Excellence - Academy of Medical Educators

Excellence in Medical Education Educational Research and Scholarship

Issue 6: February 2015

Excellence in

2

Medical Education

Excellence in

3

Medical Education

Contents Page

Editor Dr Vimmi Passi

Welcome from the Editor ............................................................................................... 4

Honorary CEO Julie Brown

1.

President of Academy

2. The Professional Standards Domain.......................................................................... 6

Professor Derek Gallen

3. Socio Cultural Theory in Clinical Education............................................................. 7

Aims and Scope

4.

The Academy of Medical Educators (AoME) was established in 2006. The main aspiration of the AoME is to improve clinical care through teaching excellence. Excellence in Medical Education has been designed with this aspiration in mind. The first five issues will focus on the AoME Professional Standards with invited expert reviews. Future issues will be based on specific educational themes with invitations to submit articles with a peer review process. Excellence in Medical Education has been designed for the active and busy medical, dental and veterinary teacher. The aim is to highlight important educational topics, discuss challenging and controversial issues and stimulate debate. The series embraces 21st Century medical education with expert reviews, interviews and specialist articles. The series will provide an inspirational and thought provoking journey into the exciting field of medical education. We welcome articles and reviews for future issues so if you would like to contribute or comment please contact the Editor, Dr Vimmi Passi, at: [email protected]

The AoME Professional Standards.............................................................................. 5

Professionalism as a Medical Educator: Developing a Scholarly Approach To Your Teaching................................................. 10

5. The Challenge of Evidence Based Practice in Medical Education: a Knowledge Management Perspective ..................................................................... 13 6. Challenging Diagnostic Overconfidence................................................................... 16 7. Expert Interview with Professor Andy Grant ........................................................... 20 8. Authors ...................................................................................................................... 23

Subscription Information Excellence in Medical Education is available online to Associate Members, Members and Fellows of the AoME.

Despatch Excellence in Medical Education will be produced six monthly.

Disclaimer The AoME cannot be held responsible for errors or any consequences arising from the use of information contained in this journal.

ISSN 2050-9588 (Print) ISSN 2050-9596 (Online)

Educational Research and Scholarship


Excellence in Medical Education


Excellence in

4

Medical Education

Welcome from the Editor

Excellence in

5

Medical Education

1. The AoME Professional Standards

Dr Vimmi Passi, Editor of Excellence in Medical Education Following the success of the first five issues, I am very pleased to welcome you to the sixth issue of Excellence in Medical Education, an exciting new educational product for the members of the Academy of Medical Educators (AoME). This series embraces 21st century medical education with expert reviews, interviews and specialist articles. It provides an inspirational and thought provoking insight into the exciting field of medical education.

The Academy of Medical Educators (AoME) is a charitable organisation developed to advance medical education for the benefit of the public through:

This Sixth Issue is the last of the series that focus on the Academy Professional Standards. This Issue focuses on the Professional Standards Domain Five – Educational Research and Scholarship. This issue takes the reader on an exciting journey from theory to practice in medical education. This Issue begins with an overview of Socio Cultural Theory in Clinical Education by Professor Andy Grant, highlighting the importance of this theory in clinical practice. This then leads onto the second article by Professor Nick Cooper on Professionalism as a Medical Educator – this excellent article discusses career development, scholarship, identity formation and recognition as a medical educator.

C. The promotion and dissemination of best practice in medical education.

A. The development of a curriculum and qualification system; B. Undertaking research for the continuing development of medical education; and

This leads onto an inspiring article by Professor John Sandars discussing the Challenge of Evidence Based Practice in Medical Education from a Knowledge Management Perspective. The fourth article provides a thought provoking article by Dr Malcolm Galloway on Challenging Diagnostic Overconfidence. The final article is a very inspiring interview with Professor Andy Grant, Dean of Medical Education at Swansea Medical School.

The Professional Standards are divided into core values of medical educators and five domains.

g d an arnin n sig f le De ng o ities i v nn cti pla a

al ation Educ ent and agem man adership le

Excellence in Medical Education has been an exciting new venture and I would like to thank all of our expert authors for their thought provoking and fascinating articles. It has been a great pleasure working with you all. We welcome articles and reviews for future issues, so if you would like to contribute, please contact the Academy of Medical Educators at www.medicaleducators.org.

In order to achieve these objectives, the AoME’s Professional Standards have been produced. These Standards have been designed to provide the basis upon which a curriculum for medical educators can be developed. They act as a framework against which professional progression as an educator can be planned and measured. The Standards are a tool designed to assist medical educators to work towards excellence.

The Standards may be used by organisations to identify the skills and competencies required of those who undertake or fulfil an educational role. Organisations may also use the Standards to develop and offer a framework for training and continuing professional development in support of medical education. The Standards could be considered when setting objectives in performance and appraisal and used for assessing the performance of individuals within organisations.

Tea c sup hing a por nd lea ting rne rs

Core values for medical educators

Assessm and fee ent dback learner to s

Dr Vimmi Passi

To be engaged in effective and appropriate professional development is an integral part of Membership and Fellowship of the AoME. The Standards aim to help clarify the professional characteristics that should be maintained and built on for the variety of roles undertaken by medical educators. The Professional Standards are divided into themes and each theme provides details of the knowledge, understanding and practice that underpin the roles of those involved in medical education.

Educational research & evidence-based practice





Excellence in

6

Medical Education

2. Professional Standards – Educational Research & Scholarship

Excellence in

7

Medical Education

3. Socio-cultural Theory in Clinical Education Professor Andrew Grant

Element Theoretical and evidence-base of medical education

Standard Level 1

Standard Level 2

4.1.1 Is aware of basic educational theories and principles

4.2.1 Understands and applies a range of educational theories and principles

4.1.2 Is aware of literature relevant to current developments in medical education

4.2.2 Critically evaluates the educational literature and applies this learning to his or her educational practice

4.1.3 Is aware of the principles of critical appraisal

4.2.3 Participates in the design and development of educational programmes, projects or research

4.1.4 Is aware of the major issues and challenges facing medical educational research

Standard Level 3 4.3.1 Demonstrates advanced understanding of a wide range of educational theories and principles 4.3.2 Critically evaluates the literature at an advanced level and applies this to his or her educational practice 4.3.3 Develops new educational insights, theories and practices, through scholarly endeavours

4.2.4 Interprets and applies the 4.3.4 Designs, supervises, results of educational research manages and evaluates research strategies or projects to his or her educational practice 4.3.5 Contributes to educational research or projects applying appropriate research methods 4.3.6 Mentors and supports the professional development of educational researchers or educational project leads

Think of a medical student on a ward round with a senior clinician and a group of his or her peers being asked to present a patient that they had just seen. There are certain rules about how to present the patient, which part of the history to present first, and the kind of medical language in which to make their presentation. During the course of the presentation the student asserts that they think the most likely diagnosis is one of pulmonary embolism, which is not in keeping with the history and the clinical findings that have been presented. The Consultant does not tell the student that they are wrong directly but encourages them to recognise for themselves how their proposed diagnosis is not compatible with the history and examination finding. If the student is not able, with questions and with help, to identify where he/she has gone wrong from his/her own knowledge, the Consultant may ask the other students in the group to help.

