John Bligh

Improving student learning.

Medical students learn in a wide range of settings: at the bedside, on the wards, in the community, in outpatient clinics and in the classroom. Sometimes this is done alone or in pairs, but mostly in small groups (and often, in much larger groups). Students use books, journals, computers, videos, television, laboratories, microscopes and dissection as resources to help their learning. In many settings, they mostly watch doctors carrying out the tasks they will themselves undertake when qualified. During electives many students gain practical clinical experience to help them apply some of the theory they have learned at medical school. Once students have qualified, learning continues alongside clinical experience and has two main components. Much of this learning is based on the work newly qualified doctors are doing, but is often unstructured, hurried and with poor access to the learning resources they have relied on at medical school. At the same time, for most specialties, learning for professional examinations is based on reading and classroom-based teaching. Medicine inevitably is a complex discipline and learning to become a doctor is a complex task. One of the most intriguing questions in medical education is: how do students learn? Whilst we can describe the settings in which students learn, and discover those that students like the most, and the least, we are struggling to find answers about the how of learning. Authors of papers in this issue of Medical Education approach this question by asking: What conditions can be created by teachers to ensure that students learn in the most effective way? A team from Maastricht led by two educational psychologists, Dolmans and Wolfhagen, has examined aspects of outpatient teaching from the students’ perspective. They used path analysis to test relationships and interactions between six common variables obtained from a questionnaire completed by students. They characterize the outpatient clinic as an educational paradox. On the one hand, it is ideal as an authentic setting for clinical teaching about a specialty, but on the other, it is one of the most difficult settings students encounter, because much of the teaching is passive and involves little feedback, it is based on a narrow range of cases and is often dependent on available time between consultations. A process evaluation approach was used in the study because the authors wanted to find out more about how students learned rather than what they learned. The variables investigated in the study included space for examining patients, the number of students involved, organizational quality, patient mix and supervision provided. The results of the study showed that each of the variables was important and influenced the quality of the experience. However, it was the influence of supervision that emerged as the most important factor, suggesting that sitting and watching in the outpatient department is a lot less useful than doing and receiving feedback on performance. Nendaz and Bordage from Chicago examine clinical reasoning skills amongst medical students from the starting point that traditional clinical teaching about history taking overemphasizes depth of data collection at the expense of focused, more structured enquiry. They argue that encouraging students to think about the data they are collecting during history taking and to relate it to understanding the patient’s problem, will lead to a more selective approach – one that more closely matches the way in which experienced clinicians work. A semantic qualifier is the expression used to describe the result of converting patient history data into abstract terms that clinicians use to depict a clinical problem. Although the use of semantic qualifiers has been shown to improve diagnostic accuracy, little work has been done on how students learn to use them. In their study, the authors found that effective use of semantic qualifiers was related, amongst other things, to the amount of content knowledge students possess and to the degree to which students are able to integrate their use into a real patient encounter. Whilst further work is needed, it is clear that structured and organized learning about history taking and identifying clinical problems should take place early and be integrated with learning about disease and illness.

Recent perspectives on clinical teaching

Clinical teaching is part of a doctor’s professional life, whether it takes place in surgeries, clinics or in hospitals, with undergraduates, postgraduate trainees or colleagues. Learning to teach well means questioning the effectiveness of some of the old teaching methods, exploring new ideas and trying out new methods in different situations. It means collaborating more closely with colleagues and learners about developing and implementing new approaches to medical education. This paper is the first of an occasional series of articles about the practical aspects of clinical teaching. The articles have the following characteristics: they explore contemporary themes in medical and health care education; they use up‐to‐date references; they are a quick and easy resource for busy teachers; they explore new ideas about teaching and learning, and they provide a reference list of relevant papers. This article deals with recent ideas about clinical teachers’ knowledge and roles, teaching and organizational strategies, and the measurement of teaching effectiveness.

Approaches to learning and studying in medical students: validation of a revised inventory and its relation to student characteristics and performance

Introduction  Inventories to quantify approaches to studying try to determine how students approach academic tasks. Medical curricula usually aim to promote a deep approach to studying, which is associated with academic success and which may predict desirable traits postqualification.

Thinking the post-colonial in medical education

Context  Western medicine and medical techniques are being exported to all corners of the world at an increasing rate. In a parallel wave of globalisation, Western medical education is also making inroads into medical schools, hospitals and clinics across the world. Despite this rapidly expanding field of activity, there is no body of literature discussing the relationship between post‐colonial theory and medical education.

Distributing menus to hungry learners: can learning by simulation become simulation of learning?

Simulation offers an important context for clinical education, providing a structured, safe and supportive environment bridging the classroom and the clinic. Two trends in the simulation community appear to be developing uncritically and without adequate evaluation. First, there is a fascination with seductive high-fidelity simulation realized through sophisticated technology. Second, simulation has increasingly appropriated learning in the psychological domain, such as communication skills, under the rationale of ‘integration’. Developments in simulation activities have largely been made in a theoretical vacuum and where theory is invoked it is learning theory rather than theory of simulation. This paper introduces theories of simulation from cultural studies as a critical balance to the claims of the simulation community. Work-based and simulation-based learning could engage in a new dialogue for an effective clinical education. Practice points•Learning by simulation can become self-referential to offer a simulation of learning.•Work-based learning requires effective structuring such as provision for hands-on practice, support, feedback and reflection.•Learning by simulation can be more effectively theorized to inform practice.•The interaction between effective simulation and work-based learning can increase the power of both.

One year's experience with a clinical skills resource centre.

To describe our experience of teaching clinical skills to first‐year medical students in a new problem‐based curriculum.

Symbiosis: a new model for clinical education

Some of the principles of symbiosis have been implicit in approaches to medical education for some time but they are increasingly difficult to maintain in large tertiary academic medical centres. The case mix of these centres is concentrated in the higher levels of tertiary care, with a predominance of acute and emergency illness. Patients frequently undergo complex technological interventions but, at the same time, have relatively short periods of time in hospitals. There is a new emphasis on patient ‘rights’ and choice, with limits to the number of skills and procedures that students and junior doctors can undertake with patients. There are strong pressures for clinicians to spend more time performing clinical services in the budget-driven management structures of hospitals, often at the expense of time for teaching. Finally, most of the burden of health care is widely distributed beyond hospitals in the community, where chronic disease represents perhaps one of the major challenges for health care systems of the future. If these trends are to continue questions may be raised about the ongoing suitability of some traditional environments for undergraduate and graduate-entry medical courses.

Interprofessional learning involving medical students or doctors

Aims  There is a belief that interprofessional learning among health care professionals promotes teamwork and collaboration, leading to improved patient care, but supporting data have not been available. Our aim was to identify recent studies on interprofessional learning involving medical students or doctors.

Undergraduate ethics teaching: revisiting the Consensus Statement.

Objective  To determine whether the recommendations of the Consensus Statement published 7 years ago have been implemented.

Author misconduct: not just the editors' responsibility

Background  Researchers everywhere are under increasing pressure to publish in high quality journals. The amount of space available in a journal such as Medical Education has not kept pace with the rise in submissions. Against a background of fierce competition, authors sometimes cut corners. This may lead to misconduct.