completely different experience as we move from restaurant to restaurant or eat at different homes. While the meal can always be improved by better wine or new ingredients, more important is how the basic ingredients are prepared and presented. As Good outlined, the literature on effective teaching is not based on evidence showing that the most effective teachers bring in new components or better ingredients. Rather the literature indicates that some teachers work with basic ingredients better than others. More important than the method of teaching is how it is implemented in practice and the student-teacher interaction.
Accrediting bodies, such as the General Medical Council in the UK, have recognised that all doctors to a greater or lesser extent have teaching responsibilities, and teaching competence is highlighted as an important learning outcome in undergraduate and postgraduate programmes. A European Union High Level Group: Train the Professors to Teach recommended,
‘All staff teaching in higher education institutions in 2020 should have received certified pedagogical training. Continuous professional education as teachers should become a requirement for teachers in the higher education sector.’
Your responsibilities as a teacher
Teaching is about much more than the transmission of information to the learner. Teaching encompasses the tasks of planning, preparing, and delivering a learning programme and assessing whether students have achieved the expected learning outcomes. Students learn all of the time. It is a natural activity. Your job as a teacher is to facilitate this. You need to:
• Know what the students you are teaching are expected to learn
• Understand how an education programme can be organised
• Be familiar with the wide range of teaching and learning approaches that can be used including recent developments in the area
• Be able to incorporate proven education principles into your teaching in order to help your students learn
• Make conscious, explicit, and judicious use of evidence regarding what works and does not work in your teaching practice
• Create the right environment to facilitate student learning
• Be able to assess the learner’s achievement of the learning outcomes and to provide feedback
A good travel agent, with special knowledge in an area, provides clients with information about their destination according to their specific requirements, assists them to explore the range of options that match their needs, arranges the necessary transport and accommodation, and advises on a programme of activities at their destination. While there are undoubted differences, as a teacher your responsibilities are in some ways similar.
An effective teacher
It is now recognised that expertise in medicine or in a content area is not necessarily associated with the skills required to teach the subject to students or trainees. While a good teacher may naturally have the skills and passion to teach others, some required skills have to be learned. Everyone can learn how to be a teacher. In teaching, much may be seen as common sense or obvious but experience shows that in practice, teachers often flounder and are found wanting. Teachers can learn from experience but this in itself is not enough. This point is illustrated when we look at golfers who go round a golf course practicing their mistakes, but if the mis-
Professional competence
Acquiring the necessary skills
Keeping up to date
Evaluating your own competence as a teacher
Personal wellbeing
Technical skills
Preparing and giving lectures
Small group teaching
Teaching practical or clinical skills
Facilitating and managing learning
Developing learning resources
Assessing trainees
Evaluating the educational programme
Using technology and social media
Approach
to teaching
An understanding of the principles of education
Appropriate attitudes, ethical understanding and legal awareness
Appropriate decisionmaking skills and best evidence-based education
Team working skills
Teaching is both an art and a science. Some teachers are instinctively good teachers but others are not. The reassuring fact, however, is that the art and science of teaching can be learned. The experienced teacher can develop further their teaching instinct and the new teacher can be helped to acquire this instinct and the necessary competencies, attitudes, and professionalism.
Teaching is a complex activity that requires the teacher to have a range of abilities. What is required of the teacher is demanding. Teaching, Brookfield (1990) suggested, is the ‘educational equivalent of white water rafting’. The teacher requires a range of technical skills but this is not enough. Their approach to teaching should be based on an understanding of basic educational principles, an appropriate attitude, informed decisionmaking strategies, and teamworking skills. The teacher is also required to have a professional approach to their teaching, keeping themselves up-to-date and evaluating their teaching performance. These abilities correspond to the three circles shown in Fig. 1.1
Here lies a problem. Staff development programmes and texts on the subject frequently address only the technical competencies, or alternatively focus on details
Fig. 1.1 The teacher’s abilities: a three-circle model
relevance. The concept of professionalism and attitudes to teaching are largely ignored. It is now recognised that the effective teacher requires a combination of technical competence, an appropriate approach to their teaching, and professionalism in their work as a teacher as shown in the equation:
An effective teacher = (Technical competencies) × (Approach to teaching) × (Professionalism)
The multiplication symbol has been used in the equation rather than the addition symbol. The implication is that a demonstration of technical competence, no matter how good, on its own is not sufficient: a zero score for the approach to teaching or for professionalism will result in a total score for the teacher of zero.