Constructivist Learning Theory As educators in general and medical educators in particular we owe a great deal to Lev Vygotsky who, in his work on the development and learning of small children, concluded that learning takes place by social interaction and only by social interaction1 Constructivism, according to Vygotsky, states that through social interaction learners are able to improve and change their understanding of phenomena within their world and within their field of experience. Social interaction leading to learning can take place between two learners and can also take place between learner and teacher 1. In our example the clinical teacher has chosen to use questioning as a form of social interaction to help the student. They have avoided telling the student that their answer is wrong and instead have asked questions that are likely to help the student to recognise from their existing knowledge that the first answer they gave as to the most likely diagnosis was wrong. Vygotsky described the zone of proximal development by which, he meant what was achievable by the student when they were supported in their learning by a teacher or peer but that they could not achieve unaided. Vygotsky left only sparse written records of his work and multiple interpretations have been made over the years 2. Going back to our example, the Consultant’s questions helped the student to recognise, by applying their own knowledge, that their original answer was wrong. Further questioning or prompting might help the students to arrive at the correct answer for themselves helping to access what they

already know but cannot apply without help. A term that is often used to describe this kind of questioning and learning support activity is educational scaffolding and in this case the scaffolding is in the form of questions that enable the student to apply their existing knowledge 3. In a lecture, or in a completely didactic teaching environment, it might be very difficult for the teacher to know whether or not the student is currently in the zone of proximal development because the level of interaction and feedback on the students’ ability to respond to the learning material is much more limited than in an interactive session such as the one just described. To return to the way the students and their teacher interact, this represents Vygosky’s assertion that not only did learning take place through social interaction but that it always took place against a cultural background, and that cultural background exerted a significant effect on learning that was taking place 4. Going back once again to our example where the student presents the patient, he does so in a specific order and using a sufficiently technical medical language. When the Consultant starts to ask questions they may be based on an assumption that there are some facts of medical knowledge that every medical student at this level would and indeed does know (e.g. characteristic pain experienced by a patient with a pulmonary embolism). The theoretical work of Vykotsky is developed by other authors and of particular value as a model against which to plan and develop clinical education is the work done on apprenticeship by Jean Lave and Etienne Wenger on situated learning. Lave and Wenger observed apprentices in a number of professional settings 5. Lave and Wenger say that learning takes place, and only takes place, by legitimate peripheral participation in communities of practice 6. If we think for a moment of a junior medical student going on to a hospital ward for his or her first clinical placement. The ward will already have an established community of practice caring for its patients with many professionals working within that community. But if, according to situated learning theory, legitimate peripheral participation has to take place if there is to be any learning, then some thought needs to be given as to how the student is involved (however peripherally) with the work of the ward.





Excellence in

8

Medical Education

Legitimacy If our student is welcomed and made to feel that they are part of the community of the practice of the ward, that their role as learner is part of the community of practice, then their presence there will feel legitimate. If on the other hand ward staff are busy with urgent patient care activities, who either ignore or worst still are somewhat short with the student for getting in the way, then their place on the ward has no legitimacy whatsoever, and learning is unlikely to take place.

learners 6. It is worth reminding ourselves at this point that according to constructivist theory it is only through social interaction that learning takes place and according to the situated learning theory it is only by legitimate peripheral participation in communities of practice that learning takes place. Therefore it behoves all of us who are responsible for student learning to think about how social interaction is taking place between our learners, between learners and teachers, and how we know that our learners are, with our support, in the zone of proximal development as much of the time as is possible.

A role on the periphery Clearly any new apprentice in a community of practice will start with a very peripheral role since they lack the knowledge and skills to practice at the centre of the community. However with development and with opportunities for learning, the learner can, in time, become less peripheral in their role and as well as being there to learn may have some place in the work of the community6. After some training some medical students may be able to assist with certain tasks such as measuring blood pressures and taking blood. If we go back to our first example, when the consultant asked the student some questions on the understanding that they would know the answers, they were assuming a level of knowledge that “everybody in medicine knows”, and by doing that they were saying to the student – we are members of the medical community of practice and there are some things that everybody, including you, knows, and that all that I am doing is helping you to apply the knowledge you already posses. By doing that the students’ membership of the community of practice is being validated.

Excellence in

9

Medical Education

References 1. Roger H Bruning, Gregory J Schraw, Monica, M. Norby. Cognitive Psychology and Instruction. Fifth Edition 2011. Pearson. Boston. Pages 192 – 198. 2. Seth Chaiklin. The Zone of Proximal Development in Vygotsky’s Analysis of Learning and Instruction. In Alex Kozulin, Boris Gindis, Vladimir S Ageyev & Suzanne Miller (Eds) CUP, Cambridge (UK). 3. Laura E Roehler, Danise J Cantlon. Scaffolding: A Powerful Tool in Social Constructivist Classrooms. In Kathleen Hogan & Michael Pressley (Eds.) 1997 Brookline Books, Cambridge Mass. 4. Renee Van Der Veer. Vygotsky in Context 1900 – 1935. In Harry Daniels, Michael Cole & James V. Wertsch (Eds.) The Cambridge Guide to Vygotsky (2007) Cambridge CUP. 5. Jean Lave. & Etienne Wenger, E. Situated Learning: Legitimate Peripheral Participation. (1991) Cambridge CUP. 6. Alan Bleakly, John Bligh & Julie Browne. Medical Education for the Future: Identity, Power & Location. (2011) Dordrecht, Springer, Chapter 4 Socio-cultural Learning Theories,

Participation We have already talked about students as they move away from the periphery of the community practice towards the centre, acquiring skills, which may enable them to be more central participants in the community of practice.

Communities of practice Communities of practice are a model of learning that is easy for anyone working in healthcare to be able to comprehend. Communities of practice bring groups of people together with varying levels of skills and experience to do the best possible job in the case of healthcare for the patient. Medical students, during their training, and indeed junior doctors, will become legitimate peripheral participants in many communities of practice and to talk again about the cultural aspects of learning by social interaction, it behoves those of us responsible for organising and supporting learning to make every effort that communities of practice that we are involved in foster legitimate peripheral participation in our





Excellence in

10

Medical Education

4. Professionalism as a Medical Educator: -

Professional identity in medicine is frequently considered as social identity, usually around the construct of developing as a physician. A recent qualitative study5 explored medical educators ‘social identity’ and found that many of their roles were operational and that developing such identity was difficult in a field where there are different roles and expectations eg manager, leader, teacher, researcher. Frequently value and recognition is perceived as less prominent compared to clinical practice and biomedical research. Developing a community of practice6 can be difficult in such circumstances so educators can often feel isolated and undervalued.

