V. HUNT, C. BULSTRODE, P. BALDWIN*, H. BULSTRODE and C. MANSFIELD
John Radcliffe Hospital, Oxford, OX3 9DU, UK
Keywords: Training, clinical teachers, medical student teaching, courses, effectiveness
A three-day course was designed to improve the skills of those who provide clinical training to medical students. This long-term follow up of past participants shows a sustained improvement to their skills, especially in terms of involving students in their own learning, and giving them positive feedback.
J.R.Coll.Edinb., 47 August 2002, 619- 622
The importance of training clinical teachers in how to best train medical students and junior doctors was highlighted some years ago.1 It is increasingly being recognised as an important way of valuing teachers, and also ensuring that the limited time available for training is used to best advantage. There are a variety of ‘Training the Trainers’ courses now available in Britain and Europe, but courses designed specifically for teachers of clinical medical students are less common.
Some medical schools simply send their new clinical teachers to the general induction course provided by their University.
In 1998 Oxford Medical School commissioned a series of courses specifically for the education of clinical teachers of medical students, as their needs were felt to be very different from the non-clinical teaching staff.2
The residential course that is the subject of this study (UNICON) was designed to fulfil this aim. SIFT funds were obtained to pay for NHS staff to attend.
The course is designed to be three days long, residential and is held in congenial surroundings well away from the hospital itself. Two day courses were also piloted in an attempt to reduce costs and make optimum use of time.
Each course has places for around 24 participants. The faculty is multidisciplinary.
The course introduces concepts such as:
• writing learning objectives
• designing training programmes
• planning teaching and on-the-job training
• structured methods of formative and summative assessment
• the value of student feedback
• the importance of constructive feedback to students
• assessing students’ professional behaviour
• the importance of role models
• the requirements of regulatory bodies such as the GMC
A course manual is sent out 4 weeks before the course and participants are asked to complete a limited amount of precourse work. The structure of the course itself is to start each section with a short talk followed by small group workshops to try out the techniques. Everyone then meets together in a plenary setting to discuss their findings. The philosophy of the course is to encourage discovery and reflective learning.
Key elements are to demonstrate how constructive feedback can and should be given using PQRS,3 and how a training event can be planned using a very simple acronym, BOGERD.3,4
The course starts by using simple clinical examples of onetoone teaching taken from clinics and wards. The programme then extends to more complex areas of teaching in small groups, and to dealing with complex communication problems such as training students with apparent behavioural difficulties. This leads into techniques for carrying out an appraisal, and the principles and practice of assessment.5
The course is also designed to give clinical teachers ‘time out’ in a pleasant environment to reflect on the problems they are experiencing in their teaching, and how they might take things forward individually and collectively.
Facilitators try to avoid educational jargon, wherever possible, and actively encourage participants to adapt the material used on the course to their own working environment. By the end of the three day course all participants are assessed to ensure that they have the tools with which to design, organise and deliver their own training programme.
There is one facilitator for every four participants. Their task is to watch carefully and ensure that each participant attempts and successfully completes the tasks set as the learning objectives of the course. If anyone is struggling with a particular concept, they receive extra help, while the rest of the course move forward to look at more complex scenarios. Participants are also encouraged to assess themselves and their peers, as a practical illustration of how powerful these techniques can be in a real life situation.
All clinical teachers are offered a follow-up visit within their own department to look at how the principles taught in the course can be implemented within their own departmental teaching programme.
Participants are invited to complete a questionnaire and give verbal feedback at the end of each course. For the purpose of this study, retrospective feedback was obtained by a questionnaire sent to delegates between 6 months and 2 years after attendance on the course. This questionnaire was specifically designed to answer the following questions:
• What did the participants feel that they had gained from the course, if anything? (Value)
• What evidence is there that any positive changes are sustained over time? (Sustained Value)
• Is there any evidence that the delegate’s departmental policy has been changed as a result of the course? (Sustained Effect)
• What difficulties have been encountered in implementing these changes? (Blocks)
• What (if any) extra workshops are needed as a follow up? (Development)
• Was a three day course more beneficial than a two day course (Cost Effectiveness)
• Should the course be residential or non-residential?
The questionnaire was designed by one of the authors (VH), and reviewed by a psychologist whose expertise is in questionnaire design. It was piloted on delegates from a sister course (Changing the Culture) and subsequently modified to eliminate any areas of ambiguity or lack of clarity.6 This questionnaire was sent to all 169 members of the clinical school who had so far attended the course, and a stamped addressed envelope was enclosed for replies.
Of 18 envelopes which were returned ‘gone away’, the addressees subsequently proved untraceable. They were classified as ‘lost to follow-up’. All were junior doctors on short-term contracts. We eventually obtained 109 out of a potential 151 returns (72%). These were initially analysed by a researcher who did not know any of the participants and who had not taken part in any of the courses (HB). This was to eliminate possible bias.
Four separate questions looked at whether there had been any perceived change in clinical teachers’ competence or confidence in teaching students. Ninety four percent felt that they had made a change, and were able to give examples from their own practice. The commonest examples were in the use of positive feedback (78%), the use of a wider range of teaching methods (63%), greater interaction between teacher and student (62%), and more student involvement in the planning of teaching (50%). Fifty seven percent felt that the course had made an overall difference to their everyday work.
Where the majority of staff in a teaching department had attended the course, 60% were able to describe specific examples of where the departmental teaching had been changed as a direct result of the course. In the free text section of this answer a common response was that they appreciated being able to design their teaching around a more rational and structured framework.
