Principles of medical education

Introduction

George Bernard Shaw famously quipped, ‘He who can, does. He who cannot, teaches’. However, the emergency physician can rarely teach without doing. The tradition for doctors to teach their colleagues and students goes back to the Hippocratic Oath, where the duties of a doctor to students are outlined: ‘… to teach them this art, if they want to learn it, without fee or indenture’.

Emergency physicians have been taking an increasing role in teaching and education, in part because of the need for all doctors to learn and refresh emergency skills, but also because emergency physicians are usually full-time and hospital-based and have access to students, patients and teaching resources. In addition, they have a unique opportunity of seeing students progress in their chosen specialty and may have multiple inputs vertically over several years in a younger doctor’s career. This can be very satisfying and also very motivating.

The emergency environment is one of constant new learning experiences while, at the same time, being the location for patient care and critical decision making. Barriers to teaching in hospitals in general, but applicable to emergency departments (ED), have been summarized by Lake in her ‘Teaching on the Run’ series as lack of time, lack of knowledge, lack of training in teaching, criticism of teaching when given and lack of rewards, either materially or by recognition.

In addition, teaching in the pressure cooker environment of an ED gives further layers of difficulty, both logistically and ethically. Challenges include:

• Patient acuity

• Shifts, requiring teaching at all hours of the day and night

• Junior medical staff from a variety of specialties and backgrounds with varying needs

• Numbers of junior medical staff and rostering affecting continuity for teacher and learner

• Huge variation in workloads from shift to shift

• Administration pressures to reduce waiting times and time-based access targets

• Physical restraints in many ED environments caused by overcrowding

The ED is a teaching environment, not only for physicians at various levels, but also for nurses, allied health workers, paramedics and others. A significant component of ED teaching is procedural. It is suggested that most patients believe they should be informed if it is the first time a doctor is performing a procedure on them, but less than half of patients feel comfortable about themselves being the first patient ever for suturing (49%), intubation (29%) or lumbar puncture (15%) for a resident. For non-procedural medicine, the evidence is that most patients enjoy being part of the teaching process, in outpatient and ambulatory settings at least, and that no extra negative effects on patients occur from teaching.

An added component of complexity in teaching in the ED is the potential for slowing patient processing by having to stop and supervise a junior. It is often so much quicker just to do it yourself. Supervising a lumbar puncture, for example, may take both the teacher and the taught away from seeing new patients for half an hour. However, as far as it has been researched, teaching in academic EDs does not appear to slow down patient care but in fact improves quality of care. Doctors who are seen by their juniors as good teachers are just as likely to see as many patients per shift as those who are not.

All emergency physicians are teachers at some stage in their career at various levels and, as in Hippocrates’ time, are mostly unpaid for it. Although most doctors become teachers, the majority of pre-vocational doctors in Australia have had no exposure to learning how to teach. Here we present the principles of teaching and learning to assist emergency physicians, whether they are involved in teaching medical students, residents, registrars or other health professionals.

Adult learning principles

Contemporary medical education needs to be couched in terms of contemporary education theory. Adult learning principles should underpin educational practice from the bedside, through the clinical skills laboratory to the seminar room. In addition, these principles are relevant to the education of the undergraduate, prevocational (first 2 to 3 years’ postgraduate) and vocational registrar years, as well as the continuing professional development of the mature medical practitioner.

Malcolm Knowles first introduced the notion of andragogy or adult learning in the early 1970s. He described five assumptions regarding how adults learn:

• As mature people they move from being dependent to being self-directing. This transition allows them to determine their own learning needs.

• Adults bring a wide range of experiences accumulated over their lifetime to the learning situation. These experiences provide both a context and a resource for new learning.

• Adults’ readiness to learn (or motivation) is linked to the applicability of the learning to their current life/employment.

• Adults are more problem-centred—that is, they want learning relating to a problem they may encounter in everyday life.

• Adults are motivated to learn by internal factors, such as desire to succeed, personal goals and so on, as compared with external factors, such as rewards.

Knowles and other authors have since developed principles of adult learning that can be used to guide education activities :

• An effective educational climate is one that allows learners to feel safe. They should be encouraged to express themselves without fear of judgement.

• Establishment of learning needs requires learner participation so that their intrinsic motivation to learn is engaged. The process of developing learning needs helps to assist learners’ self-reflection and establish relevancy for them.

• Once a need has been identified, learners should be involved in determining specific learning objectives for the educational intervention.

• Designing the educational intervention should be collaborative, ensuring communication between the learner and teacher/facilitator. This will ensure that the methodology chosen will be relevant to the learner’s needs.

• Learners should be encouraged to identify appropriate resources to assist their achievement of learning objectives. This will ensure that activities are learner-centred and self-directed as required by adult learners.

• Facilitators should assist learners to implement their learning plans so that objectives are achieved.

• Learners should be involved in evaluating their learning.

However, these principles of adult learning are irrelevant to the emergency physician educator unless they are actively applied to the education of their postgraduate charges. The question remains of how these principles are put into practice. Table 27.3.1 outlines some examples of how these principles may be incorporated into education within the ED.

Learner-centred education

Many traditional medical education experiences are teacher centred. The teacher is the expert and determines what, how, when and where much is learnt. The teacher is the active participant and the learner is the passive recipient. However, a more effective approach to education is the learner-centred approach. Learner-centred education refers to educational events that place the learner in the pivotal position, responsible for determining learning objectives, actively engaging in learning opportunities and participating in evaluation. This is more in line with adult learning principles. Learner-centred education does not disregard the expertise of the teacher but rather directs the use of that expertise to learning that is relevant to the individual learner.

So how does the ED physician become a learner-centred educationalist? The following suggestions are provided to assist:

• Orientation—to the unit, to the department, to the rotation. Junior medical staff require an orientation for a number of practical workplace reasons, such as awareness of policies and procedures, occupational health and safety, rostering, pay and so on. However, this is an important opportunity from an educational perspective. The orientation can allow exploration of the junior doctor’s learning goals and objectives, past experiences, confidence with procedural tasks, and expectations of their ED rotation. The orientation allows the educational supervisor the opportunity to establish their expectations and ground rules in terms of educational interactions, when feedback will be given and how education with patients will occur. The ED supervisor can acknowledge barriers to learning which are more specific to the ED environment and discuss how these will be overcome.

• Ask the resident to select a patient to present rather than dictating which patient or topic will be discussed.

• Ask residents about past experiences to assist in determining their confidence in managing certain conditions independently. Obviously, supervision will be required until this is determined firsthand, but demonstrating insertion of an intravenous (IV) cannula to an intern who has previously inserted numerous IVs may not be the most appropriate use of your time, and you will not know unless you ask!

• Present junior medical staff with suggested topics for in-service education and ask them to prioritize.

• Ask junior medical staff to present a case to their peers. Let them determine the format they want to use and resources they require. Junior medical staff are not a homogeneous group. They differ in how they learn, what they need to learn and why they want to learn. By involving learners in the planning, implementation and evaluation of their learning experiences, both relevance and motivation to learn will be facilitated.