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- Herausgeber: John Wiley & Sons
- Kategorie: Fachliteratur
- Serie: At a Glance
- Sprache: Englisch
Covering the core concepts, activities and approaches involved in medical education, Medical Education at a Glance provides a concise, accessible introduction to this rapidly expanding area of study and practice.
This brand new title from the best-selling at a Glance series covers the range of essential medical education topics which students, trainees, new lecturers and clinical teachers need to know. Written by an experienced author team, Medical Education at a Glance is structured under the major themes of the discipline including teaching skills, learning theory,and assessment, making it an easy-to-digest guide to the practical skills and theory of medical education, teaching and learning.
Medical Education at a Glance:
- Presents core information in a highly visual way, with key concepts and terminology explained.
- Is a useful companion to the Association for the Study of Medical Education’s (ASME) book Understanding Medical Education.
- Covers a wide range of topics and themes.
- Is a perfect guide for teaching and learning in both the classroom and clinical setting.
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Seitenzahl: 354
Veröffentlichungsjahr: 2017
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Library of Congress Cataloging-in-Publication Data
Names: McKimm, Judy, editor. | Forrest, Kirsty, editor. | Thistlethwaite, Jill, editor.
Title: Medical education at a glance / Judy McKimm, Kirsty Forrest, Jill Thistlethwaite.
Other titles: At a glance series (Oxford, England)
Description: First edition. | Hoboken, NJ : John Wiley & Sons, Inc., 2017. |
Series: At a glance series | Includes bibliographical references and index.
Identifiers: LCCN 2016045903 (print) | LCCN 2016046543 (ebook) | ISBN
9781118723883 (pbk.) | ISBN 9781118723814 (pdf) | ISBN 9781118723821 (epub)
Subjects: | MESH: Education, Medical
Classification: LCC R735 (print) | LCC R735 (ebook) | NLM W 18 | DDC
610.71–dc23
LC record available at https://lccn.loc.gov/2016045903
Cover image: © kali9/Gettyimages
CONTENTS
Preface
Acknowledgements
About the editors
Judy McKimm
Kirsty Forrest
Jill Thistlethwaite
Contributors
Part 1 Overview and broad concepts
1 What is medical education?
Professional education and training
2 Stages of medical education
Basic medical education
Postgraduate training
Continuing professional development
3 Evidence-guided education
The nature of evidence
Research and evaluation
Quantitative and qualitative data
4 Learning theories: paradigms and orientations
Philosophies and paradigms
Orientations to learning
5 Learning theories and clinical practice
Sociocultural theory
Work-based learning
Perspectives on learning
6 The curriculum
Curriculum in context
Educational philosophy and theories
Curriculum alignment
Curriculum structure and approach
7 Planning and design
Components of course or lesson planning
Learners' needs
8 Equality, diversity and inclusivity
Definitions
Challenges
9 Principles of selection
Interviews
Selecting for professional attributes
Situational Judgement Tests
Multiple Mini Interviews
10 Evaluation
The purpose of evaluation
Outcomes-based evaluation
Process evaluation
11 Educational leadership
Leadership approaches
Three skills sets
Three levels
Three expertise sets
Three key personal qualities
Three ways of learning
12 International perspectives
International learners, doctors and teachers
Towards transnational medical education
Internationalisation of the curriculum
Global health and international electives and social accountability
Part 2 Medical education in practice
13 Large group teaching: planning and design
Planning a lecture
Presentations
Lecture planning
14 Large group teaching: delivery
Practice makes perfect
Scaffolding and signposting
How to introduce interactivity
15 Small group teaching: planning and design
Why small group teaching?
Planning
16 Small group teaching: delivery
Facilitating discussion
17 Clinical teaching: planning and design
Learning in clinical practice
Creating a good learning environment
Challenges and concerns
Set clear boundaries
18 Clinical teaching: delivery
Formal teaching sessions
Purposeful observation
Teaching on the run
19 Simulation: planning and design
How is simulation used?
