Education - Dr Tom



This is the answer by Dr Tom MacFarlane who is the 'Guru' of MRCOG. He conducts free tutorials and uploads the audio load casts on Dropbox.

Education.
I am not an expert in this topic and offer this as some help to working out answers if you get a question on teaching methods, which apparently has happened. If you are an expert and can improve what follows, that will be much appreciated.
If you get a question in the exam, please try to remember as much as possible, particularly the option list and send it to me.
There is often a variety of different techniques that could be used. I would guess that the exam committee will take care to restrict the option list so that it is clear which is the best. I have too many options on my list, but I wanted to cram in as many as might come in the exam.
Lead-in.
The following scenarios relate to medical education
Pick one option from the option list.
Each option can be used once, more than once or not at all.
Abbreviations.
EMQ:​extended, matching question.
PBL:​problem-based learning.
Suggested reading.
There is a good introduction to PBL : here.
There is an open-access TOG article by Duthie and Garden that gives you much of what you need. TOG.  2010; 12: 273-280. There is a very interesting article from the 1950s by Ian Aird, a famous, multi-talented surgeon, who attended the 1st. World Congress on Medical Education, but I’d leave it for after the exam. Some of the themes that we are familiar with now were emerging then: the superiority of group discussion over formal lectures.  
It is amusing to see the old-fashioned, arrogant, self-esteem of the British Establishment in self-satisfied conclusions such as: “in this particular field the English schools are thoroughly effective”: this relating to “to the subtle and humane harmony which ought to exist between the doctor and his patient”. 
Background facts.
My generation grew up on lectures and, if they were lucky, the occasional tutorial. Medical education theory has taken off since then and increasing numbers of doctors are taking postgraduate degrees in the subject. It is now recognised that the traditional lecture, though cheap and “efficient” in that you can have a large number of recipients with little outlay in resources, is not much good in educating people as only about 5% of what is imparted actually sticks. At the other extreme, being the one doing the teaching leads to high retention of information, around 90%. Next best is practising an activity with about 75% retention and discussion in a tutorial group with about 50%.
When I tried to find the source of research behind the pyramid, I could not find it and I think it is just another bit of information that has started somewhere and been repeated so often that it is now “received wisdom”. Fortunately, the exam committee will treat it as true, so you can quote it, but retain your scepticism about the origins and validity of the figures. Does “teach back / immediate use of learning really lead to 90% retention, and if it does, for how long?
PBL, in which the student takes responsibility for acquiring information is much better than lectures in the amount learned. Not surprisingly, undergraduate teaching has moved away from lectures to PBL in many medical schools.
One of the questions you might be asked is about the various roles of the teacher. In the old days the main role of the teacher was as provider of information both theoretical and practical. With PBL the teacher does less direct information-provision and more setting the scene in which the student can learn optimally. This means planning the syllabus, deciding the most appropriate teaching methods. The students need an agenda for what they need to learn and the teacher must help steer them towards this. Most learning activities need materials of one kind or another and the teacher has a role in producing these, as I am doing typing this answer, but it could be a video of how to do a forceps delivery or a website with a load of EMQs. The teacher in much of this is acting as “facilitator”. The role of facilitator extends to making sure that techniques such as the doughnut round described below work efficiently that group activities work well with students knowing and observing the rules. The facilitator needs to ensure that all the students are benefitting not just the most confident and assertive. The teacher is also a role model. I teach that you can learn from all your bosses. The good ones you aspire to be like, but even the worst of them are role models, even if it means that you do everything in your power to be nothing like them and to avoid their habits and techniques. 
We could list the functions of the teacher as:
Facilitator:
​contributing to the creation of an appropriate syllabus
​choosing appropriate learning methods
​enabling students to make best use of the learning opportunities
​generating helpful teaching materials.
Role model:​ideally personifying what a good consultant should be.
Assessor / analyst: ​students should be involved in assessing their progress, but the teacher has an overarching responsibility.
​the teaching programme and its outcomes must be scrutinised to enable improvement.
Information source:​in the old days this would have topped the list. There is still a need for information provision, but no longer with the notion that the teacher is the main, comprehensive source.
Other meanings.