Teaching Skills

Scholarship

There has been a proliferation of Higher Education Institutions (HEI) offering postgraduate courses in education, usually at masters level. The year on year increase in new programmes, both by face-to-face and distance learning, demonstrates an appetite from junior doctors for gaining qualifications to support potential future educational roles in the NHS. Additionally the availability of intercalated Bachelor and Masters degrees, Academic Foundation Programmes and Academic Clinical Fellowships in Medical Education have all raised the profile of medical education as a ‘discipline’ in its own right.

Poor funding of medical education research compared to biomedical and health services research is challenging for medical educators but Boyer’s seminal work14 provided a framework for medical educators where teaching should be appraised as a form of scholarly work. In 2006 a Consensus Conference on Educational Scholarship convened by the Association of American Medical Colleges (AAMC) outlined that a ‘scholarly approach depended on drawing on the results of others while scholarship required demonstrating work through peer review and dissemination of results’15. While many educators will not focus on roles in medical education research adopting a scholarly approach will surely help support the identity of a medical educator and enhance future recognition.

Professor Nick Cooper

While there are debates in the literature about professionalism in medicine this usually concentrates on areas of clinical practice, ethical dilemmas and breaches of patient safety and dignity1. Is ‘professionalism’ in medical education different? While the purpose of education may be to support learners in the clinical environment, patient safety and improved healthcare outcomes remain paramount. Although for many autonomy and self-regulation are key features of professionalism other authors have expanded these concepts and Hilton2 describes 6 domains of medial professionalism, which include ethical practice, reflection and self- awareness, responsibility and accountability, respect for patients, teamwork and social responsibility. These same attributes are surely necessary for a professional approach to education and Hesketh et al3 suggested a framework with 12 learning outcomes. Building on this work the AoME has developed a Professional Standards Framework4 buildsing on core values for medical educators. Developing an identity as a medical educator is key to acquiring professional recognition and this may entail developing a scholarly approach to teaching and educational scholarship, throughout a career in different branches of medicine, in addition to the acquisition of teaching skills. This article explores these inter-relating themes as a proposed model for the professional development of a medical educator. Recognition

Teaching Skills

Identity

Career Development

Identity Construction

Is there evidence that such courses make a difference? Research by Gibbs and Coffey7 across 22 Universities in 8 countries suggested that there was a link between academic development programmes and change in teacher behaviour and student’s approach to learning. Evidence for the impact of short courses is less robust although a questionnaire self assessment study of consultants on a 3 day teaching course suggested some benefits in the acquisition and use of teaching skills and the authors concluded that ‘the teaching course is an effective vehicle for increasing consultant teaching skills’ 8. Other studies suggest that many teachers develop skills through the acquisition of tacit knowledge9, 10 by doing, a form of experiential learning where reflection is an important aspect.

Career Development Scholarship

11

Medical Education

have been developed in postgraduate education while expansion in medical school numbers in the last decade, accompanied by an increase in community clinical learning has exposed more doctors to clinical teaching. Sutkin et al11 undertook a literature review to answer the question ‘What makes a good clinical teacher in medicine? arguing that outstanding clinical teachers should serve as excellent role models. A systematic review of faculty development programmes12 in medical education suggested that while there was an aim to improve teaching effectiveness there was little support in developing communities of practice in the workplace, which would enhance the identity for the medical educator and support their individual development within a supportive and nurturing educational environment. Irby13 argues that as the complexity of medical knowledge increases targeted faculty development is needed as the teacher transforms multiple forms of knowledge to support learners in an increasing demanding clinical practice. This is important as we develop continuing opportunities for educators to provide appropriate focused instruction for learners.

Developing a scholarly approach to your teaching Many doctors have been involved in medical education, from the time of Hippocrates to Osler and the present day, yet only in the last 15-20 years has there been an impetus to ‘professionalise’ this important aspect of a doctor’s role.

Excellence in

Opportunities for career development in medical education are increasing. Clinical and Educational Supervisory roles

Future developments with the GMC include the potential to recognize the medical educator as an area of practice alongside different medical specialties. While increasingly some HEIs are rewarding staff for teaching expertise – Lund University Faculty of Engineering18 and University of Western Australia19 describe such approaches, too often promotion is based on research output. Attempts to overcome such problems are now being tackled and at University of Alberta a web based annual report system helps to provide evidence of scholarly activity.20

The Future While the resources to conduct medical education research are limited21 and the nature of evidence may differ22 in educational research compared to clinical research it is vital that medical educators are recognized for their expertise, scholarship and professionalism in their educator role23. These roles may in themselves be quite different whether in educational leadership, management and administration as well as front line roles in teaching24. This will support their concept of identity and the AoME can help all medical teachers both in their own personal development but also to support the evolving levels of recognition with the GMC.

Recognition The AoME through its Professional Standards Framework provides recognition for the medical educator and obtaining feedback on educational activities is a key component of personal and professional development16. Evidence of a reflective approach to teaching and learning will increasingly be required for annual NHS appraisals when teaching is a recognized component of job planning. The General Medical Council (GMC) Recognising and approving trainers: the implementation plan17 provides a framework based on the Academy standards for such a process and being a member of good standing with the AoME will provide necessary evidence to support such a process.





Excellence in

12

Medical Education

References 1. O’Flynn S, Kelly MA, Bennett D. Professionalism and identity formation: students’ journeys and emotions. Med Educ 2014 48: 463-465 2. Hilton S. Medical professionalism: how can we encourage it in our students. Clinical Teacher 2004 1: 69-73 3. Hesketh EA et al. A framework for developing excellence as a clinical educator. Med Educ 2001 35: 555-564 4. Academy of Medical Educators Professional Standards. Academy of Medical Educators, 2014 5. Sabel E, Archer J. “Medical Education is the Ugly Duckling of the Medical World” and Other Challenges to Medical Educators’ Identity Construction: A Qualitative Study. Academic Medicine 2014 89: 14741480 6. Wenger E. Communities of Practice. Learning, meaning and identity. Cambridge: Cambridge University Press, 1999 7. Gibbs G, Coffey M. The impact of training of university teachers on their teaching skills, their approach to teaching and the approach to learning of their students. Active Learning in Higher Education 2004 5: 87-100 8. Godfrey J, Dennick R, Welsh C. Training the trainers: do teaching courses develop teaching skills? Med Educ 2004 38: 844-847 9. McLeod PJ, Steinhert Y, Meagher T, Schuwirth L, Tabatabai D, McLeod AH. The acquisition of tacit knowledge in medical education: learning by doing Med Educ 2006 40: 146-149

14. Simpson D et al. Advancing educators and education by defining the components and evidence associated with educational scholarship Med Educ 2007 41: 1002-1009

Excellence in

5. The Challenge of Evidence Based Practice in Medical Education: a Knowledge Management Perspective

15. Browne J, Cooper N, Bligh J. How to….Become recognized for your teaching Education for Primary Care 2011 22: 124-126

Professor John Sandars

16. General Medical Council. Recognising and approving trainers: the implementation plan. London: GMC 2012

Background

17. Olsson T, Roxa T. Assessing and rewarding excellent academic teachers for the benefit of an organization European Journal of Higher Education 2013 3: 40-61 18. www.ecm.uwa.edu.au/staff/learning/FASE 7.2.2014

accessed

19. Fisher B, Rourke L. Recognising and rewarding clinical educator scholarship Med Educ 2014 48: 544 20. Colliver J, Cianciolo AT. When is enough enough? Judging the sufficiency of evidence in medical education Med Educ 2014 48: 740-747 21. Patricio M, Vaz Carneiro A. Systematic reviews of evidence in medical education and clinical medicine: Is the nature of evidence similar? Medical Teacher 2012 34: 474-482 22. Van Melle E, Lockyer J, Curran V, Lieff S, St Onge C, Goldszmidt M. Toward a common understanding: supporting and promoting educational scholarship for medical school faculty Med Educ 2014 48: 1190-1200 23. Bligh J, Brice J. further Insights Into the Roles of the Medical Educator: The Importance of Scholarly Management Academic Medicine 2009 84: 1161-1165

10. MacDougall J, Drummond MJ. The development of medical teachers: an enquiry into the learning histories of 10 experienced medical teachers Med Educ 2005 39: 1213-1220 11. Sutkin G, Wagner E, Harris I, Schiffer R. What Makes a Good Clinical Teacher in Medicine? A review of the literature Academic Medicine 2008 83: 452-465 Leslie K, Baker L, Egan-Lee E, Esdaile E, Reeves S. Advancing Faculty Development in Medical Education: A Systematic Review Academic Medicine 2013 doi: 10.1097/ACM.ObO13e318294fd29 12. Irby D. Excellence in clinical teaching: knowledge transformation and development required Med Educ 2014 48: 776-784 13. Boyer EL. Scholarship Reconsidered: Priorities of the Professoriate. Princeton, NJ: Princeton University Press 1990

13

Medical Education

Petersen made a plea in 1999 for evidence based practice in medical education and highlighted that “tomorrow’s doctors need informed educators not amateur tutors”1. This plea is still as relevant in 2014. However, the notion of evidence based practice in medical education is a challenge to all medical educators and in this article I will present a knowledge management perspective since it can offer some useful insights into this challenge. The term “knowledge management” may be unfamiliar with many medical educators but can be simply considered to be a systematic approach to the creation, storage, dissemination and application of knowledge within organisations 2. Understanding the nature of “knowledge” is fundamental for appreciating both the challenge of evidence based practice in medical education and knowledge management. Aristotle was the first to present an important distinction between two main categories of knowledge: explicit and tacit 3. Explicit knowledge represents knowledge that has been codified, usually in the form of text. This category of knowledge is that which is presented as “evidence” for evidence based practice, such as guidelines or systematic reviews of research studies. In contrast, tacit knowledge is developed through years of professional experience and tends to be revealed when observing their expertise or skilful professional practice. However, when experts talk to others about their practice it can also reveal their tacit knowledge but this is very rarely considered to be worthy of the title of “evidence”, and is often belittled as anecdote. These distinctions are important since both explicit and tacit knowledge are required to inform effective decision making. For example, “knowing what to do” (such as the findings from previous research) also requires “knowing how to do it”, with knowledge required about the difficulties of implementing previous interventions. A major challenge for knowledge management, and also for evidence based practice, is how to develop and provide a system that considers both explicit and tacit knowledge.

Knowledge management challenges Creation of knowledge Research may not provide knowledge that will be useful to inform the decisions of medical educators. Unfortunately,

external funding bodies may have very specific research questions that may not be so highly relevant to practitioners. For example, policy makers may want to focus on outcomes, such as the effectiveness of a particular intervention, but do not provide sufficient funding opportunities to understand the process of how the intervention worked within a particular context. This tacit knowledge is essential for the wider transfer of the intervention to other contexts. An important practical limitation in the creation of evidence is the necessary methodological procedures required to provide new knowledge that is considered to be of high quality in the “hierarchy of evidence”, such as a randomised controlled trial (RCT). There are difficulties when conducting a randomised controlled trial (RCT) in education 4. A RCT requires, as its name suggests, strict control of all factors except for the variables of interest. However, in medical education it is often impossible to adequately control for important variables. For example, students may be at different levels in their prior attainment and time in training, there may be a variety of implementers (teachers), or a difference in the intensity of intervention between the groups or a high dropout rate. Also, there are often concerns about whether it is ethical to compare an intervention group with a non-intervention control group since it is important not to disadvantage groups of learners.

Storage and dissemination of knowledge Having knowledge that can be used for decision making requires easy access to the available knowledge, including both the explicit and tacit categories. Relevant published evidence may be difficult to retrieve since medical education research is widely dispersed across many journals in both medicine and social sciences, and also a lot of potentially useful medical education research is not published in journals. A quick perusal of the abstracts and posters at a medical education conference quickly reveals the extent of research in medical education, and these often include the important experiences of “how to do it”. However, these presentations are only rarely archived or indexed, thereby limiting retrieval and dissemination of the findings. The last decade has seen the increasing use of a variety of social media, such as blogs and discussion forums, in all aspects of professional life and medical education is no exception. The use of social media creates opportunities for





Excellence in

14

Medical Education

sharing the essential tacit knowledge required for decision making but archiving and searching the range and variety of this rich knowledge base is almost impossible at the present time.

Application of knowledge The professional expertise of medical educators is a skilful blend of both explicit and tacit knowledge that requires an approach that is more than mere blind application of published evidence to practice. Professional practice is highly context bound and effective decision making about the most appropriate intervention requires sharing of tacit knowledge that is gained from local and wider contexts.

Responding to the challenge Opportunities need to be created for medical educators to actively participate in all aspects of the knowledge management of medical education and there are a few priority areas for action. In the creation of knowledge, medical educators can try to influence funding bodies to fund research methodologies that have an increased focus on both process and outcome. Realist evaluation recognises that the outcome of an intervention in a complex social system, such as found in medical education, may not have a direct causal link between the intervention and the outcome5. A realist evaluation attempts to identify the various environmental factors in the context so that they can be used to inform the application of the findings to other contexts. For example, the use of a particular intervention may show improved performance but it is rare for the findings to highlight the unique context in which the intervention was implemented, such as high commitment of time by tutors to deliver the intervention or that mandatory attendance by the students was required. Similarly, action research6 and design based educational research7 embrace the complexity of the social system and context within which a medical education intervention is implemented. These approaches use iterative cycles to increase understanding of the facilitating and constraining factors that determine the effectiveness of an intervention. However, there are few studies using these approaches in medical education, although these approaches are commonly used in other areas of education 8.

look down upon “the swampy lowlands” of professional practice9. There has been an increasing trend for many medical education journals and conferences to have linked social media to allow the audience to share opinion and experiences but an important step may be to ensure that what is often regarded as simple anecdote can be presented in a more scholarly way. Single case studies can be important sources of evidence to inform decision making and this can be achieved by linking observations from the single case experience to a wider body of literature (“how do the findings add to what is already known”), interpreting findings within a theoretical framework and providing sufficient details about the context so that “naturalistic generalisation” can be obtained10. The application of knowledge can be improved by creating opportunities to share their tacit knowledge, with medical educators actively engaged in communities of practice and collaborative decision-making. These communities need to move beyond simple journal clubs, that often reinforce the “evidence is best” paradigm, to more inquiry based communities that engage in critical review of personal practices11. Action learning sets can provide opportunities for professional and personal growth but at the same time have a focus on developing and implementing medical education interventions12. These opportunities require adequate protected time for busy medical educationalists but the main barrier that may need to be overcome is a change in mind-set to value their importance.

Conclusion Evidence based practice is an essential aspect of the scholarship of medical education and the use of a knowledge management perspective can provide useful insights into some of the challenges that currently face all medical educators. A clear message appears to be that valuing professional expertise is essential for the implementation of medical education interventions, with obvious implications for enabling participation in this essential aspect of being a medical educator.

Excellence in

15

Medical Education

References 1

Petersen S. Time for evidence based medical education: tomorrow’s doctors need informed educators not amateur tutors. BMJ (1999) 318(7193), 1223 -1224

2

McInerney C R & Koenig M E. Knowledge management (KM) processes in organizations: Theoretical foundations and practice. Synthesis Lectures on Information Concepts, Retrieval, and Services (2011) 3(1), 1-96.

3 Baumard P. (1999) Tacit knowledge in organisations. London:Sage, 1999 4 Sullivan GM. Getting off the “gold standard”: randomized controlled trials and education research. J Grad Med Educ (2011) 3(3), 285-289. 5 Pawson R & Tilley N. Realistic evaluation. Thousand Oaks,CA,:Sage, 1997 6 Elliot J. Action research for educational change. Maidenhead: McGraw-Hill International, 1991 7

Van den Akker J., Gravemeijer K, McKenney S & Nieveen N. (Eds.) Educational design research. Abingdon: Routledge , 2006

8

Sandars J, Singh G & McPherson M. Are we missing the potential of action research for transformative change in medical education?. Educ Prim Care (2012) 23(4), 239.

9

Schön DA.The crisis of professional knowledge and the pursuit of an epistemology of practice. J Interprof Care (1992) 6(1), 49-63.

10 Sandars J. Single-case research: an underused approach for medical educational research. Educ Prim Care (2009) 20(1), 8. 11 Tripp D. Critical Incidents in Teaching: Developing Professional Judgement. Abingdon: Routledge, 2011 12 McGill I & Beaty L . Action Learning: a guide for professional, management & educational development. Abingdon: Psychology Press, 2001

In the storage and dissemination of knowledge, there is a need for all involved in medical education, including professional organisations, conference organisers and publishers, to value the importance of professional expertise and the “tacit knowledge” dimension for the decision-making aspect of evidence based practice. It is too easy for the “high, hard ground” of academic certainty to





Excellence in

16

Medical Education

6. Challenging Diagnostic Overconfidence Dr Malcolm Galloway

Introduction No-one can reasonably be expected to be familiar with every disease that can afflict the human body. There are areas of knowledge that we use in our day-to-day diagnostic practice with which we are well acquainted, but for much of the rest, we should be able to manage by knowing when we are uncertain, and if so, what to do about it. Unfortunately, our meta-knowledge, our knowledge about what we know, and in particular, the calibration of the degree of certainty of our knowledge, is limited. There is some evidence of a link between the certainty of a doctor in a diagnosis and the chance that it is correct, but the link is weak1. Worryingly, the least well performing people in a variety of domains are typically the most overconfident2 3 4. Overconfidence in diagnostic certainty has been suggested as one of the key factors behind the approximately 15% of medical diagnoses which are incorrect3. This article briefly reviews some of the evidence relating to the problem of overconfidence in medical diagnosis, and how we might minimise the impact of this pervasive cognitive bias.

What Is Overconfidence? Overconfidence is one of the best-documented cognitive errors5 6. The term overconfidence is however confusingly used to refer to two distinct phenomena – positive illusions and excessive certainty. Most people believe that they, and the groups with which they identify, are better than most others in most domains7. Sadly, we can’t all be better than average – we tend to have positive illusions about our relative merits. Being highly educated doesn’t protect us from this. For example, 94% of academic professionals believe they are in the top half of their profession8. Excessive certainty (or judgment overconfidence) describes the tendency we have to believe that our knowledge is more certain than it really is. It is well documented in a variety of cognitive tasks, but is generally not found in simple sensory tasks (where underconfidence is more typical)9. If excessive certainty was specific to one particular artificial task in a laboratory setting, in might be of limited relevance to medical educators, however there are differences between individuals in their susceptibility to excessive certainty

Excellence in

17

Medical Education

The simplest technique to reduce overconfidence (and some other cognitive biases) is just to ask yourself “why might I be wrong?”. There is good evidence that this is effective and generalizable to a variety of contexts. We have a tendency to look for evidence that supports our suppositions. By consciously considering arguments against our preferred diagnosis we challenge that bias in evidence consideration15.

in different tasks. For example, individual differences in excessive certainty in general knowledge items is associated with overconfidence in a motor skill task and in eyewitness information recall10 . I would suggest that assessing the degree of excessive certainty of students, trainees and doctors in a non-medical cognitive task may highlight a cognitive bias that could be impairing their practice or learning.

Another promising but simple intervention is the use of a diagnostic checklist19 20 or simple heuristic reminder (such as ‘consider the serious and the treatable’). Overconfidence in a presumed diagnosis may lead to premature closure of the diagnostic process. Being prompted by a checklist of possibilities to consider in various diagnostic situations may help ensure possible alternative diagnoses are at least considered.

Both types of overconfidence (excessive certainty and positive illusions) have been demonstrated in a wide range of populations, including doctors 11. They may not necessarily be correlated12, and when dealing with medical overconfidence, it is important to be clear about which kind of overconfidence we are dealing with.