Benefits of simulation teaching
Simulation and learning
Special types of simulation
20 Simulation: delivery
Delivering simulation activities
The course/session
Deliberate practice
Feedback
The structured debrief
21 Patient involvement in education
The patient voice in education
Levels of patient involvement
Preparing to involve patients
22 Ward-based and bedside teaching
Orientation
Clinical teacher preparation
Learning and teaching tips
23 Learning and teaching in ambulatory settings
Early patient contact
Models of learning and teaching
24 Teaching in the operating theatre
Benefits of operating room teaching
Specific learning models
25 Interprofessional education
Rationale
The interprofessional curriculum
Interprofessional facilitation
Evaluation and research
26 Reflective practice
Reflection and professional behaviour
The experiential learning cycle
Reflection for personal development
Facilitating reflection
27 Teaching clinical reasoning
Clinical knowledge
Understanding diagnostic tests
Psychology and cognitive biases
Evidence-based medicine
Decision-making strategies
28 Professionalism
Definitions
Professionalism courses
Learning and teaching methods and principles
29 Peer learning and teaching
Rationale
Evidence
Learning and teaching activities
Training for the educator role
Peer appraisal of teaching
30 Communication
The communication curriculum
Barriers to good communication
31 Problem-based and case-based learning
32 Learner support
Extra support may be required
An integrated, supportive approach
An inclusive learning environment
Identify struggling learners early
A duty of care
33 Supporting professional development activities
A professional development framework
Appraisal
Coaching
Mentoring and supervision
Counselling
34 Mentoring and supervision
Building relationships
Mentoring
Supervision
35 e-Learning
Advantages and challenges
How to design an e-learning module
Design considerations
Modes of delivery
Learning environments
36 Social media
How is social media being used for learning and teaching?
Selecting and implementing social media technologies
Managing risks and limitations
Part 3 Assessment and feedback
37 Feedback
Feedback and the learning process
Principles of effective feedback
Receiving feedback
Barriers to effective feedback
38 Principles of assessment
Curriculum alignment
Definitions
Programmatic assessment
39 Written assessments
Types of written question
Tips for writing good questions
40 Assessment of clinical skills
The Objective Structured Clinical Examination
Other types of clinical skills' assessment
41 Work-based assessment
Types of WBA
Evaluation
42 Assessing professionalism
Written assessment
Practical assessment
Work-based assessment
Feedback
43 Portfolios
The rationale for portfolio-based assessment
Personal development plans
What do portfolios look like?
Assessment of portfolios
Effectiveness of portfolios
44 Setting pass marks
Setting standards for written tests
Setting standards for OSCEs
45 Developing yourself as a medical educator
Development activities
Associations
Research and publication
Professional recognition
Further reading
Part 1 Overview and broad concepts
Part 2 Medical education in practice
Part 3 Assessment and feedback
References
Index
EULA
List of Tables
Chapter 1
Table 1.1
Chapter 2
Table 2.1
Chapter 3
Table 3.1
Chapter 4
Table 4.1
Chapter 5
Table 5.1
Table 5.2
Chapter 6
Table 6.1
Chapter 7
Table 7.1
Chapter 10
Table 10.1
Chapter 15
Table 15.1
Chapter 16
Table 16.1
Table 16.2
Chapter 35
Table 35.1
Chapter 36
Table 36.1
Chapter 38
Table 38.1
Chapter 39
Table 39.1
Chapter 40
Table 40.1
Chapter 41
Table 41.1
Chapter 44
Table 44.1
Table 44.2
List of Illustrations
Chapter 1
Figure 1.1
Medical education: a global movement
Chapter 4
Figure 4.1
Orientations on learning.
Chapter 5
Figure 5.1
Scaffolding and the ZPD
Chapter 6
Figure 6.1
Curriculum alignment.
Figure 6.2
Not just one curriculum.
Chapter 7
Figure 7.1
Example lesson plan
Figure 7.2
Sample timetable
Figure 7.3
Designing a course
Figure 7.4
The educational cycle
Chapter 8
Figure 8.1
Intersecting identities
Figure 8.2
Equality or fairness?
Chapter 9
Figure 9.1
Examples of selection processes
Figure 9.2
Anytown Mini Multiple Interview
Chapter 11
Figure 11.1
Leadership in threes. Source: McKimm
et al
., 2016.
Figure 11.2
The leadership triad
Chapter 12
Figure 12.1
Model depicting the development of an international medical educator. Source: McLean
et al
., 2014. Reproduced with permission of Taylor & Francis.
Figure 12.2
Global consensus on social accountability: ten areas for action. Source: http://healthsocialaccountability.sites.olt.ubc.ca/files/2011/06/11-06-07-GCSA-English-pdf-style.pdf (accessed Sept. 2016). Reproduced with permission of Global Consensus on Social Accountability.
Chapter 13
Figure 13.1
Lecture theatre
Figure 13.2
A bad power point slide
Figure 13.3
Example lesson plan. Source:
Essential Guide to Generic Skills.
Copyright © 2006 Nicola Cooper, Kirsty Forrest and Paul Cramp. Published by Blackwell Publishing Ltd. Reproduced with permission of Kirsty Forrest.
