Seven Strategies for the Empowered Teacher -

Newer Approaches to Teaching - Learning

Prof. K.R. Sethuraman, MD PGDHE,

(Formerly) National Teacher Training Centre, (NTTC), JIPMER, Pondicherry. 605006 India

INTRODUCTION

This is not a major review article on all the innovations in teaching learning. This is just an overview of seven principles derived from the "Edinburgh Declaration" of the world conference of 1988 on Medical Education. They are meant to provoke us into taking some bold initiatives to change our educational process for the better.

1. National Health Priorities to be the main focus

We should internalise that the goal of medical education is to produce a graduate doctor capable of managing common problems in the country - not pundits in individual disciplines. The focus should therefore be on major health problems of India. We should evolve lesson plans that stress on our priorities and health care needs. An example is therapy for HIV: highly active anti-retroviral therapy (HAART) is beyond the means of most HIV cases in India. We need to stress more on how to manage with what is currently available and affordable.

2. Move from "Ivory tower" approach to realistic health care settings

Two-thirds of rural Indian families are in debt and penury because of health care expenses. Can we educators adopt western model of "evidence at any cost" approach? For example, Mendel's Textbook of Infectious diseases (1993) states that MRI is the best way of documenting sinus infections, without qualifying it any further on cost-benefit ratio or its necessity in all cases!

We educators must realise that bio-medical knowledge is not "value-free" but is based on values derived from ethics, sociology and medical philosophy. Are we empowered to impart value-based education and enable our students practise ethical, appropriate and efficient health care without driving our patients into deep debt? Problem solving exercises given as assignments or for group discussion are relevant methods to impart this skill.

3. Aim for competence - not memorisation of facts

Doctors are problem solvers by their profession. To achieve this capability, our students need to be educated and evaluated for clinical competence. If the examination system merely tests memorising capacity of the students, how and why would they acquire clinical competence?

Lecture method is notorious for its weakness in imparting problem solving skills. Clearly, we should move away from didactic lectures to better methods described below. Even in a lecture, a �buzz session� can be used to promote attainment of higher cognitive skills like problem solving ability. Clinical skills laboratory is a good set up to impart clinical competence in our students. In such a lab, several methods can be combined to systematically train our students in various skills that make up clinical competence.

4. Promote active self-directed learning

The half-life of most scientific knowledge is only a few months to a few years. Yesterday's dogma memorised by us when we were students have already been consigned to pages of history. The same fate awaits the dogma of today that we so didactically and enthusiastically drill into the minds of our students. If this is realised, then the teacher of today will be more open, humble and promote self-directed learning methods that will enable the students to be life-long learners.

The World Wide Web -the Internet- is yet another development that makes any teacher humble. There are 250 million bits of data in the Web for every one of the 6 billion people in the world today! Information is plenty and at available at the touch of a few keys (buttons). Why should we then expect our students to carry so much of evanescent information in their heads? The over crowded curricular time is better spent in fostering "information processing" skills.

Today's teacher has to evolve into an information manager than information provider. They should use methods to promote active learning:

For cognitive skills, case studies, clinico-pathological exercises, simulated patient management problems (SPMP) and tailored response tests (TRT) may be used. These are useful even for a large group of students.

For clinical and practical skills, objective structured format is very useful. Though objective structured clinical/practical examination (OSCE/OSPE) started as an evaluation tool, it is a very effective method for remedial education. One can accurately pinpoint learning error in every student and correct each one individually. Since the method is objective, senior students or junior faculty staff can do observation for error detection.

For imparting communication skills, standardised patients (SP) are useful. In the West, actors are standardised to play the role of patients but here, we can train actual patients to give consistent responses and use them as SPs. They can also be trained to assess the quality of each student as a communicator. SPs can sit in OSCE stations and brief clinical encounters staged between them and the trainees. Post encounter debriefing helps to identify the strengths and weaknesses of communication in each candidate.

5. Integrate Scientific Evidence with Clinical Practice

We often tend to teach scientific facts and principles in theory classes but in real life practice, follow empiricism and non-evidence based medicine. This dichotomy confuses our students. Openness and a spirit of scientific enquiry must prevail in clinical teaching and clinical practice. There are situations when empiricism must be used but our students must know why it should be so.

An easy example can be derived from the earlier point on the need for MRI scan to delineate para-nasal sinus infection. It is obvious that for an acute sinusitis, the cost of MRI justifies an empiric therapy than go after "scientific proof" at a great cost. But how often do we discuss such practical points with our students? As educators, we should be role models in the practice of evidence-based medicine and combine it with empirical artful practice as and when indicated. Grand rounds, clinical demonstrations and simulated patient management problems (SPMP) are relevant methods to achieve such integration.

6. Foster capacity to perform as a team

In the current reality of a complex medical world, it is almost impossible to provide effective healthcare single-handedly. It is essential for our students to acquire the skills of teamwork.

Teaching methods that involve teamwork help them to learn these complex skills. Fieldwork, group assignment, group discussion and co-curricular team based activities may be adopted to build this capacity in our students.

7. Impart ethical sensitivity and behavioural skills

A family doctor of yore was a friend, philosopher and a guide even though the therapeutic armamentarium at his/her command was, going by current standards, weak and often ineffective. With more powerful and effective interventions available today, it is easy for our students to think that they can handle patients in a mechanical and uninvolved fashion and still be successful. But this is a totally wrong assumption.

Going by the current crisis of confidence in the West where patients migrate from scientific medicine to empirical alternative systems, it is obvious that holistic and humane approach is more important to people than fragmented de-humanised health care of high technology.

As educators, we have to realise that as health care becomes more complex and more fragmented, it is necessary for doctors to be more humane, ethical and non-exploitative in their practice. We need to adopt "value based education" to correct this anomaly. Narratives, Case studies, Simulation Role-play and T-group discussions are some of the relevant T-L methods for this purpose.

SUMMARY

World medical council has adopted the Edinburgh Declaration in 1993. All over the world, the medical councils of individual nations are trying to change the curricula and coax medical educators to adopt innovative teaching-learning methods to produce future doctors we all can be proud of. We should whole-heartedly support this worthy cause on an individual as well as collective basis.

References

1. EBM working group. Evidence-based Medicine. A new approach to teaching the practice of Medicine. JAMA 268: 2420-5; 1992.

2. Sethuraman KR. Objective Structured Clinical Examination - II edition. (2000) Jaypee Brothers Medical Publishers. P.B. No 7193, New Delhi-110002.

3. Allen S et al. Tailored Response Test: a new approach for teaching in medical education. Medical Education, 1997:197.

4. Education and Debate: Economic notes - a series of seven articles in BMJ Vols 319 and 320, 1999-2000. Link: www.bmj.com (search for articles on economic notes in 1999 & 2000)

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This paper was presented in the National Workshop on "Quality Management in medical Education, Organised by the Maharashtra University of Health Sciences (MUHS) in March, 2001

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