Al Dowie

Teaching professionalism in the early years of a medical curriculum: a qualitative study

Context  Despite the growing literature on professionalism in undergraduate medical curricula, few studies have examined its delivery.

What makes a good clinical student and teacher? An exploratory study

BackgroundWhat makes a good clinical student is an area that has received little coverage in the literature and much of the available literature is based on essays and surveys. It is particularly relevant as recent curricular innovations have resulted in greater student autonomy. We also wished to look in depth at what makes a good clinical teacher.MethodsA qualitative approach using individual interviews with educational supervisors and focus groups with senior clinical students was used. Data was analysed using a “framework” technique.ResultsGood clinical students were viewed as enthusiastic and motivated. They were considered to be proactive and were noted to be visible in the wards. They are confident, knowledgeable, able to prioritise information, flexible and competent in basic clinical skills by the time of graduation. They are fluent in medical terminology while retaining the ability to communicate effectively and are genuine when interacting with patients. They do not let exam pressure interfere with their performance during their attachments.Good clinical teachers are effective role models. The importance of teachers’ non-cognitive characteristics such as inter-personal skills and relationship building was particularly emphasised. To be effective, teachers need to take into account individual differences among students, and the communicative nature of the learning process through which students learn and develop. Good teachers were noted to promote student participation in ward communities of practice. Other members of clinical communities of practice can be effective teachers, mentors and role models.ConclusionsGood clinical students are proactive in their learning; an important quality where students are expected to be active in managing their own learning. Good clinical students share similar characteristics with good clinical teachers. A teacher’s enthusiasm and non-cognitive abilities are as important as their cognitive abilities. Student learning in clinical settings is a collective responsibility. Our findings could be used in tutor training and for formative assessment of both clinical students and teachers. This may promote early recognition and intervention when problems arise.

Phronesis or "practical wisdom" in medical education

These well-known words could read like a rallying cry against some highly lamented erosion of educational standards, but in a compact form they also contain the idea that there are different categories of learning, and suggest a basic epistemological taxonomy of `information± knowledge± wisdom’ . Without attempting to treat it as a rigorously developed theory, how might this threefold classi® cation potentially relate to medical education? Naturally we want our students to be well informed, and later as doctors to keep up to date with developments in their ® elds of specialization, having the ability to utilize information technology and online search resources to support a critically oriented evidence-based practice. But information, together with IT skills for literature and database searches, would hardly of itself constitute an acceptable standard of learning. Obviously medical students require to build up an essential core of knowledge and clinical skills to carry forward from year to year through to graduation and beyond. These might, for example, be represented by a set of curriculum outcomes specifying appropriate levels of knowledge across systems and themes according to each stage of the undergraduate degree. But there are limits to our capacity for accumulating and retaining information and knowledge, and it is now a truism to state that to overcrowd the curriculum is to overload the students and so to diminish their performance.The issue is then one of students becoming aware of the limits of their information and knowledge while being able to use that which they have in order to access what they lack. So while there is no quarrel about the legitimacy of information and knowledge as two out of the three types of learning as far as they go, it does seem that (as with a three-legged stool) two out of three is not quite enough. What, then, of the third classi® cation of learning posited above? On the face of it a somewhat nebulous term, wisdom might seem inappropriate hereÐ a category more associated with the poet, the contemplative, or the sage who knows `best’ than with perhaps the hearty young adult doing medicine at university. But it depends on what we mean by the word. That there is indeed some notion of wisdom actively operating in curricula is evidenced by the value placed by medical schools on the personal and professional characteristics of their studentsÐ the formative as well as normative aspects of their trainingÐ demonstrating that schools are concerned not only with the competences of the doctors they produce, but also with the quality of person produced as a doctor.Yet it is not enough vaguely to invoke the concept of wisdom as something worth cultivating in the medical student without specifying quite what that means. While knowledge, skills and attitudes may well be expressed in terms of curriculum outcomes, to what extent can or should the same be done with the category of wisdom, how can it be articulated coherently and systematically, and whose idea of wisdom should it be anyway? At this point it is worth taking a philosophical step back to introduce the concept of phronesis, otherwise known as practical wisdom, or practical reason, which may be identi® ed as having some relevance for medical education, particularly in the relationship between theory and practice. But before describing what is meant by phronesis it will be helpful in the middle section of this short article to make a temporary detour into the philosophical ® eld of epistemology where questions concerning the nature of knowledge, the forms it can take and its limits have historically been located. While in more recent history there has been a modulation away from theories of knowledge towards those of interpretation, meaning and claims to validity Ð a turn from epistemology to hermeneuticsÐ it remains the case that classical analyses of knowing, in spite of having originated from another era, continue to have present-day relevance in their capacity to inform contemporary discussion. One such analysis is in the epistemology of Aristotle (dating from the 4th century BCE), which sets out various types of knowledge. Among these are gnosis as acquaintance, sophia as philosophical wisdom, and nous as intuitive comprehension. Importantly, knowledge applies both to the arts (technai) and to the sciences (epistemai), an insight which in spite of its antiquity is of modern and postmodern signi® cance, since in terms of the sociology of knowledge it is still the case that what counts as knowledge can in some contexts be narrowly de® ned purely in relation to scienti® c knowledge (a scientistic position). Arising from these two domains of the arts and sciences are the terms techne, which is craftmanship, and episteme, which is a deductive grasp of causation, or explanation. In the context of medical education, then, it could be said that there are the epistemai of anatomy, physiology and biochemistry, together with the study of normal and abnormal structure, function and behaviour. There is also