Chapter 14
Figure 14.1
Lectures should be stimulating
Figure 14.2
Keep focus on the audience
Figure 14.3
Student learning and interactivity. Source:
Essential Guide to Generic Skills.
Copyright © 2006 Nicola Cooper, Kirsty Forrest and Paul Cramp. Published by Blackwell Publishing Ltd. Reproduced with permission of Kirsty Forrest.
Figure 14.4
Learning pyramid. Source: The National Training Laboratories Institute (Bethel, Maine).
Chapter 15
Figure 15.1
Examples of small-group teaching
Chapter 16
Figure 16.1
Seating arrangements. Source: McKimm and Morris, 2014.
Chapter 17
Figure 17.1
Clinical teaching environments (a) Family doctor consultation (b) Bedside teaching (c) Operating theatre
Figure 17.2
PACE model of graded assertiveness
Figure 17.3
‘# hello my name is' .... see http://hellomynameis.org.uk/
Chapter 18
Figure 18.1
The Trialogue. Source: McKimm, 2008.
Figure 18.2
ISBAR
Chapter 19
Figure 19.1
Simulation
Figure 19.2
Simulation activities integrated into the learning programme. Abbrev: WPBAs, workplace-based assessments.
Chapter 20
Figure 20.1
Key to successful simulation is the scenario that is designed and delivered. Source: Forrest K, McKimm J, Edgar S (eds) (2013)
Essential Simulation in Clinical Education
. Wiley Blackwell. © Copyright NHS Yorkshire and the Humber Clinical Skills Team 2012. Reproduced with permission.
Chapter 21
Figure 21.1
Level of patient involvement. Source: Adapted from Tew
et al.,
2004.
Chapter 22
Figure 22.1
Orientation
Figure 22.2
Thinking aloud
Chapter 23
Figure 23.1
Models of consulting
Chapter 24
Figure 24.1
Example form to give to a student to observe the ‘teacher' in theatre
Figure 24.2
Role modelling
Figure 24.3
Attributes of a negative role model
Chapter 25
Figure 25.1
The four-dimensional framework for IPE. Source: Lee,
et al
., 2013. Reproduced with permission of Australia and New Zealand Association of Health Professional Educators.
Figure 25.2
Interprofessional education model. Source: Charles
et al
., 2010. Reproduced with permission of Taylor & Francis.
Chapter 26
Figure 26.1
Framework for reflection. Source: Gibbs, 1988.
Chapter 27
Figure 27.1
Clinical knowledge
Figure 27.2
Cognitive biases
Figure 27.3
Decision-making strategies
Chapter 31
Figure 31.1
Four levels of inquiry-based learning. Source: adapted from Banchi and Bell, 2008.
Chapter 32
Figure 32.1
The ‘web of support' for undergraduate students. A good support system should have multiple access points, with all recognised front-line staff trained in referral processes that direct the learner into the support system, whether the student is on clinical placement or university based. Source: Vogan
et al.,
2013.
Figure 32.2
The Swansea Six Ds Model. A framework developed at Swansea University Medical School to be used by those involved in identifying and helping students in difficulty. It provides a lens through which student difficulties can be visualised and managed by a support tutor. The complete tool (not shown) takes each of the six ‘Ds' and describes what might be going on for the student, outlines some positive and negative aspects associated with the descriptor and suggests referral and remediation strategies. Source: Vogan
et al
., 2014.
Chapter 33
Figure 33.1
Professional development framework
Figure 33.2
Employees want to know...
Chapter 34
Figure 34.1
The GROW model. Source: www.mentoringforchange.co.uk/classic/ (accessed Sept. 2016). Reproduced with permission of Dr Mike Munro Turner.
Figure 34.2
Heron's (1986) six categories of interventions
Chapter 35
Figure 35.1
The e-learning spectrum
Figure 35.2
The e-learning toolbox
Chapter 36
Figure 36.1
The seven Cs of social media
Chapter 37
Figure 37.1
Kolb's learning cycle
Figure 37.2
Johari window. Source: Luft and Ingham, 1955.