Only five of the respondents had attended as non-residential delegates. It was, therefore, not possible to make a comparison between residential and non-residential. However, the comments from those who were residential made it unequivocally clear that the evenings of the course were of crucial importance to mull over the concepts discussed in the day. It was also an opportunity to share good practice between different departments who rarely had an opportunity to do this otherwise.
Fifty-six respondents attended a two day course, and 53 a three day course. It was possible, therefore, to compare teaching effectiveness and confidence, application to everyday work, and changes at departmental level. All were improved in those who attended a three day course compared with a two day course. (Figure 1)
Figure 1: n=53 for 3 day course n=56 for 2 day course
To address the issue of whether or not the course was effective over time, returns were divided into those from delegates who had attended the course within the last 6 months (19), those who had attended between 6 and 12 months ago (46), and those who had attended more than 12 months ago (44). The results show that there is relatively little decay in the effect over time. (Figure 2)
Figure 2: Decay of proportion recording ‘improvement’ over time since they attended the course
Over 30% of respondents gave ‘lack of time’ as the primary reason for failure to implement the changes suggested on the course. Eleven percent mentioned the need for a defined core curriculum agreed by the whole department before many of the changes could be implemented.
There were many suggestions for further training, with a marked preference towards the management of poorly performing students, those with behavioural problems, examination and assessment techniques and, to a lesser extent problem-based learning. Most of these topics are touched on
in the present course, but clearly there is a demand for further training in these important areas. Examining has already been made the subject of a separate half day course, which now runs well.7
Medical schools should provide educational support for clinical teachers responsible for medical students learning in a busy clinical setting. As well as developing skills in clinical teaching and assessment, courses should provide a forum in which clinical teachers can discuss their current difficulties and possible solutions to problems encountered. Appropriate training opportunities should be provided for all clinical teachers, junior as well as senior staff, and staff from different disciplines to foster a multidisciplinary approach.
UNICON offers such a grounding for clinical teachers. The Quality Assurance Agency for Higher Education and the Education Committee of the General Medical Council have both commended the commitment of the School to promoting the professional development of clinical teachers through the UNICON programme.8
The residential aspect is especially appreciated. The course appears to bring about a sustained change of behaviour in almost all those who attend. This is despite the fact that many of the teachers felt that they had been given little choice on whether they wanted to come on the course or not. Our experience has been that anyone who feels that they have been pressurised to attend arrives with a very negative attitude which is initially difficult to dispel. However, if no incentive is offered then it is difficult to persuade busy clinicians to give up time to come of such a course unless attendance is mandatory. Paradoxically, once they are there, they genuinely seem to enjoy the opportunity to take time away from their practice and to reflect on this and the teaching they provide.
One of the key questions asked is whether everyone in a department needs to attend such a course, before change can be observed, or whether there is a critical mass which will lead to change.
There are two ways of looking at this from the data we have gathered. The first is that if we look at decay in numbers recording ‘improvement’, coupled with time since attending a course, most of the variables can be seen to be decaying slowly. This is what one might expect. However, it is noticeable that ‘Departmental change’ actually increased with time. We believe that this may be a result of some departments gradually building up a critical mass of teachers who had attended the course and which then resulted in a change in departmental teaching programmes. The two two-day courses in this study were both organised specifically for one department. This department, therefore, immediately had a critical mass of teachers who had attended. It is noticeable that it is ‘Change in departmental policy’ which is again at variance with the rest of the data, and is found to be nearly as good on a 2 day course than a 3 day one. (Figure 1) When taken together, these two pieces of circumstantial evidence appear to point to the fact that a critical proportion of teachers in a department need to have attended a course before it is possible for that department to start implementing change on a greater than individual level.
Residential courses lasting three days are expensive in cost and time, but there is clear evidence from this study that the benefit is significantly greater than from a 2 day course.
There are also hidden benefits in terms of bonding the clinical teaching faculty and giving them good quality time out from their routine work. It must remain, however, a decision for the authorities funding such training as to how such courses should be organised. Our experience of one day or even half day courses is that it is very difficult to achieve sustainable changes in behaviour in these short periods, which allow little time for reflection and consolidation.
1. Bulstrode CJK, Holsgrove G. BMJ 312:326-7
2. Hunt VL, Bulstrode CJK. University Consultants’Course (UNICON), based on Changing the Culture, Skills Unit (Oxford) 1998
3. Bulstrode CJK, Hunt VL Training in Practice, p9:2000 Skills Unit (Oxford)
4. Bulstrode, CJK, Hunt VL. Educating Consultants, SUMIT Oxford 1997
5. "What is Mentoring?”, The Lancet 25 November 2000, vol 356:9244, p 1788
6. Hunt VL, Bulstrode CJK. Changing the Culture, Skills Unit (Oxford) 1998
7. Examining in Practice, 2nd edn, Skills Unit (Oxford) 2001 in association with the Intercollegiate Specialty Boards of Surgery
8. Quality Assurance Agency for Higher Education, Subject Review Reports, University of Oxford, Medicine, May 2000
9. The Education Committee of the General Medical Council. Report of the Visit to the University of Oxford School of Medicine, February 2001, http://www. gmcuk.org
Sadly, Pamela Baldwin died before the completion of this project. Her wish was that such training would provide a more supportive environment for medical students and junior doctors. We hope we have gone some way to achieving this. Her inspiration, constructive criticism and friendship were invaluable, and she is greatly missed.
We would also like to thank our facilitators, who have given their time and support so generously. The success of these programmes is largely due to their on-going help and constructive criticism.
Copyright: 8 April 2002
Correspondence : Victoria Hunt, Stream house, Mill Street, StantonSt John, Oxon, OX33 1HQ