Another method of improving confidence calibration is to make decision makers accountable for their decision. This may be a variant of ‘why might I be wrong?’ due to the internal pre-emption of criticisms that others might make of their judgements 15.

How Can Overconfidence Be Challenged As a profession, medicine, with its experience-based hierarchy might expect that experience alone would combat overconfidence. There is some evidence that older adults have greater insight into the limits of the certainty of their knowledge13. Unfortunately, experience does not always lead to improved calibration. Sometimes it can even compound the problem14 . So it would seem that just waiting for doctors to recalibrate with experience isn’t likely to work. Could we solve the problem by paying doctors bonuses for accurate diagnoses? Probably not - financial reward does not appear to lead to improvement in calibration15, and in some circumstances may reduce improvement6. Can awareness of overconfidence be sufficient to combat the problem? When confronted with the evidence relating to overconfidence, we tend to accept that this is a problem, but a problem for other people. Most people think they are less biased than most people16. Biases may be easy to identify in others, but are inherently difficult to identify in ourselves by introspection alone17. Even Daniel Kahneman, a guru of decision making research, has commented that “…my intuitive thinking is just as prone to overconfidence, extreme predictions, and the planning fallacy as it was before I made a study of these issues.”18 If even he can’t change his own thinking, how can the rest of us? Well, there is evidence that we can change our thinking and behaviour, so perhaps Kahneman is being excessively certain in his belief that his own biases are unimproved.

There is evidence that feedback can help reduce overconfidenc21, although there is some variation in the literature on the benefits of feedback on calibration, and the type of feedback is likely to affect its efficacy22 23. A study of psychology students showed that if asked in regular formative assessments to rate their degree of certainty in their answers, and reminded of their certainty ratings when provided with the correct answers, their overconfidence in their answers was transformed to underconfidence23. Swapping one cognitive bias for another in the opposite direction may not sound like progress, but it does demonstrate that confidence calibration can be modified by relatively simple interventions. Russo and Schoemaker24 have described the successful use of a training package in which geologists were shown to substantially reduce their overconfidence in their geological predictions. This package focused on simulations based on real-life previous examples, in which the geologists had to make predictions and describe their level of certainty. There are parallels with the use of simulation in medical training. Allowing students and trainees to make diagnoses in a low-risk environment, and encouragement to reflect on the relationship between their degree of certainty in their preferred and the actual diagnosis is likely to be beneficial. Relatively brief calibration training can substantially reduce overconfidence in the certainty of general knowledge25. We don’t yet know whether such generic metacognitive training would lead to improvements in the professional activity of doctors26 27, but has been shown to improve the calibration of certainty of profession specific predictions in

information technology professionals25. Interventions to improve calibration of confidence are unlikely to be equally effective for all participants. People vary in their capacity to improve as a result of feedback28 29. Some people retain their overconfidence despite repeated feedback demonstrating their miscalibration. There is even the danger of increasing protective illusions of ability if the feedback is seen as threatening to the recipient’s selfesteem29 30. The autopsy, one of the most useful forms of feedback for challenging diagnostic overconfidence has been in decline for many years31. Given the need to challenge overconfidence, this is a concerning trend. Autopsies are the ultimate tool for showing when an overconfident diagnosis was wrong, and losing the feedback on diagnostic error provided by autopsies is likely to enhance clinical overconfidence, and threaten patient safety. We should integrate autopsy-related feedback and learning wherever possible in undergraduate, post-graduate and continuing professional training. The increased use of computers in medical education may provide an opportunity to improve metacognitive awareness. Traditionally computer-based learning has aimed to impart knowledge or skills, however systems that can monitor student responses and identify and provide feedback on cognitive errors hold promise11. Computer games designed to educate about other cognitive biases have been shown to be effective at reducing such biases (at least within the confines of the game environment)32. Croskerry and colleagues have suggested a series of stages that doctors need to go through to effectively challenge their own cognitive biases33. For overconfidence we could image the following model 1 – I am unaware of overconfidence as a problem 2 – I am aware that overconfidence is a problem for other people 3 – I am aware that I am also probably overconfident 4 – I want to de-bias my overconfidence 5 – I take action to reduce my overconfidence 6 – I maintain my improved confidence calibration The first step is to become aware of the problem. This could be achieved by ensuring that cognitive errors in diagnosis are included in undergraduate and post-graduate curricula. Medical educators should take advantage of opportunities to highlight issues relating to cognitive errors wherever they may occur, from bed-side to the mortuary. It is likely that emotionally vivid examples, whether from personal experience, or related in teaching sessions, are likely to





Excellence in

18

Medical Education

be more engaging than teaching about these issues in an abstract way, detached from clinical practice. The second step is likely to be difficult for many, given that we generally think we are less biased than other people16. There is a metacognitive leap from appreciating that people generally need to challenge their biases, to accepting that we also may be less than perfectly calibrated ourselves. Reflective practice may be helpful with this, as may feedback and engagement with external quality assessment. Unfortunately, given the tendency of the least able to most over-estimate their abilities, there is a risk that those with the most to gain from a reduction in their overconfidence may be least likely to perceive the need to use such strategies. Once the doctor has decided that they want to challenge their overconfidence, they need to decide what action has the best combination of practicality and efficacy. Unfortunately there is currently a dearth of specific evidence on this in relation to medical practice.

Reflections for Medical Educators Might we as medical educators be contributing to the problem of overconfidence in doctors? Confidence is easily mistaken for competence. We should consider whether we subconsciously reward confidence in medical school admission processes, in our students and trainees, and among our peers. We should also consider whether we are acting as a role-model of metacognitive awareness or of overconfident practice.

Conclusion Overconfidence is a cause of misdiagnosis and is a risk to patient safety. We need to develop evidence-based tools to challenge this cognitive bias, but until these are available, some simple strategies are likely to be helpful. Regularly ask yourself why you might be wrong, seek and reflect on feedback, and consider using diagnostic checklists (or cognitive strategies such as ‘consider the serious and treatable’) in areas of particular diagnostic risk.

Acknowledgement I am extremely grateful to Kristoffer Ahlstrom-Vij (senior lecturer in philosophy at the University Of Kent) for helpful advice and discussion.