The technical competencies
The competencies expected of teachers include the ability to:
• Prepare and give lectures or presentations that engage the audience and make use of appropriate technology
• Choose appropriate small group methods and facilitate a small group teaching session
• Teach practical or clinical skills in a variety of settings, including the workplace
• Facilitate and manage the student’s learning in a range of settings, giving the learner support to obtain the maximum benefit from the learning opportunities available, helping the student to assess his or her own competence, and providing feedback to the learner as necessary
• Plan an education programme for the students or trainees that combines appropriate learning opportunities to help them to achieve the expected learning outcomes
• Identify, develop, and adapt learning resources for use by students in the form of handouts, study guides, or multi-media presentations
• Assess the achievement of learning outcomes by the students or trainees using appropriate technologies including written, performance-based, and portfolio assessments
• Evaluate the education programme
• Make appropriate use of technology and social media
In how many of these skills does a teacher need to be highly proficient? Depending on the local circumstances, the required level of mastery of the skills may vary. It can be argued, however, that a level of understanding and basic level of proficiency in all of the skills is necessary.
How a teacher approaches their work
An effective teacher, in addition to having the necessary technical competencies, approaches their teaching with:
• An understanding of basic educational principles
As discussed in Chapter 19, an understanding of basic educational principles helps teachers to adapt the teaching approach to their own situation, to deal with problems and difficulties encountered, and to respond to the need for change.
• Appropriate ethics and attitudes
The ethical standards expected of medical teachers in their work as a teacher or researcher in medical education has been a focus of attention. Also important and a key factor in student learning is the teacher’s attitude, passion, and enthusiasm for the subject and for their teaching. The teacher’s passion for their teaching helps to motivate and inspire the learner.
• Strategies for decision making
Paralleling the move to evidence-based medicine, the need for the teacher to make education decisions informed by the best evidence available is very much on today’s agenda. At the same time, the good teacher has to be able to behave intuitively and to respond appropriately to unexpected situations as they arise in the classroom or workplace learning situation.
• Team work skills
Collaboration and team work are now a feature of education practice and is necessary for the successful implementation of curriculum developments such as integration, interprofessional education, and outcome-based education.
The teacher as a professional
The effective teacher is a professional.
• Teachers as professionals should be inquirers into their own competence, should reflect on their own teaching practice, and should audit the quality of their teaching
• Teachers should have the necessary abilities and have the personal responsibility to keep themselves up-to-date with current approaches to teaching
• The teacher should communicate their experiences and lessons learned to others. This contributes to a scholarship of teaching as described by Boyer (1990)
• Some teachers will successfully innovate in their teaching practice and contribute to the development of new courses and curriculum reform
• The teacher as a professional should take responsibility for their own wellbeing
The teacher cube
The three dimensions relating to the work of the teacher can be represented in the form of a cube (Fig. 1.2) with each of the sides representing:
• The roles of the teacher
• The competencies expected of a teacher
• The teaching context or culture where learning takes place
The cube should help you to understand your responsibilities as a teacher.
What is expected of you as a teacher at a time of change
Your role as a teacher
You should be aware of your role as a teacher – as an information provider, facilitator, curriculum developer, assessor, role model, manager and leader, scholar, and professional (Harden and Lilley, 2018). This represents one face of the cube. A teacher charged with giving a series of lectures will need to be skilled in lecturing (the teaching competence) but will also have to consider whether their role is that of an information provider, a facilitator of the student’s learning, or a role model. They must also consider how the lectures relate to the overall curriculum and the learning outcomes in the early or later years of the course. A clinical supervisor or postgraduate trainer should not only have the necessary clinical teaching skills, but have also an understanding of their role, including that of role model. They also need to have an appreciation of the context in which the trainees are learning, including the availability of learning resources such as simulators. During your career your role and the context in which you work are likely to change.
The competencies expected
In addition to expertise in a subject, the competencies presented in the three-circle model and described in more detail in the chapters in this book are necessary. While the context in which you work will vary, there are some common principles and approaches, as we describe, which are universally applicable.
The context
The third side of the cube represents the context or culture in which you are teaching. This may be in the community or a hospital setting, it may be with students early in their medical studies, or with postgraduate trainees who have completed their undergraduate programme. Education in medicine takes place in a wide variety of settings. The education context influences how the curriculum is structured, the defined learning outcomes, the available learning opportunities and resources, and the approach to assessment (Brett et al., 2018). Consideration needs to be given to geographical context, including cultural values and the availability of learning resources. Geographical variations may include different power relationships and different expectations, different clinical contexts, different roles for students and trainees, and different roles expected of the teacher. The teacher should not only