Chapter 38
Figure 38.1
Assessment for the learner
Figure 38.2
Assessment for institutions
Figure 38.3
Elements involved in a programme of assessment
Figure 38.4
An example of a postgraduate programme of assessment
Chapter 39
Figure 39.1
Example of a single best answer (SBA) question
Figure 39.2
Item analysis data following a computer marked test
Chapter 40
Figure 40.1
Schematic of an OSCE circuit
Figure 40.2
Example of a checklist-based OSCE mark sheet
Figure 40.3
Example of a domain-based OSCE mark sheet
Chapter 41
Figure 41.1
Examples of a mini-clinical exercise (mini-CEX) form
Chapter 42
Figure 42.1
Example of professional assessment blueprinting
Figure 42.2
Example (part only) of end of clinical placement assessment form
Chapter 43
Figure 43.1
Assessing using portfolios
Chapter 44
Figure 44.1
Distribution of test marks amongst 250 candidates
Figure 44.2
Using the borderline regression method for an OSCE
Chapter 45
Figure 45.1
The teacher–researcher continuum
Figure 45.2
Developing your educator practice
Figure 45.3
Academy of Medical Educators' Professional Standards Framework. Source: Reproduced with permission from AoME.
Guide
Cover
Table of Contents
Preface
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Preface
Welcome to the first edition of Medical Education at a Glance. This book was conceived as an introduction to key aspects of medical education, which would provide an accessible overview for those new to medical education or a handy summary for those more experienced. We also envisaged that it would provide a taster for medical educators who might then wish to explore the more substantial books produced by Wiley such as Understanding Medical Education (2nd edition) and Researching Medical Education.
Medical Education at a Glance will be relevant to doctors, dentists, nurses and other healthcare professionals at various levels (including students), as well as to support staff. The book is particularly appropriate for guiding medical students and doctors in training and their teachers, supervisors, mentors and trainers. It aims to inform and encourage those engaged in improving education and training. As well as the chapters written by ourselves, we have been fortunate in attracting additional contributors with huge expertise and knowledge about medical education in both the academic and clinical environments.
In the usual at a Glance style, the book is designed to summarise what are often fairly complex or substantial topics, so that readers learn some of the language and key terms while gaining a broad understanding of the topic. Given this approach, we cannot go into depth on any one area and so further reading and resources are identified for each topic for the reader to explore further. What we have aimed to do is provide an introduction to some key educational concepts as they relate to clinical practice and university-based education. We have tried to make the chapters practically focussed with examples of how concepts or approaches might be applied in practice. Each chapter (or group of chapters) is free standing, although reading the whole book will provide a good grounding in medical education theory and practice.
The book begins with an overview and introduction to medical education, its purpose, structure and predominant educational or learning theories. It also considers some of the core aspects of contemporary education including curriculum, selection, leadership and international contexts. We move on to consider approaches to learning and teaching planning and implementation in different contexts and with different groups of learners. The later chapters consider assessment and feedback in both the academic and clinical environments. A comprehensive further reading, resources and reference list concludes the book. We hope that you enjoy the book, and that it stimulates you to reflect on and develop your own educational practice and that of others.
Judy McKimm, Kirsty Forrest and Jill Thistlethwaite
Acknowledgements
We would like to acknowledge all the contributing authors who have offered different perspectives on various aspects of medical education. The book reflects our experiences over many years working with learners, teachers and patients in a range of international contexts and we would also like to acknowledge their contribution to our understanding of medical education. Finally, as ever, we'd like to thank our partners – Andy, Derek and George – for their unfailing support and patience.
About the editors
Judy McKimm
Judy's current role is Director of Strategic Educational Development and Professor of Medical Education in the College of Medicine, Swansea University. From 2011 to 2014, she was Dean of Medical Education at Swansea and before that worked in New Zealand from 2007 to 2011, at the University of Auckland and as Pro-Dean, Health and Social Care, Unitec Institute of Technology. Judy initially trained as a nurse and has an academic background in social and health sciences, education and management. She was Director of Undergraduate Medicine at Imperial College London until 2004 and led the curriculum development and implementation of a new undergraduate medical programme. In 2004–2005, as Higher Education Academy Senior Adviser, she was responsible for developing and implementing the accreditation of professional development programmes and the standards for teachers in HE. She has worked on over 60 international health workforce and education reform projects for DfID, AusAID, the World Bank and WHO in Central Asia, Portugal, Greece, Bosnia and Herzegovina, Macedonia, Australia and the Pacific. She has been a reviewer and accreditor for the GMC, QAA, the Higher Education Academy and the Academy of Medical Educators for many years and is a member of ASME Executive and Council. She is programme director for the Leadership Masters at Swansea and Director of ASME's international Educational Leadership programme. She writes and publishes widely on medical education and leadership and runs health professions' leadership and education courses and workshops internationally. Her most recent books are Global Health (with Brian Nicholson and Ann Allen), Health Care Professionalism at a Glance (with Jill Thistlethwaite), Clinical Leadership Made Easy (with Helen O'Sullivan) and the ABC of Clinical Leadership, 2nd edition (with Tim Swanwick).