References 1. Friedman, C. et al. Are clinicians correct when they believe they are correct? Implications for medical decision support. Stud. Health Technol. Inform. 454–458 (2001). 2. Langendyk, V. Not knowing that they do not know: self-assessment accuracy of third-year medical students. Med. Educ. 40, 173–179 (2006). 3. Berner, E. S. & Graber, M. L. Overconfidence as a Cause of Diagnostic Error in Medicine. Am. J. Med. 121, S2– S23 (2008). 4. Kruger, J. & Dunning, D. Unskilled and unaware of it: how difficulties in recognizing one’s own incompetence lead to inflated self-assessments. J. Pers. Soc. Psychol. 77, 1121 (1999). 5. Klayman, J. Overconfidence: It Depends on How, What, and Whom You Ask. Organ. Behav. Hum. Decis. Process. 79, 216–247 (1999). 6. Jemaiel, S., Mamoghli, C. & Seddiki, M. W. An Experimental Analysis of Over-Confidence. Am. J. Ind. Bus. Manag. 03, 395–417 (2013). 7. Alicke, M. D., Klotz, M. L., Breitenbecher, D. L., Yurak, T. J. & Vredenburg, D. S. Personal contact, individuation, and the better-than-average effect. J. Pers. Soc. Psychol. 68, 804 (1995). 8. Phua, D. H. & Tan, N. C. Cognitive aspect of diagnostic errors. Ann Acad Med Singap. 42, 33–41 (2013). 9. Olsson, H. & Winman, A. Underconfidence in sensory discrimination: The interaction between experimental setting and response strategies. Percept. Psychophys. 58, 374–382 (1996). 10. Bornstein, B. H. & Zickafoose, D. J. ‘I Know I Know It, I Know I Saw It’: The Stability of the ConfidenceAccuracy Relationship Across Domains. J. Exp. Psychol. 5, 76–88 (1999). 11. Crowley, R. S. et al. Automated detection of heuristics and biases among pathologists in a computer-based system. Adv. Health Sci. Educ. 18, 343–363 (2013). 12. Hilton, D., Régner, I., Cabantous, L., Charalambides, L. & Vautier, S. Do positive illusions predict overconfidence in judgment? A test using interval production and probability evaluation measures of miscalibration. J. Behav. Decis. Mak. 24, 117–139 (2011). 13. Pliske, R. M. & Mutter, S. A. Age Differences in the Accuracy of Confidence Judgments. Exp. Aging Res. 22, 199–216 (1996).

Excellence in

19

Medical Education

14. Brozynski, T. The impact of experience on risk taking, overconfidence, and herding of fund managers  : complementary survey evidence. (2004).

28. Eberlein, M., Ludwig, S. & Nafziger, J. The Effects of Feedback on Self-Assessment. Bull. Econ. Res. 63, 177– 199 (2011).

15. Larrick, R. P. in Blackwell Handbook of Judgment and Decision Making (eds. Koehler, D. J. & Harvey, N.) 316–338 (Blackwell Publishing Ltd, 2004). at

29. West, R. F. & Stanovich, K. E. The domain specificity and generality of overconfidence: Individual differences in performance estimation bias. Psychon. Bull. Rev. 4, 387– 392 (1997).

16. Pronin, E. How We See Ourselves and How We See Others. Science 320, 1177–1180 (2008). 17. Ahlstrom-Vij, K. Why We Cannot Rely on Ourselves for Epistemic Improvement. Philos. Issues 23, 276–296 (2013). 18. Daniel Kahneman Quotes at BrainyQuote.com. BrainyQuote at 19. Ely, J. W., Graber, M. L. & Croskerry, P. Checklists to Reduce Diagnostic Errors: Acad. Med. 86, 307–313 (2011). 20. Lee, C. S., Nagy, P. G., Weaver, S. J. & Newman-Toker, D. E. Cognitive and System Factors Contributing to Diagnostic Errors in Radiology. Am. J. Roentgenol. 201, 611–617 (2013).

30. Beer, J. S. Exaggerated Positivity in Self-Evaluation: A Social Neuroscience Approach to Reconciling the Role of Self-esteem Protection and Cognitive Bias: Social Neuroscience of Exaggerated Positivity. Soc. Personal. Psychol. Compass 8, 583–594 (2014). 31. Galloway, M. The role of the autopsy in medical education. Hosp. Med. Lond. Engl. 1998 60, 756–758 (1999). 32. Dunbar, N. E. et al. in Persuasive Technology (eds. Spagnolli, A., Chittaro, L. & Gamberini, L.) 92–105 (Springer International Publishing, 2014). at 33. Croskerry, P., Singhal, G. & Mamede, S. Cognitive debiasing 2: impediments to and strategies for change. BMJ Qual. Saf. 22, ii65–ii72 (2013).

21. Bolger, F. & Önkal-Atay, D. The effects of feedback on judgmental interval predictions. Int. J. Forecast. 20, 29– 39 (2004). 22. González-Vallejo, C. & Bonham, A. Aligning confidence with accuracy: Revisiting the role of feedback. Acta Psychol. (Amst.) 125, 221–239 (2007). 23. Renner, C. H. & Renner, M. J. But I thought I knew that: using confidence estimation as a debiasing technique to improve classroom performance. Appl. Cogn. Psychol. 15, 23–32 (2001). 24. Russo, J. E. & Schoemaker, Paul J. H. Managing Overconfidence. MIT Sloan Rev. 33, 7–18 (1992). 25. Hubbard, D. W. & Hubbard, D. W. in How to Measure Anything 57–77 (John Wiley & Sons, Inc., 2010). at 26. Croskerry, P., Singhal, G. & Mamede, S. Cognitive debiasing 1: origins of bias and theory of debiasing. BMJ Qual. Saf. 22, ii58–ii64 (2013). 27. Graber, M. L. et al. Cognitive interventions to reduce diagnostic error: a narrative review. BMJ Qual. Saf. 21, 535–557 (2012).





Excellence in

20

Medical Education

7. Interview with Professor Andrew Grant Professor Andrew Grant is dean of medical education at Swansea University. His initial training is in medicine and he still practices as a GP. Andrew Studied medical education at Maastricht and did a masters and doctoral research into reflective learning in undergraduate medical education. In 2012 Andrew led a GMC-funded project exploring support for medical students with mental health problems. With others Andrew has recently set up the Unit for study of doctors’ and medical students’ mental health and wellbeing which is based in Swansea.

When working on my PHD which was about reflective learning I had my introduction to qualitative research and I had the good fortune to have Professor Rosin Pill as my research mentor and was very grateful for her time and patience and willingness to continue to challenge me on

21

Medical Education

be able to offer through listening and through consultation. I continued to study as a member of the Barlint group at the Tavistock Institute at North London as a young practitioner. The most defining roles of my career as medical educator without doubt came when I went to Maastricht to study for the Masters in Health Professions Education. The theoretical learning for the early parts of that course brought about in me an awakening of the real meaning of learning and alongside that the real task of an educator. I had been a trainer in general practice and also taught medical students at this stage for long enough to have observed many of the phenomena that was described in our theoretical learnings but with no idea that an author or authors had put their names to these phenomena and described them in an academic way. Top of the list for me is the concept of knowledge being something that is constructed by the learner rather than something that is transmitted from teacher to learner by various teaching techniques, i.e. lectures, seminars and e learning. Alongside that I began my early understanding of Socio Cultural Learning Theory (although I didn’t call it that then) and in particular the teachings of Vygotsky on the Zone of the Proximal Development and educational scaffolding. These have provided a theoretical underpinning for my work as an educator since that time and continue to do so.