A medical education view on sociological perspectives on professionalism

The paper entitled ‘Sociological interpretations of professionalism’ in this issue of the journal argues that professionalism is a multidimensional concept and ‘an extremely value-laden term with societal, institutional, historical and contextual expectations built into it’. The authors argue that writers in the medical education literature take a simplistic approach towards discussing professionalism because of their lack of familiarity with how sociologists approach problems. Their paper seeks to provide an overview of sociological frameworks and a way into the relevant sociological literature. It gives us a whistle-stop tour through significant writings by sociologists on professionalism from the 1920s until the present day.

The influence of structural and institutional change on teaching and culture in clinical settings: An exploratory study

Abstract Objectives: Learning in clinical settings is a function of activity, context and culture. Glasgow University’s Medical School has undergone significant curricular change in recent years. This has coincided with change to National Health Service consultants’ contracts, the introduction of the European Working Time Directive and the Modernising Medical Careers training initiative. We wished to explore teachers’ and students’ perspectives on the effects of change on our clinical teachers’ capacity for teaching and on medical culture. Methods: A qualitative approach using individual interviews with educational supervisors and focus groups with senior clinical students was used. Data were analysed using a “framework” technique. Results: Curricular change has led to shorter clinical attachments in the senior clinical rotation, which combined with more centralised teaching have had adverse effects on both formal and informal teaching during attachments. Consultants’ NHS contract changes the implementation of the European Working Time Directive and changes to postgraduate training have adversely affected consultants’ teaching capacity, which has had a detrimental effect on their relationships with students. Medical culture has also changed as a result of these and other societal influences. Conclusions: The apprenticeship model was still felt to be relevant in clinical settings. This has to be balanced against the need for systematic teaching. Structural and institutional change affects learning. Faculty needs to be aware of the socio-historical context of their institutions.

Making sense of assessment in medical ethics and law

Are curricula in medical ethics and law effective in producing ethical doctors? Assessment is central to this question, both in setting the standards that students are expected to meet and in establishing the extent to which learning correlates with these. Medical ethics and law: a practical guide to the assessment of the core content of learning from the Education Steering Group of the Institute of Medical Ethics is an excellent guide for educators in approaching this curriculum task. If the teaching moment is temporally antecedent to assessment, it is not logically prior to assessment decisions as if these were simply retrospective, and we cannot speak meaningfully of assessment without also speaking of intended learning. The IME assessment guide places emphasis on the alignment of learning, teaching and assessment in curriculum design; on specifying in advance the learning opportunities available to students; on delivering these via appropriate forms of learning; and on matching suitable methods for testing this learning in both summative and formative modes. Variety in assessment is essential across the cognitive, the affective and the psychomotor domains of learning, and the IME assessment guide provides illustrative examples of, and templates for, types of assessment that are relevant to these. The practical advice offered is as applicable in schools of nursing and in dental schools as it is in medical education.

Innovative Specialist Training Programme for General Practice in Angus, Scotland: A Qualitative Evaluation

Prompted by criticism of the hospital component of existing general practice vocational training schemes (GPVTS) and the proposed changes to the regulatory framework for approval of training, an innovative specialist training programme for general practice was developed in Angus, Scotland from August 2002. It was imporEducation for Primary Care (2007) 18: 35–44 # 2007 Radcliffe Publishing Limited

Diabetic Foot Ulcer: Amputation on Request?

In 2000, a Scottish surgeon received significant publicity for amputating lower limbs from healthy patients who were thought to have a Body Integrity Identity Disorder (1). We present a type 1 diabetic patient with a recurrent foot ulcer who requested a lower-limb amputation. Although very different, this situation also created difficult ethical issues that we have attempted to address. Peter C. Brown (aged 54 years) was diagnosed as having type 1 diabetes at age 21 years. Between early 2006 and November 2008, he had several admissions with a diabetic foot ulcer that partly resolved but never fully healed (2). By early November 2008 and after discussions with his family, he decided that he …

Policy needs to be revisited

Consent should be obtained before publishing case reports.1 Signed consent forms include patient’s name and the manuscript title, which often states the illness. Several UK journals insist that consent forms are sent to their editorial offices. In the UK, processing of personal data is governed by the Data Protection Act …

Private Wisdom and Public Practice: Formation and Governance in the Medical Profession in the United Kingdom

In 2006, the Chief Medical Officer for England published the report Good Doctors, Safer Patients in a call for strengthened regulation of the medical profession. The changing relationship between patients and doctors in the United Kingdom arises from the interplay between societal expectation and clinical governance, personal formation and professional practice, private being and public doing. The wisdom of professional practice is in the habits of professionals, a practical wisdom that is the reflex of professional identity. Socialization into a profession is the formation of such identity through the legitimate peripheral participation of the apprentice, oriented towards the contingent granting of admission to the community of practice. The conditional nature of continued insider status, permitting members to interact with clients across the professional boundary, is essential to the contract through which the profession enjoys the privileges conferred by society. The governance of the profession is therefore also necessarily circumscribed, a political reality that is currently evidenced in the regulation of medical practice in the United Kingdom.