Kirsty Forrest
Kirsty is Deputy Head of Medicine in the Faculty of Health Sciences and Medicine at Bond University, Australia. Prior to this she was Associate Dean, Learning and Teaching and Director of Medical Education in the Faculty of Medicine and Health Sciences Macquarie University (2013–2016). She moved from the UK where she was an Honorary Senior Lecturer at the University of Leeds (2005–2013) and Clinical Education Advisor for the Yorkshire and Humber Deanery (2009–2013). She received her medical degree from the University of Edinburgh and has specialty fellowships in anaesthesia from the UK and the Australian and New Zealand Anaesthetic Colleges, and continues to work clinically. She has a Masters in Medical Education from the University of Sheffield and has coauthored and edited a number of medical textbooks. These include: How to Teach Continuing Medical Education, Essential Guide to Acute Care, Professional Practice for Foundation Doctors – Becoming Tomorrow's Doctors, Essential Guide to Educational Supervision in Postgraduate Medical Education and Simulation in Clinical Education.
Jill Thistlethwaite
Jill Thistlethwaite is a health professional education consultant, medical adviser at NPS MedicineWise and adjunct professor at University of Technology Sydney. She received her medical degree from University College London and has since practised as a general practitioner (family doctor) in both the UK and Australia. She received her PhD on the topic of shared decision making and medical education from the University of Maastricht. For over 20 years she has worked across the continuum of health professional education at undergraduate, postgraduate and continuing professional development (CPD) levels. Her main interests are interprofessional education (IPE) and collaborative practice, professionalism and communication skills. Jill has written/coedited several books and book chapters, and has published over 90 papers in peer-reviewed journals. Her most recently published books are: Values-based Interprofessional Collaborative Practice; Health Care Professionalism at a Glance with Judy McKimm and Leading Research and Evaluation in Interprofessional Education coedited with Dawn Forman and Marion Jones. She is coeditor-in-chief of The Clinical Teacher and an associate editor of the Journal of Interprofessional Care. In 2014, she was a Fulbright Senior Scholar at the National Center for Interprofessional Practice and Education in the USA.
Contributors
Michelle McLean, Chapter 12
Professor of Medical Education and Academic lead for PBL, Bond University, Australia
Andrew Grant, Chapter 26
Practising GP and Professor and Dean of Medical Education, Swansea University Medical School, UK
Nicola Cooper, Chapter 27
Consultant Physician & Hon Clinical Associate Professor, Derby Teaching Hospitals NHS Foundation Trust, and Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham, UK
Claire Vogan, Chapter 32
Associate Professor and Director of Student Support and Guidance, Swansea University Medical School, UK
Sean Smith, Chapter 35
Systems Developer, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, UK
Sam May, Chapter 36
Lecturer in Medical Education, Swansea University Medical School, UK
Heidi Phillips, Chapter 37
Practising GP and Admissions Director for Graduate Entry Medical Programme, Swansea University Medical School, UK
Luci Etheridge, Chapters 38–41, 44
Consultant Paediatrician, St George's University Healthcare NHS Foundation Trust, and Honorary Senior Lecturer, St George's, University of London, UK
Rebecca Hodgkinson, Paediatric Registrar at Evelina London Children's Hospital, Former Chair London School of Paediatrics Trainee Committee and Former Trainee representative RCPCH Assessment Committee
Kathy Boursicot, Director, Professional Assessment Consultancy, Singapore
Part 1Overview and broad concepts
Chapters
1 What is medical education?
2 Stages of medical education
3 Evidence-guided education
4 Learning theories: paradigms and orientations
5 Learning theories and clinical practice
6 The curriculum
7 Planning and design
8 Equality, diversity and inclusivity
9 Principles of selection
10 Evaluation
11 Educational leadership
12 International perspectives
1What is medical education?
Practice points
Medical education draws from a range of disciplines to design and deliver programmes, and engage in research with a common goal of ensuring doctors are caring, competent and safe to practice
It is jointly delivered by universities and healthcare providers
Medical educators need to be aware of global trends and issues and challenges arising from both the education and healthcare sectors
Table 1.1 Issues in international higher education and health care
Issues in higher education
Issues in health care
‘Massification' (huge growth) of university-based education
Demand for healthcare practitioners outstripping supply
Impact of learning technologies (e.g. simulation, mobile learning)
Impact of technologies (e.g. remote monitoring of conditions, telemedicine)
Student/learner expectations
Patient expectations
Cost of delivery
Workforce maldistribution
Preparing for employability in a changing, global environment
Increase in non-communicable disease, pandemics, antimicrobial resistance
Internationalisation – threats from the global market
Community/primary care emphasis
Equality and diversity of staff and students, including unequal access and outcomes
Inequalities of health access and outcome within and between countries
Regulation and quality control of education
Environmental threats
Figure 1.1 Medical education: a global movement
Medical education is ‘the process of teaching, learning and training of students with an ongoing integration of knowledge, experience, skills, qualities, responsibility and values which qualify an individual to practice medicine. It is divided into undergraduate, postgraduate and continuing medical education, but increasingly there is a focus on the “lifelong” nature of medical education.' (IIME, 2016).