Please describe your current roles Professor Andrew Grant

Who were your most influential teachers My most influential teacher by far was my O Level and A Level Chemistry teacher in secondary school. The reason that I am still so inspired by him and his teaching was his dedication to being a teacher and to his profession. Mr Bowen had no goal from his teaching other than the success and future happiness of his pupils. For that he was prepared to work very hard indeed and expected the same of us. He gave me a great deal of encouragement and in particular was very positive when I told him I wished to apply for medical school. Indeed he was as happy when I got a place at Charing Cross medical School as he could possibly have been. There was, for many years, a commercial on television recruiting people into the teaching profession and the strap line was ‘Nobody forgets a good teacher’ and I always used to say out loud ‘Mr Bowen’. I can only aspire to his levels of professionalism and altruism as a teacher and in life in general.

Excellence in

my ideas and assumptions. Without doubt my thesis was a very different piece of work as a result of her help. My role models have been my clinical colleagues who are able to continue to practice medicine in a thoughtful, compassionate and patient-centred way despite all the clinical pressures and working in the health service. I am in awe of the way that some people continue to put their patients first, to give their patients all of the time they need, whilst finding themselves under massive competing pressures.

Please describe the most defining moments of your career. Undoubtedly the defining moment of my career as a medical practitioner comes from my year as a registrar (or as a trainee as we were called then) under the support of my generous, supportive trainer Charmian Goldwyn and whilst studying the works of Michael Balint, I was able to experiment and develop as a practitioner in a way that I hadn’t previously imagined possible. This helped me as a practitioner to become more patient centred, more holistic and become a little more aware of the therapeutic interventions that I may

I took on the role of Dean of Medical Education at Swansea University in the summer of 2014 so am still very new in this job. The course is still in its early stages and has as yet only had one cohort of graduates but evaluation of the graduates opinion of the education and the way the students are prepared for clinical practice suggests the course is very successful at turning out confident well prepared doctors. My role is one of supporting the very dedicated team that puts on this course while challenging them to deliver a course that is academically stretching to the very bright graduate entrants. In the busy organisation, as well as executing the complexities of delivering a programme it also essential to ensure that learning is taking place at a level that will produce a level of graduate that is not only knowledgeable but also competent and able to apply what they know. It is my task therefore sometimes to ask if we might do things differently from how things have been done in previous years or to challenge people to revisit the theoretical underpinning of their educational activities. As well as my work with the Graduate Entry Medicine course I have also worked with a colleague to develop a Professional Doctorate course in Health Professions Education and this is running for the first time this year. My role within the Academy of Medical Educators has been to lead the Recognising Teaching Excellence workshops

and in particular to develop a more effective mechanism for addressing the queries of those people who think that membership or fellowship of the academy might be of help to them and their career but who need more information.

Challenges for medical educators in the UK There are of course many challenges to medical educators in the UK and also to those in Higher Education centres in the UK and in most parts of the world. However I believe that the greatest challenge is to ensure that our interventions as medical educators continue to stimulate the best possible learning to produce the best possible graduates. Not least among the threats to this are the students themselves. Medical students work very hard, they have a great workload and a great deal invested in their studies and their career and as such they are inclined to work in a very strategic manner. This is of course some of the students some of the time rather than all of the students all the time! It behoves us as medical educators therefore to constantly think about the educational effect on learning interventions and assessments. An assessment that stimulates the student to leave the wards and clinics and go and study in the library is probably likely to have a more negative effect on their learning compared to a workplace-based assessment where preparation can only take place within the clinical arena and with real patients. I would not wish to diminish the concerns of producing high class education in an environment where education often finds itself having to compete for a people’s time and resources with research and other university priorities, and of course the constant need to reduce costs and save money. Increases in student fees in the UK have understandably raised student expectations. The planned changes in legislation bringing full registration forward to the time of graduation posed a particular threat to Graduate Entry courses such as the one at Swansea as it appears likely that the current shortened 4 year courses may not produce enough hours of tuition to satisfy European law. This is currently being negotiated.

What are the most important values for medical educators? The single most important value that a medical educator has to put across in every aspect of their practice as a medical educator and as a practitioner (where relevant) is that of patient centredness. The top priority for our future graduates is that they should put their patients first. Understandably they have their own needs and requirements but when they go out into the world and practice medicine their number one priority should be the patients well-being and to have acquired the knowledge and skills required to deliver that that. I include good communication with patients and their families in patient-centredness.





Excellence in

22

Medical Education

Secondly, but not completely separately, is the need to demonstrate an empathy and understanding to our students, their needs and the pressures put on them. Initially I think that our students often appear demanding and it takes a while to recognise that there are many demands on the students themselves, many of those placed on the students by themselves but also from family, friends, school background etc. I know from my own research that medical students suffer from a higher prevalence of mental ill health than the general population and from age-matched controls. One of the causative features of this is the pressurised environment in which medical students work as well as the driven perfectionist personalities of those that come into medicine. My research therefore showed that as well as being willing to provide whatever support is necessary for students who experience issues with mental health it is also important to recognise that all medical students work in a milieu of pressure, stress and tension and that we should expect this and help them to develop coping mechanisms.

Excellence in

23

Medical Education

7. Authors

Dr Nick Cooper, Associate Professor Clinical Education, Plymouth University Peninsula School of Medicine and Dentistry Chair AoME Membership Committee / Lead Assessor AoME

What are your aspirations for the Academy? Undoubtedly my aspirations for the Academy have changed. I now recognise the massive role it has to play in supporting and professionalising people who teach students and qualified practitioners in the dental, medical and veterinary medicine professions. Currently some of this group particularly those working in the Health Service rather than Higher Education have few chances of developing a level of professional recognition for their teaching activity and I believe that the Academy does offer this. However, although the Recognising Teaching Excellence workshops have been more successful in the current year than previous years there are still too few of them still for the people that might benefit from joining the Academy but have no easy of finding out about this. We have made a short video which is now on the Academy website as well our power point presentation to reach out to those people who are not able to attend our workshops.

Professor John Sandars, Director of Research, Academic Unit of Medical Education, The University of Sheffield.

Dr Malcolm Galloway, Consultant Neuropathologist/ Honorary Senior Lecturer, University College London/ Royal Free Hospital





Academy of Medical Educators

9th Floor, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS Tel: (0)2920 743524 Charity No: 1128988 Company No: 5965178 Email: [email protected]

www.aome.org