Brainstorming:​This sounds like the electrical chaos of an epileptic seizure. But we have all done it. A group sits around and fires off all they can think about a subject. This includes what you know as well as what you imagine might be relevant or possible, even if it is crazy. The idea is to get the maximum number of ideas. the flow could easily be inhibited if comment is allowed while the brainstorming is being done. So the ideas should just be recorded and you hope that one will spark a load more.  At the end of the session, the ideas can be evaluated. You might use this approach at the first meeting of a group who are going to write a protocol to make sure that you have covered all the areas the protocol should deal with.
Delphi technique:​I think this takes its name from Delphi in Greece. In ancient times people went there to consult a priestess called Pythia who was known as the oracle and believed to be able to tell the future. However, her utterances were far from clear and could often be interpreted in such a way that opposite meanings could be drawn, hence “Delphic” now meaning “ambiguous”. I tell you all this as it may help you remember. Basically the technique involves getting the opinions of a bunch of experts about some complex problem for which there is no real evidence-based solution. The experts offer their opinions in a first round, the facilitator produces a summary, which the experts comment on in a second round until a consensus is reached. Perhaps this is how Green-top Guidelines emerge when there is a lack of clear research evidence about best practice!
Doughnut round:​Do doughnuts exist in every culture? In the west it is a pastry in the shape of a ring (annulus or toroid for the mathematician) which has been deep-fried and, therefore, very good for your coronary arteries and chances of type II diabetes, particularly as it is served dusted with sugar and with a coating of chocolate, maple syrup or equivalent health food.
​The idea of the doughnut round is that students meet regularly, usually once a week with a facilitator. They are giving reading materials and asked to prepare questions for other members of the group. The physical layout of the group is a circle and they may even devour doughnuts! The facilitator will assist the group in laying down ground rules for behaviour, e.g. to ensure that there is mutual respect, no scoffing at the person who does not have an answer etc.
Snowballing.​The idea behind this is the snowball that is rolled down a snow-covered slope. As it moves, more snow sticks to its surface so that it gradually swells in size. A facilitator taking on a new group of students might find that their knowledge about a subject or investigative skills were greater than anticipated so that the proposed project “snowballs” into something bigger or more intricate than first envisaged. 
1 minute preceptor:​A “preceptor” is a teacher and the term is often used for one teaching a practical skill. The “1 minute preceptor” concept comes from an article by Neher et al: J Am Board Fam Pract. 1992 Jul-Aug;5(4):419-24. It is what you do when you use a case that is active on the ward or labour ward for opportunistic teaching without realising it has a fancy name or appreciating that someone has analysed its various stages. 
​Neher et al described 5 stages to the process, which they called “microskills”:
1. getting a commitment
2 probing for supporting evidence
3. teaching general rules
4. reinforcing what was done well
5 correcting mistakes.
Some of the language such as “commitment” is not especially transparent. What is means is getting the student to commit to a task or complex of tasks.
Let us say you are on the labour ward and an abnormal CTG is reported. You might decide that this is a good case to use to get your junior colleague to improve their CTG knowledge. You might get them to “commit” to going through the CTG training package, which might take a couple of hours and then give you an analysis of what is happening with the patient. When they return, you ask them for an analysis of the CTG and for the evidence they use to categorise it. You might then ask for further investigation or management proposals. A general rule might be that CTGs are not diagnostic and need to be interpreted against the clinical background and perhaps indicate a need for scalp pH tests. It is always good to praise the student – we all respond to this, but mistakes must always be dealt with. This has to be done without making the student feel stupid. “When we start out in this area, a mistake that most of us make is …..”
Schema activation.​This is something you do subconsciously in many teaching situations. If I say “problem-based learning” it will produce a response from you based on the concepts you have in your head about the topic. This is your “schema” and it may be highly sophisticated and evidence-based or just a load of old prejudices. If you were asked to introduce PBL to your peers as the hospital was about to take medical students for the first time, you might start with schema activation. This would entail getting them to talk through their ideas either individually or in a group. You could then bring information to add to what they already know, correct misapprehensions etc.
Schema refinement.​This is the more advanced version of activation. It is the sort of thing that happens when I ask you to write an essay plan in the tutorial group. We know that you have a lot of knowledge about most subjects and here you use your “schema” to deal with the specific task created by the essay. We would then use the collective discussion to bring all the schemata of those in the group to produce a perfect essay plan and also to amend / improve the individual schemata.