Medical education has evolved over the last century to become a discrete educational field of study, which has shaped not only the way doctors are educated and trained but has also influenced wider education. Prior to the Flexner Report (Flexner, 1910), medical education was undertaken on an apprenticeship model, and it was usually the most privileged and wealthy who had access to such training. The Flexner Report recommended that the American and Canadian medical school system be transformed to one which provided university education in the basic medical sciences and also trained students in the workplace to be practising clinicians. Since then, around the world, basic (undergraduate or prequalifying) medical education has moved into universities, and medical education at all stages has become ever more tightly controlled and regulated.
Professionals who are involved in the education of students, doctors in training and qualified practitioners are termed medical educators. Medical educators come from a range of backgrounds: education, other health professions and the social and behavioural sciences, as well as from the biomedical sciences and medical specialties (i.e. practising clinicians). Doctors' world views and paradigms have traditionally reflected positivism, the scientific method and the pragmatism of the real world. This is both a strength and a weakness: a strength in that it can bring scientific rigour to research, and engagement in everyday clinical practice brings authenticity to teaching, learning and practice-based research; a weakness in that ‘medical education is about people and the way we think, act and interact in the world. Medical education research is not a poor relation of medical research; it belongs to a different family altogether' (Monrouxe and Rees, 2009, p. 198).
Currently, a range of approaches in medical education practice and research exists – from social, behavioural and management sciences, and the humanities as well as from more traditional disciplines. This has led to a richness and diversity of activities and outcomes, which utilise different approaches from other subject disciplines (particularly school and adult education) to explore what works, why and how? in the real world. For example, situational, experiential and outcomes-based education are derived from general education; and patient safety and simulation education was extended and adapted from work done in the airline and nuclear industry. And the ‘taken for granted' role of reflection in developing medical professionals drew heavily on Schön's (a philosopher) work on learning organisations and the reflective practitioner (e.g. Schön, 1987). See later chapters.
Medical education also gives back to the wider education and health community through specific educational strategies and social accountability initiatives: the social good of Tan et al. (2011). For example, problem-based learning (PBL), developed at McMaster University, Canada in the 1960s, is now used in many educational sectors and the objective structured clinical examination or OSCE (Harden and Gleeson, 1979) is now widely used in veterinary and health professions' education.
Professional education and training
The first professions established were medicine, divinity and law, and medical doctors continue to have a very privileged position in society. It is partly because of the high status of medicine that medical education is somewhat set apart from the education and training of other health professionals. Medical schools often operate semiautonomously, have relatively high power, utilise different funding streams and offer higher rates of remuneration for their clinical teachers than other disciplines (Swanwick, 2014). At postgraduate level, doctors have one of the longest training periods of any professional before they are deemed fit for independent practice, typically overseen by specially established postgraduate colleges.
Despite these differences, medical schools have to abide by the rules and regulations of the universities in which they reside in order to be able to award medical degrees. Programme approval and quality assurance mechanisms operate in exactly the same way for medical programmes as they do for any other programme. Medical education and training (and the activities of individual doctors) is subject to regulation from regulatory and professional bodies (e.g. medical councils), just as other health and social care professions are. Basic medical education and training (just as in undergraduate nursing, social work or physiotherapy programmes) is delivered both in the workplace and the university, with the involvement of practitioners and others not directly employed by the university.
Current concerns and issues
Many of the concerns in medical education are those experienced by all higher education and health organisations (Table 1.1). Medical education needs to take account not only of educational concerns and issues, but also those affecting the health services in which the training and education are carried out. At the heart of medical education is the need to produce and maintain safe, competent, caring doctors, so patient safety and fitness to practice issues are high on the agenda. Simulation and the use of computer-based and mobile learning technologies are helping to prepare learners for clinical practice, although they can never compensate for learning from real patients, their families and communities. Changes in health structures and systems, the impact of technologies resulting in shorter inpatients' stays and consequent limitations on clinical placements have huge impact on the type and quality of clinical education that can be provided.
