Learning and Teaching
last authored: July 2011, David LaPierre
Introduction
Knowing how to learn effectively is fundamental to success in becoming a health care professional, and likewise, knowing how to teach is critical in raising new generations of colleagues.
SharingInHealth's model is to have preclinical material learned under the guidance of trained tutors who have some clinical experience, but not necessarily are working as licensed practitioners. As training progresses, training will be more and more under the supervision of clinicians who are providing care and teaching at the same time.
While teaching is a part of the culture of medical practice - Hippocrates wrote almost 2500 years ago that the duty of the physician is "to teach them the art if they want to learn it, without fee or indenture", we feel is extremely important to adequately prepare, and compensate, clinical teachers for their efforts. While compensation is not addressed here, this page has extensive information on practical advice for both learners and teachers. Resources are applicable for both learners and teachers, as we all play both roles during our training, practice, and lives.
The SiH Model
We are focused on competency-based approaches for learning and teaching. Different approaches are needed at pre-clinical vs clinical levels, and both tools and training (ie learner and faculty development) are required.
Feedback is designed to improve competency. It should be received at least weekly, but ideally daily. Evaluation, on the other hand, is used for advancement and awards. This is typically carried out mid-unit and at the end of the unit, however unit may be defined.
What Is Learning?
Learning is the process of getting information - both cognitive and procedural - into storage. Learning may occur in various settings: clinical (skills and behaviours), education (teaching, supervision), administration (committees, leadership roles, etc), and research.
Learning may be formal (process is primarily controlled by tutors), informal (unplanned, opportunistic), or self-directed. Effective learning brings the student into a place of uncertainty, leaves them there for a while, and then leads them to closure and consolidation.
Small-Group Learning
Small group learning may occur at various levels, from high school through to continuing education. There are many educational paradigms for small group learning, which may also be called case-based learning or problem-based learning. There is variation in how much preparation learners have done before presented with the case, and how many resources they have discovered beforehand.
The SiH model has learners primed with background information that is relevant to the case, ensuring content foundations are present. This foundation is built upon through the case through discussion, critical thinking, role play, and simulation.
Learners as Teachers
Near-peer teaching is very effective (ten Cate and Durning, 2007, Secomb 2008). Learners need to know how to teach as we raise up new generations of educators. Learners often spend a significant proportion of time teaching, enjoy it, and feel they benefit themselves. Teaching allows senior learners to hone their approach to a problem, increase their knowledge, and make this knowledge explicit.
Senior learners are closer to the junior, have more time and opportunity for direct observation, are seen as less threatening, and are often ranked higher than faculty by medical students.
For more information, see learning in small group cases.
Clinical Learning
The following are described further in the links:
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Task: what to do, for how long Attending role: when and how to reconnect Patient: chief complaint, other important issues Product: what is expected of learner at end |
Get commitment Question for reasoning Take-home points What went well? Correct errors |
Summarize history and exam Narrow differential Analyze differential Probe the preceptor Plan management Select issue for further learning |
Feedback
Feedback quick notes
- Continue to...
- Start, or do more of...
- Consider...
- Stop, or do less of...
Feedback is the presentation of information designed to improve a learner's awareness of their performance, including positive and negative aspects. It should build the learner up and motivate them to continually strengthen their practice. More on feedback is given here.
Tracking Learning
It is important to be deliberate in designing and tracking the learning journey. Tools such as learning portfolios or dossiers are widely used. SiH terms this tool a 'competency tracker', and a parallel project is underway to design such a tool.
It is important for teachers to be involved in the learning process, and to help learners embrace gaps and identify the most important next steps. It is also crucial to organize and save pertinent strategies the learner may use to fill in their knowledge gaps.
The following is to sort and integrate where appropriate
Specific Learning Objectives are
- Specific: focus on knowledge or skill
- Measurable: establish and outcome
- Attainable:
- Realistic: link to specific patients
- Timely: consider demands (call, etc)
Challenges
Challenges include:
- defining teaching
- time constraints
- varied level of interest
- different levels of learner
- sufficient knowledge?
Common problems include:
- lack of clear objectives and expectations
- focus on recall, rather than problem-solving skills and other higher level competencies
- teaching aimed too high
- passive observation on the part of the students
- inadequate supervision and feedback
- little opportunity to reflect and discuss
- teaching by humiliation
- informed consent not sought by patients
- lack of respect for patients' privacy and dignity
- lack of concordance with rest of curriculum
An introductory learner will be dependent, requiring an authority role as teacher. As the learner becomes interested, the teacher shifts to motivating and facilitating. Finally, as the learner becomes self-difected, the teacher steps back and delegates tasks to the learner.
Set
What do you want to accomplish?
What is the learner's motivation?
Is the topic relevant, with well-understood importance?
Setting Objectives
Objectives should be linked with evaluations, and with what the learner is doing right now.
The junoirs should be actively equipped to influence the outcome, with ongoing feedback.
How much time do you have?
Set conditions under which the task will be learned and performed.
Make clear the criteria for evaluation.
Body
Closure
Leave learners with a sense of accomplishment and summarize.
Give them a chance to reflect on the task and their performance.
Role Modeling
Very important.
Learning styles
Prepare, practice, reflect, feedback (a circle)
some like to start at prepare, others at practice. How to allow for both? Build this into a learning portfolio.
Kolb's Learning Styles
Experiental learning
measures how we perceive and how we process
Question 1: do you learn best when you're immersed in an exeperience, or would you rather have someone give you a heads-up?
Question 2: after you've been learning, do you prefer to think and reflect, or to start applying new knowledge?
accomodators
preferred learning methods:
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Divergers: imaginative, creative
preferred learning methods:
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convergers
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assimilators
preferred learning methods:
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active experimentation (doing), concrete experience (sensing, feeling), reflective observation, (watching, pondering), abstract conceptualization (thinking)
Giving Effective Explanations
Check undserstanding before you start, and periodically summarize and reassess. Asking the learner to summarize is powerful. Provide bite-zied chunks. Provide context as possible. Repeat take-home messages.
Life-Long Learning
Adults are independent and self-directed. They have a great deal of experience from which to draw lessons and are reflective. Learning ideally integrates with the rest of a busy life, with context of specific problems. It can be helpful to explicitly define these.
Adults tend to be interested in immediate problem-centred approaches, though are motivated by internal drives, rather than external ones.
Adults need to be actively involved and usually learn by doing.
Unknown unknowns are critical.
Health care professionals will demonstrate ongoing, reflective learning, as well as the creation, sharing, and translated of medical knowledge.
Adult learning must be fostered in a climate of safety and freedom to experiment (dlp: simulations). Early successes are important to build confidence.
Learners should also be actively involved in the planning and unfolding of curriculum, ideally suited for their specific needs. This frequently requires diagnosis.
Learners should be assisted to identify resources and strategies that work specifically for them.
Learners should also be supported in carrying out their learning plans, with collective evaluation culminating from ongoing feedback.
Staying on top of literature
Create a system that alerts you to relevant horizons and innovations, evidence-based guidelines, and dangerous discoveries.
Get tables of contents for top 4-5 journals emailed to you. Make things as automatic as possible. Push as much as possible to email. While people may choose according to their interests, these can include:
- JAMA
- Lancet
- British Medical Journal
- New England Journal of Medicine
Coppus, 2007. New publications daily.
Neuropsychobiology of Learning
Associative learning includes both operant and classical conditioning.
Nonassociative learning includes habituation and sensitization.
Cellular Learning
Learning happens primarily at the level of the synapse, either by changes in synaptic strength (neurotransmitter release or postsynaptic responsiveness) or by formation of new synapses
Habituation
habituation is a decrease in response to repeated stimuli. It appears mediated by a block in presynaptic calcium release.
Sensitization
sensitization occurs via a block in presynaptic potassium channels, prolonging the action potential and resulting in greater neurotransmitter releases
Learning and emotion
Mood-congruent learning.
What motivates people to learn? Fear and shame are unfortunately still very common.
Additional Resources
Practical Prof - clinicial preceptor advice from Alberta
http://reviewing.co.uk/
ten Cate O, Durning S. 2007. Peer teaching in medical education: twelve reasons to move from theory to practice. Med Teach. 29(6):591-9.
Secomb J. 2008. A systematic review of peer teaching and learning in clinical education. J Clin Nurs. 17(6):703-16
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