Scenario 1.
A woman is admitted with an eclamptic seizure. The acute episode is dealt with and she is put on an appropriate protocol. You wish to use the case to outline key aspects of PET and eclampsia to the two medical students who are on the labour ward with you. Which would be the most appropriate approach? Answer 9. This is exactly what the 1 minute preceptor is about.
Scenario 2.
You have been asked to provide a summary of the key aspects of the recent Maternal Mortality Meeting to the annual GP refresher course. There are likely to be 100 attendees. Which would be the most appropriate approach? With so many and just you, you might feel that you have no option but a lecture, but try to conjure up a better option. 
Answer. 7. An interactive talk with EMQs is likely to be better than a straight lecture. 
Scenario 3.
You have been asked to teach a new trainee the use of the ventouse. Which would be the most appropriate approach?
Answer 5. This has to be hands-on. You demonstrate then get them to do it.
Scenario 4.
You have been asked to teach a group of medical students about PPH. To your surprise you find that they have good basic knowledge. Which technique will you apply to get the most from the teaching session?
Answer 14. Snowballing. You are going to change your stance and adapt to their greater knowledge.
Scenario 5.
Your consultant has asked you to get the unit’s medical students to prepare some questions about breech delivery which they can ask of their peers when they next meet. Which technique will you use?
Answer. 6. You might be tempted by brainstorming, but this is pretty much a description of the doughnut round.
Scenario 6.
You have been asked to discuss 2ry. amenorrhoea with your unit’s medical students. You are uncertain about the amount of basic physiology and endocrinology they remember from basic science teaching. Which technique will you use?
Answer 11. This is schema activation to find out what they know.
Scenario 7
The RCOG has asked you to chair a Green-top Guideline development committee. You find that there is very little by way of research evidence to help with the process. The College has assembled a team of consultants with expertise and interest in the subject. Which technique would be best to reach consensus on the various elements of the GTG?
Answer 4. Delphi. This is getting your experts to agree a consensus statement.
Scenario 8
Which of the listed teaching techniques is least likely to lead to deep learning?
Answer 8. The poor old-fashioned lecture.
Scenario 9
An interactive lecture with EMQs is the best method of teaching. True or false.
Answer. False. There is no best method. It depends on the circumstances.
Scenario 10
Only 20% of what is taught in a lecture is retained. True or false.
False. It is 5%.
Scenario 11.
The main role of the teacher is information provision. True or false.
False. It used to be, but not now.
Scenario 12.
The main role of the teacher is to be a role model.  True or false.
False. The main role is to facilitate learning.
Option list.
1. brainstorming.
2. brainwashing
3. cream cake circle.
4. Delphi technique.
5. demonstration & practice using clinical model.
6. doughnut round.
7. interactive lecture with EMQs.
8. lecture.
9. 1 minute preceptor method.
10. teaching peers / junior colleagues
11. schema activation.
12. schema refinement.
13. small group discussion.
14. snowballing.
15. snowboarding.
16. true
17. false


Manchester MRCOG Tutorial Group​               www.drcog-mrcog.info         Tom McFarlane​Page 6.

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