Both health care and education are now global industries and, in many countries the numbers of student places in programmes are capped. Due to these factors, as well as universities becoming more entrepreneurial, many medical schools are seeking other ways (including developing collaborations with overseas partners) to expand student numbers. The expanding knowledge base in medicine and consequent curriculum pressures are leading educators to explore different curricular models as they prepare students and doctors for 21st century practice (Lueddeke, 2012) (see Chapter 6). The internationalisation of medical educators is reflected in the way individuals, groups and organisations collaborate and share practice and ideas around the world. Whilst this rich diversity of perspectives may lead to debate and disagreement about the right way to do things, all medical educators share a common purpose: to provide medical education that leads to those who engage in it striving to provide the best health care to the patients and communities they serve.
2Stages of medical education
Practice points
Broadly, four distinct stages exist in medical education and training:
Basic medical education – delivered by universities in collaboration with health providers
Early postgraduate or internship, where the newly qualified doctor works under close supervision
Specialist postgraduate training, where the doctor trains for a particular specialty or career
Continuing professional development and updating
Table 2.1 The four stages of medical education
Stage
Who is involved
Key features
Years (approx.)
Basic medical education
Medical students
This is a university-based ‘medical degree'
Students enter after secondary school (undergraduates) or after another degree (graduate entry)
4–7
Early postgraduate
Doctors in training e.g. Junior Doctor, Foundation Doctor, Intern
Early career doctors, retain generalist roles
Under direct supervision
Geared towards achieving defined competencies
1–2
Postgraduate
specialty
Doctors in training, e.g. Resident, Registrar
Training for a particular specialty/career, e.g. a ‘surgeon' or a ‘psychiatrist' and/or on academic/teaching/research pathways
Working under supervision to a defined curriculum and competencies
Involved in training juniors and students
4+
Continuing Professional Development (CPD)
Continuing Medical Education (CME)
All practising, registered doctors
Maintaining, updating, diversifying, subspecialising
Often linked to formal appraisal, relicensing and revalidating processes
Ongoing – the rest of your career
Source: adapted from McKimm et al., 2013.
The stages of medical education comprise basic (undergraduate) medical education, postgraduate medical education (including vocational training, specialist training, and research doctoral education), continuing medical education (CME) and the continuing professional development (CPD) of medical doctors (WFME, 2016).
Basic medical education
Basic or undergraduate medical education refers to the period that begins when a student enters medical school and ends with the final examination for basic medical qualification. In some countries, however, undergraduate education refers to pre-medical college education, which results in a Bachelor's degree and is the training students receive before entering medical school.
Basic medical education is usually provided by universities, whose programmes are accredited by a regulatory body (such as a medical council). Accreditation is a quality assurance process that aims to evaluate educational and training institutions, programmes and practices to determine whether applicable (i.e. national and/or international) standards are met. Increasingly, undergraduate programme accreditation is tied to the regulation and licensing of health professionals, most commonly to initial licensing and registration.
Successful completion of medical programmes leads graduates to professional registration and entry into postgraduate training. Many programmes also include opportunities for additional full-time study leading to an intercalated degree, such as a BSc, Masters or PhD in a related science or social science.
Worldwide, two main curriculum models for basic medical education exist, although within these a variety of educational offerings are provided:
traditional undergraduate programme
, lasting 5–7 years, primarily for school leavers;
graduate entry programmes
, lasting 4–5 years for graduates with a prior university degree or qualified health professionals. Students on these programmes are also referred to as medical students and can leave with further Bachelors', or more frequently Masters' qualifications. The Masters' degrees often include a strong element of research training.
The latter, most notably in Australia, North America and Europe, are new professional degrees based on the broad-based undergraduate degrees. The rationale behind such shifts was in response to international changes, such as the Bologna Agreement (European Commission, 2015), which aims to streamline and align all higher education programmes and levels in the EU. See Chapter 6 for further description of curriculum models.
Postgraduate training
Internationally, effective postgraduate education is highly structured with clear definition of standards, outcomes and competencies delivered by trained supervisors and measured by a wide range of assessments, as described in Chapters 38–44.
In many low and middle income countries (LMICs), however, whilst basic medical education may be offered, it is at postgraduate level, and in particular in speciality training, that more development is needed. In some areas this has been addressed at regional level through defining standards and sharing resources. Reciprocal agreements exist between councils of some countries to facilitate the movement of individual doctors, whereas between others additional examinations or evidence has to be provided. Most countries have provision for employing doctors who are non-specialists
Academic training
Many countries offer specific programmes for doctors who wish to combine their medical training with research, education or leadership/management development. The most common programmes focus on clinical or laboratory-based research, typically giving opportunities for doctors in training to step out of clinical training for a period of time or to extend their training whilst studying for a doctorate or master's degree alongside clinical practice.
Internship
While differences exist between countries as to the structure and length of medical education, most require new medical graduates to undertake a period of supervised practice (typically 1 or 2 years) often with a limited scope of registration. This period of internship is typically structured around clinical placements in a small range of core clinical specialties: medicine, surgery and primary care. Because doctors also need skills in assessing and managing patients with acute, undifferentiated presentation, many internship programmes also include an emergency medicine rotation. Other rotations are highly variable between programmes and jurisdictions, and may include paediatrics, reproductive health, mental health and community placements. Progression from internship normally requires satisfactory completion of formal assessments, often with a strong emphasis on workplace-based assessment, but some include written assessment.
In the US however, the majority of graduates from medical school progress into residency speciality training programmes. This initially reflected that American students were graduate entrants in medical school and therefore already more mature, and traditionally the students had a higher level of patient contact and management exposure prior to graduation.
Speciality training
Specialty training is where doctors become a specific ‘type' of doctor, such as surgeon, psychiatrist or ‘general practitioner' (GP, family doctor). The length of speciality training ranges from 3 to 10 years depending on the specialty and country/region. In high income countries (e.g. Canada, UK, US) around 60 specialities and subspecialties exist. In LMICs, the number of subspecialties tends to be much lower because health services are less specialised, there are fewer qualified specialists and subsequently a lack of training posts. In order to address this, agreements with other countries have been established to train doctors in required specialties (e.g. surgery, family medicine), who then return to their home country to practise. As in undergraduate education, specialty training may also have a focus on acquiring knowledge and skills that will enable the practitioner to function at an advanced level in rural, remote or relatively under-resourced settings.
Each specialty generally has its own set of national educational standards and assessments, administered by a professional body that is distinct from the overall medical regulator (and may also be distinct from providers of undergraduate education, e.g. professional boards or medical colleges). Specialty training posts are often strictly controlled at national level, tied to workforce planning and the future needs of the healthcare system. Once a doctor has undergone the relevant clinical experience and passed examinations, they become eligible for the specialist register and can gain a post as a consultant or specialist. Hodges and others have critiqued the ‘time-served' apprenticeship model of training, suggesting that moving towards competency-based and more tailored personalised training may be more appropriate to address individuals' different rates of learning and experience (Hodges and Lingard, 2012).
Continuing professional development
Once qualified and registered in their field, most countries require doctors to engage in (and be able to evidence) a commitment to education throughout their career in the form of continuing professional development (CPD) or medical education (CME). The main purpose of CPD is for doctors to keep up to date with evolving knowledge and procedures, and to ensure safe practice. Engagement in CPD is typically through participation in small, accredited training/educational courses that are assigned ‘points' or ‘credits'. The number of credits is broadly correlated with the time taken to complete the activity. Increasingly, evidence of CPD participation is a requirement for relicensing (or revalidation). Relicensing is typically undertaken on a 3 to 5-year cycle. It sometimes involves examinations but generally is carried out using a portfolio of evidence.
3Evidence-guided education
Practice points
Ideally, education should be developed and delivered and guided by evidence
There is a need for good-quality evidence to inform medical education
An increasing number of good-quality systematic and narrative reviews are being published
Table 3.1 Comparison between methodologies
Qualitative
Quantitative
Mixed methods
Assumptions
Constructivist
Interpretive
Inductive
Positivist
Deductive
Pragmatist
Research questions
Exploratory
Broad
Seek understanding
Describe
Provide insights
Specific
Narrow
Hypothetical
Test theories
Determine
Relate
Cause
Significance
Inquiry approaches
Grounded theory
Phenomenology
Ethnography
Case studies
Narrative
Surveys
Experiments
Numerical data analysis
Mix
Data collection
Unstructured/semistructured interviews
Focus groups
Open-ended questions
Texts
Observation
Structured interviews
Closed questions
Numbers
Online polls
Randomised controlled trials
Mix of both, e.g. either: quantitative first to define interview topic; or qualitative first to define survey questions
Data analysis
Thematic
Discourse
Statistical tests
Considerations
Less generalisable
Trustworthiness
Reflexivity
Validity
Reliability
Confounding variables
Source: adapted from Creswell, 2009.
Box 3.1 Interviews
Structured:
questions and areas to explore are set prior to the interview. They are explored in order. Less commonly used in qualitative approaches.
Semistructured:
