FAMILY MEDICINE EDUCATION IN ASIA PACIFIC REGION

 

WORKSHOP PROCEEDINGS

 

 

 

Clinical Teaching

 

 

1995

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

New Century Hotel

Taipa, Macau

June 15- 17, 1995

 

Jointly organised by

WONCA Asia Pacific Working Party and

Associacao dos Medicos de  Clinica Geral  de Macau

 

 

 

Host

Associacao dos Medicos de  Clinica Geral  de Macau

WONCA

ASIA PACIFIC

WORKING PARTY

WORKSHOP 1995

 

 

 

 

 

 

 

PROCEEDINGS ON WORKSHOP 2:

FAMILY MEDICINE EDUCATION IN ASIA PACIFIC:  CLINICAL TEACHING

 

 

 

 

 

 

 

 

 

 

 

JUNE 15-17, 1995

New Century Hotel

Taipa, Macau

 

 

 

 

 

 

Host Organization:

Associacao dos Medicos de  Clinica Geral  de Macau

 

 

 

 

 

 

 

 

 

TABLE OF CONTENTS

 

FOREWORD                    

 

   Dr Lindsey Knight

 

   Convenor

 

   WONCA Asia Pacific Working Party

 

 

 

PREFACE

 

    Dr Zorayda E.Leopando, M.D.

 

    WONCA Regional Vice-President  for Asia Pacific

 

 

 

ORGANIZING COMMITTEE  AND EDITORIAL BOARD

 

 

 

EXECUTIVE SUMMARY

 

PLENARY PAPERS

 

 

 

 The Family Medicine Clinical Teacher

 

  Prof Wesley E. Fabb

 

 

 

Educational Planning in Clinical Teaching

 

A/Prof Goh Lee Gan

 

 

 

Assessing Clinical Performance in Family Medicine

 

Dr Neil Spike

 

 

 

WORKSHOP RESULTS

 

 

 

1.   Assessing Learner’s Needs  for  Developing Learning Plans

 

 

 

2.  Clinical Teaching Skills: The Consultation

 

 

 

3.  Clinical Teaching Skills:  Small Group Teaching

 

 

 

4.  Clinical Teaching Skills: Clarifying and Fostering Learning

 

 

 

 

 

CONCLUSION AND RECOMMENDATIONS

 

 

 

BACKGROUND PAPERS

 

 

 

Faculty  Development Program in Family Medicine for Asia Pacific

 

 

 

Course Proposal and Program

 

 

 

Course Report

 

 

 

LIST OF PARTICIPANTS

 

 

 

 

 

ORGANIZING COMMITTEE

 

PROJECT DIRECTOR:  A/Prof Zorayda E. Leopando

DEPUTY DIRECTOR:  A/Prof Goh Lee Gan

 

Host Organizing Committee

 

Over-all Chair:                     Dr Jorge Leitao Pereira

   Secretary :  Dr Carlos Canhota

Treasurer:  Dr Chau Chi Hong

Facilities Coordinator:  Dr Tito Lopes

Members:

Dr Chan Im Kuan

Dr Cheang Seng Ip

Dr Fong Hou Meng

Dr Irma Almeida

Dr Jose Baptista Pereira

Dr Kun Sai Hoi

Dr Maria August Drago

Dr Maria Dillard Fonseca

 

ADVISERS: 

 

   Prof  Wesley Fabb

    Chief Executive Officer, WONCA

 

        Dr  Eddie T. Chan

    Regional Vice-President for Asia Pacific, WONCA

 

        Dr Lindsey Knight

    Convenor,  WONCA Asia   Pacific Working Party

 

 

EDITORIAL BOARD FOR THE PROCEEDINGS

 

A/Prof  Zorayda E. Leopando

A/Prof Goh Lee Gan

Prof John Richards

Dr  Jorge Leitao Pereira

Dr  Carlos Canhota

 

Editorial Consultants

 Prof Wesley Fabb

Dr Lindsey Knight

 

PREFACE

 

            Teacher training in Family Medicine is a priority project in the Asia Pacific Region. This is a  need identified by most of the WONCA member organizations. 

 

Standards and levels of development of Family Medicine Education in the region vary from country to country. This is due to the fact that Family Medicine has variety in its time of existence.  Thus,  you will find that the level of participation from various member organizations vary. Some countries send lecturers and facilitators while others come as workshop participants.  Others contribute various resources.  Teacher training activity in the region is a cooperative endeavor.

 

The Workshop on Clinical Teaching held in Macau on June 15-17, 1995 was another  resounding  success.  The spirit of sharing was very evident in the 4 workshops held and in the plenary  sessions  too.  Discussions were lively and productive,  as  you will see when you read the proceedings. 

 

These Proceedings are again intended not only to record the workshop but as a learning tool for teachers in Family Medicine. This is a follow-up to the Manila proceedings “ A  Workshop on Core Curriculum”  which the region produced in 1993.   The document covers the “How’s and Why’s” in teaching and learning.   

 

I would like to express my deepest appreciation to the following who have made the workshop and these  proceedings  a success:.

 

·        The Organizing Committee from Macau led by Jorge,  Carlos and  Tito -- your  efficiency and warm hospitality is  incomparable.  You really  made our stay in Macau memorable.

 

·        The sponsors of the activity :  Astra HK,  Banco Comercial de Macau,  Camara Municipal das Ilhas,  Direccao dos Servicos de Turismo de Macau,  Dr Edmund      Ho , Fundacao Oriente,   Leal Senado  de Macau,  Sociedade de Turismo  e Diversoes de  Macau. Thank  you for the support you have given  which has contributed greatly to the success of the session.

 

·        To Wes,  my predecessor  Eddie and   my  working  team  Lee Gan -- thank you for  all the effort you have put  into this program. Preparing   for this activity covered  2 years and  5 countries.  The planning meetings we had    although  hectic  were enjoyable.  

 

·        To all the participants,  thank you for your active involvement.

 

·        To the Editorial Board,  thank you for your patience and contribution.

 

Zorayda  E. Leopando, M.D.

Project Director

Regional Vice President of WONCA for Asia Pacific      

1996   


PLENARY PAPERS (1)

 

THE FAMILY MEDICINE CLINICAL TEACHER

Professor Wesley E. Fabb

 


INTRODUCTION

 

A Family Medicine teacher is a role model, motivator, knowledge and skill disseminator, assessor and researcher.

 

 

ROLE MODEL

 

Role modeling is the most important thing that teachers do.  We do it all the time. No matter what we are doing, whether good or bad, the trainees are watching every move we make.

 

There are four important aspects of role modeling: embodiment of values, exemplar of attitudes, champion of standards, and demonstrator of process.

 

Embodiment of values 

 

The teacher is an embodiment of values. There are many examples.

 

One of these is being a caring and nurturing person. To be such a person, we must learn to value people. We must be patient centered.

 

We must be focused on the doctor-patient relationship.    We value this most important relationship - between our patients and ourselves.  However, we cannot deal with just the patient, we need to think of the family to which the patient belongs because the family is a very important determinant of health and illness.  The sick person is influenced by the family and vice versa.

 

We must value community data (cultural, economic).  We need to be community minded.

 

We value contextual information (family, community and work).

 

We value continuity of care; we keep records. We value comprehensive care; we are available and accessible.

 

--------------------------------

Professor of Family Medicine, Department of Family and Community Medicine, Chinese University of Hong Kong; Chief Executive Officer, World Organization of Family Doctors

Exemplar of attitudes

 

The attitudes we exhibit are really important.  

 

To students, we need to be positively helpful.  We need to build their esteem.  We should not put down, but rather, we should build up.  One of the big problems of today is that many people have lost their self-esteem.    We must behave congruently.  Whatever we do, we must be consistent.  We must exhibit awareness, openness, and genuineness.

 

To patients, we need to avoid negative stereotypes such as: being unapproachable, being domineering, being condescending and adopting a ‘know-all’ attitude. Patients are much better at reading the doctor than we are at reading the patients.  They are very sensitive in picking up anything that is disparaging or negative coming from doctors.

 

 

 Champion of standards

 

The teacher is a champion of standards. He defines criteria (What things are important?) and sets standards (What quality is acceptable?).  He helps his students to achieve these standards.

 

 

Demonstrator of process

 

The teacher is a demonstrator of process.  He shows how, explains why, and reflects on an action that has been taken.

 

 

MOTIVATOR

 

The teacher is a motivator. He inspires by example, excites by challenge, challenges with questions, and he promotes reflection

 

 

KNOWLEDGE AND SKILLS DISSEMINATOR

 

The teacher is a knowledge and skills disseminator. In this context, he disseminates concepts, principles, guidelines and rules of thumb, essential facts, and essential skills.

 

 

There are several tasks that the teacher undertakes as a knowledge and skills disseminator. He:

 

·         exudes enthusiasm (in this way he get the attention of his students all the time and this facilitates learning),

·         focuses attention to important areas of the subject and areas that are likely to be problematic to comprehend,

·         set objectives for the learning task,

·         checks prior learning,

·         tries to make learning meaningful and memorable,

·         Facilitates encoding /recall of information so that he student is able to retrieve when this is needed,

·         assesses learning.

 

The main purpose of learning is to be able to get the information from memory when this is required later.   In other words, if one learns something and it disappears into a black hole, it is no use. 

 

The teacher facilitates encoding /recall of information so that the student is able to retrieve it when this is needed. One way is through the use of mnemonics. The idea behind mnemonics is to inject sense into apparently senseless material. For example, the mnemonic  “Ten zebras beat my cow “ makes remembering the branches of the facial nerve memorable.  It stands for temporal, zygomatic, buccal, mandibular and cervical branches.

 

Another way of helping the student learn is to get the student to go beyond “what is it?” to think about “how” and “why”, to relate the new information to his existing knowledge and to use the new information as often as possible.

 

Explicit categorisation of the subject helps the student store information. For example, we can categorise the learning of a medical condition as the presenting symptoms, differential diagnosis, impor-
tant physical signs, relevant investigations and

management. The latter can be categorised further into specific treatment, symptomatic treatment, supportive treatment, and indications for referral and follow-up care.  Explicit categorisation is also helpful in patient education.

 

 

 

ASSESSOR

 

The teacher is also an assessor. He

 

·         establishes what to assess

·         determines how this is to be done

·         designs valid assessment tools

·         reliably assesses the student, and

·         gives constructive feedback.

 

 

RESEARCHER

 

The teacher is also a researcher. The activity of research has been labelled as “organised curiosity”. 

 

The teacher is a “reflective doctor”.  He

 

·         asks pertinent questions like “why?”,   because it will keep students thinking all the time,

·         formulates plausible hypothesis,

·          designs sound research,

·         collects data reliably,

·         analyzes data validly  through the use of  the  right  methods  of analysis,

·          draws conclusions fairly.

 

 

CONCLUSION

 

To be a family medicine clinical teacher is a challenging job. It is also a rewarding one. In the process of teaching, one teaches oneself to be a better teacher and a better doctor too. ¨

PLENARY PAPERS (2)

 

EDUCATIONAL PLANNING IN CLINICAL TEACHING

Assoc Prof  Goh Lee Gan

 


DEFINITIONS

 

Educational planning may be defined as planning of learned experiences that the trainer wishes the learner to be exposed to achieve learning goals.  Educational planning (syn. Curriculum planning) puts the syllabus into operation. Curriculum is the combination of methods and the syllabus.

 

INTRODUCTION

 

Educational planning can be looked upon as trying to help the learner arrive at an intellectual or skill destination. The logical questions to ask then are: “Whre are you now and where do you want to go?” (aims and objectives); How are you getting there? (the methods of learning), and “How do you know you have arrived? (assessement).

 

“Where are you now?” is an important starting point because the postgraduate doctor, unlike the undergraduate doctor does not start with a clean mental slate.  The clinical teacher needs to plan the learning experience to continue from what he already knows.

 

 

THE LEARNER

 

To be effective, educational planning needs to be adult learner oriented.  The need to establish what the learner already knows has been mentioned. The other principles of adult learning are described below:

 

·         Adults come to learning situations with a variety of motivations and expectations.  Check these out.

 

---------------------

Head, Division of Family Medicine, Department of Community, Occupational and Family Medicine; National University of Singapore

 

·         Adult learning often involves relearning rather than new learning.  Respect their previous knowledge and motivation to learn.   It is necessary to bring enthusiasm and to recognize that there is a possibility of resistance to change.

 

·         Adults prefer problem solving to didactic teaching. A lot of resources come from each of us. 

 

·         Adult learners can serve as co-teachers.   Do not overlook the potential of peer teaching.

 

·         Feedback is more important than tests and formal evaluation.

 

 

THE LOGICAL LINKS OF EDUCATIONAL PLANNING

 

Planning forges the logical links between

·         intentions (objectives),

·         methods (teaching and learning activities) and

·         assessment of student learning.

 

The educational planner has to define the intentions, the methods of learning and teaching, and the type of assessment to be done on the learning that has taken place.

 

DEFINING LEARNING OBJECTIVES

 

There are three domains of objectives:

·         Knowledge (cognitive)

·         Skills (psychomotor)

·         Attitude (affective)

 

Knowledge objective

 

An example of knowledge objective is: Be able to identify benign and malignant skin lesions.

 

Three subgroups of knowledge objectives may be recognised: ability to recall information, understand and apply knowledge, and solve problems.

 

Skills objective

 

In clinical learning, the student is taught to look at the case from a problem-solving point of view. Clinical teachers are often given some fixed topics to cover.  But very often, he can teach anything he wants by concentrating on problem solving skills.

 

An example of skills objective is: Be able to establish why the patient came.  

 

Skills objective can also be stated in the standard of performance required:

-     very qualified or very competent,

-     familiar with or competent, and

-     awareness.

 

Skills objective can also be stated as:

-     able to perform,

-     able to  interpret,

-     have observed.

 

Attitude objective

 

An attitude objective is more abstract. One example is: Be able to demonstrate willingness to be critically evaluated by peers.

 

Figure 1.  An example of skills learning objectives

 

Clinical consultation skills

 

At the end of the course, the participant must be able :

·          to take a comprehensive history

·          to perform a complete physical examination

·          to draw up a problem list

·          to gather information that he/she needs

·          To relate to the patient and make sure that resources have been used to the best advantage.

 

 

DEFINING LEARNING AND TEACHING ACTIVITIES

 

The scope of learning and teaching activities is wide. They are shown in Figure 2.

 

Figure 2. Scope of Learning and Teaching Activities

One to one

Case discussion

 

Topic discussion

 

Random case analysis

 

Direct observation

 

Small group

Case discussion

(10-15 members)

Topic discussion

 

Problem solving

 

Portfolio learning

 

Gaming

 

Workshop

Discussion

 

Problem solving

 Brainstorming

Buzz groups

Role play

 

 

DEFINING ASSESSMENT

 

It is important to relate assessment to objectives. 

 

There are two forms of assessment.

·         Formative --- giving feedback

·         Summative - grading competence

 

Assessment drives what is learnt and how it contributes to the study.

 

 

OTHER EDUCATIONAL PLANNING CONSIDERATIONS    

 

 

Sequencing 

 

Sequencing in the context of medical education is the order the objectives of learning are organised.

 

Principles to be observed in sequencing are:

·         a logical or historical development of the subject

·         emphasizing important themes or concepts

·         proceeding from what students know to what they do not know

·         proceeding from concrete experience to abstract reasoning

·         starting from unusual,  novel  and complex situations  and working backwards towards understanding

 

 

Course co-ordination and administration

 

This is an important part of educational planning.  The activities of various teachers need to be co-ordinated such that there is minimal overlap of the topic. The speakers need to be told the teaching requirements to be fulfilled.

 

 

Allocation of time

 

Time tabling is very important. The time allocated must be sufficient. For a presentation of a topic, 20 minutes is a good time allocation unit.  For a workshop with a report back activity, one hour or an hour and a half may be needed.

 

Allocation of teaching rooms, clinics, laboratories and equipment

 

If there are workshops, “break out” rooms for small group discussion will be needed.  For clinical teaching in the consultation room, the allocation will be one to two learners to a room.

 

Technical and administrative support

 

Where audio-visual equipment is needed, technical staff must be considered unless the trainer is able to operate it. Clerical staff may be needed to register learners at the beginning of a course.

 

Provide good teaching environment

 

A quiet environment is needed.

 

EDUCATIONAL PLANNING IN THE CONTEXT OF CLINICAL TEACHING

 

How to improve the clinical tutorial

 

There are several ways that one can try to improve the clinical tutorial.

 

·         Move from a disease oriented approach to a problem solving oriented approach.

 

·         Plan the teaching. Do you have fixed topics to cover or do you have a free hand?  Be sure what you intend to cover. 

 

·         Involve the student. Make it clear that all are to participate and come prepared with cases for presentation and read up aspects of the literature.

 

·         Provide a good teaching environment. Encourage active participation; be a facilitator, not a fountain of knowledge.

 

·         Concentrate on problem solving. Bring a case on the topic; avoid conducting tutorials in which you or your students present topics

 

A plan for a problem-solving tutorial

 

Some thoughts and preparation as well as a procedure are needed for a problem-solving tutorial.

 

Procedure

·         A week before the tutorial, designate one or two students to prepare a case for presentation.  Tell them they are to be prepared on all clinical and theoretical and theoretical aspects of the case.

 

·         At the start of the tutorial, outline the aims of the exercise.

 

·         Get the prepared students to give the presenting complaint or allow the patient to tell the story.

 

·         Stop, and ask the other students what they think the problem or diagnosis could be.  Ask them to justify their suggestions.  Encourage the other students to react to these suggestions.

 

·         Allow the presentation of more data.

 

·         Stop again, and ask the group whether they have changed their views and why.

 

·         Continue the process.

 

 

Helping the learner learn through feedback

 

·         Asking questions

·         Outcome vs. process

·         Convergent vs. divergent

·         Feelings versus facts

·         Complex vs.  simple

 

·         Fostering self- critique

·         Encourage openness

·         Clarify matters of fact

·         The learner first

·         Good points first

·         Recommendations, not destructive criticisms

 

·         Constructive Feedback

·         Direct observation

·         Timely

·         Specific

·         Explore underlying difficulties

 

Techniques for teaching particular practical skills and clinical skills

 

The Clinical interview

·         video recording

·         simulated patients

·         role-play

 

The Physical Examination

·         direct observation

·         simulated devices

·         simulated patients

 

 

 

CONCLUSION

 

Educational plans operationalises the syllabus. It needs to define learning objectives, methods and activities, and assessment of what has been learnt. Other activities to be considered are sequencing, course co-ordination, allocation of time, teaching rooms, equipment and teaching environment. Educational planning for clinical teaching needs to consider specific procedures and techniques.¨

 

 


 

PLENARY PAPERS (3)

 

ASSESSING CLINICAL PERFORMANCE IN FAMILY MEDICINE

Dr Neil Spike

 


INTRODUCTION

 

Where to begin and what to assess?  When the breadth of family/general practice is considered, is it possible, or necessary, to assess all the clinical skills that are required for practice?  Indeed, have all these skills been clearly identified?

 

As most assessments are undertaken to certify a level of achievement, the assessment of clinical competence takes on great importance.  A number of studies have shown, and most of us will already be aware, that assessments have marked effect on what is learnt and how candidates study.  Therefore, it is vital that assessment methods are appropriate and that there is a correct balance between the assessment of theoretical knowledge and clinical skills.  The assessments must also be of high quality allowing correct decisions to be made so that candidates and the community are not disadvantaged.

 

 During this presentation, we hope to address a number of important issues:

 

·         Defining what is meant by the terms clinical competence and clinical performance

 

·         Discussing the role of formative  and summative assessment in training

 

·         Providing guidelines for assessment,  including  the development of an assessment matrix,  available assessment methods                 and the need for standard setting, and

 

·         Identifying the criteria for examinations to assess clinical competence, e.g. validity, reliability, feasibility, and fidelity.

 

 

----------------------------------------------

Director of Assessment, Royal Australian College of General Practitioners

CLINICAL COMPETENCE VS CLINICAL PERFORMANCE

 

First, we must decide what it is we wish to assess. Do we want to assess competence or performance?  Second, be crystal clear in what we mean by these terms.  In the literature, they are sometimes used synonymously, but I believe they are different.

 

Most will be familiar with the pyramid of behavior (See Fig 1). It clearly indicates that competence and performance are separate stages in this behavioral process.

 

 

Figure 1. The Pyramid of Behavior
 

Clinical competence is defined in terms of what the doctor should be able to do at an expected level of achievement, e.g., entering unsupervised general practice (as for the RACGP Examination). More simply, it is what the doctor is capable of doing.

Clinical performance is defined as what the doctor does in real clinical practice. This has two components – a process and outcome. Process refers to what actually happens during a clinical contact and the outcome is the result in terms of patient care and well being. Assessments may be of either or both areas.

 

From the assessment point of view, it is far simpler to measure competence than performance. This is what is done in many assessments, including that of the RACGP. However, there are many studies, which show that competence does not always correlate highly with actual performance in practice.

 

The difference between clinical competence and clinical performance is illustrated in Fig 2. According to Newell, clinical competence may be regarded as mastery of a body of relevant knowledge and the acquisition of a range of relevant skills, including interpersonal, clinical and technical components.

 

Such knowledge and skills are interrelated and useful only if they are used in clinical problem- solving. Competence itself is only of value as a prerequisite for performance in the real clinical setting. Attitudes influence competence and performance, but are difficult to assess.

 

 

Figure 2. Components of clinical competence
 

 

ASSESSMENT AND TRAINING

 

An Educational Paradigm for Training

 

Some may be familiar with the Educational Paradigm for Training, developed by Oliver Samuel in the United Kingdom, where a triangle is used to demonstrate the relationships between aims (What is the aim of the training program?), methods (How can training be carried out most appropriately?)  and assessment (What has been learnt?  Is training successful?).

 

When the triangle is entered at the point of aims, by clearly defining the aims, appropriate methods can then be devised to achieve these aims.  Assessment then follows to determine if learning has actually been achieved. (Figure 3).

 

 

Figure 3. Entering at point of aims
 

Historically, many institutions have entered the triangle at the point of methods.  Much teaching was taking place before aims had been defined.  The results of teaching were not always checked by assessment.  (Figure 4)

 

Figure 4. Entering at point of methods
 

The triangle may also be entered at assessment.  Following a pre-course assessment, aims can be discussed with the learner in the light of their assessment and the appropriate learning methods devised.  Subsequently, the learner is reassessed to determine that learning has actually occurred.  (Figure 5).

 

Figure 5. Entering at point of assessment
 

An assessment may be used to review both the aims and the methods allowing for their modification. (Figure 6).

 

Figure 6. Assessment both to assess aims and methods
 

Samuel suggests that it is not of great importance at which point the triangle is entered, but stresses the educational process is only complete when all three points has been covered.

 

Formative and Summative Assessment

 

All will be familiar with these commonly used terms and the difference between them.  Marking and grading involve summative assessment while reviewing and giving feedback involve formative assessment.  It is not intended to review the variety of formative assessment tools available, but it is worthwhile to remember some of the weaknesses. It provides no information about the cause of those strengths and weaknesses.  More importantly. formative assessment lacks reliability because of the range of influences on the judgment of trainers.

 

It is worthwhile to also comment on some issues relating to summative assessment and the relationship to training.  The summative assessment process should reflect the areas covered during training, assuming they are relevant to actual practice.  There should be a cooperative approach between those involved in the delivery of the training and those responsible for conducting summative assessment.  (Training Program- Board of Examiner Working Party)

 

In Australia, completion of the training Program and the College Examination are used as indicators of competence to enter unsupervised general practice; e.g. be awarded the FRACGP.

 

The Working Party mentioned earlier has a number of issues to address:

 

·         Is it appropriate for educators involved in formative assessment to also be involved in the summative assessment of the same individual?

 

·         When should summative assessment take place?

 

·         Does it necessarily need to occur as the end-point of training?

 

·         Is it feasible to undertake mini-summative assessment during training?

 

·         If doctors successfully complete their     summative assessment requirements, prior to the completion of training, should these exempt them from completing training?

 

It must always be remembered that these two forms of assessment are separate in their function and failure to recognize this will only lead to further confusion.

 

Guidelines for Assessment

 

Newble and his co-authors provided a literature-based series of guidelines foreseeing clinical competence in 1994.  These guidelines assume that the purpose of the assessment has already been determined. They are divided into four major areas:

 

1.        Defining what is to be tested

2.        Selecting appropriate test methods: for achieving what we want

3.        Addressing issues of test administration and scoring, 

4.        Setting standards for performance.          

 

Each of the four major tasks can be divided into a number of smaller steps:

 

1.   Defining what is to be tested

 

      1.1.  Identify the range of clinical problems to be included

 1.2. For each problem, define the clinical tasks expected

      1.3. Prepare a blue print for a selection of problems

 

2.  Selecting test methods

 

2.1.          Select methods most appropriate to the clinical tasks

      2.2.   Allow clinical tasks to dictate the method

      2.3.  Recognize practical constraints on     method selection

 

3.     Addressing issues of test administration and scoring

 

      3.1.   Determine the level of efficiency needed

      3.2.   Decide how candidate performance is to         be recorded

      3.3.   Determine a method to assign a score to cases

      3.4.  Ensure the test provides an unbiased                measure of performance

      3.5.  Evaluate need for equating scores across         different examinations

      3.6.   Review procedures to ensure there is no trivialisation

 

4.  Setting standards for performance   

 

   4.1.       Determine the type of standard desired           and appropriate method

   4.2.       Develop procedures for communicating          results of test

 

 

DEVELOPING A TEST MATRIX

 

The blue print or matrix suggested by Newble and his co-authors is a complex, multidimensional grid.  The use of the matrix ensures that the clinical problems are truly representative and that there is an adequate sample of the problems provided.

 

An example of a matrix is outlined in Figure 7, using Hubbard’s classification of clinical competence.

 

Figure 7. A Test Matrix

Clinical competence

Problem 1

Problem 2

Problem 3

Problem 4

History

 

 

 

 

Physical examination

 

 

 

 

Tests & Procedures

 

 

 

 

Diagnostic acumen

 

 

 

 

Treatment

 

 

 

 

Judgement & Skill

 

 

 

 

Continuing Care

 

 

 

 

Doctor-patient relationship

 

 

 

 

Responsibility as Doctor

 

 

 

 

 

The actual assessment should involve those clinical tasks that are important to the completion of the presenting problem.

 

A detailed description and analysis of the strengths and weaknesses of various assessment methods is found in a book by Neufeld and Norman.  Assessing Clinical Competence.

 

Multiple assessment methods are now available and should be selected to suit specific needs.  Some of these methods include:

·         Objective-type items - MCQs *

·         Long menu MCQs/ Un-Q format

·         Free response questions (short answers)

·         Essays - short and long

·         Modified essay questions (MEQs)

·         Patient management problems (PMPs) - written or computer-based *

·         Key feature questions (Cambridge cases)

·         Unstructured vivas - theoretical,  short cases,  long cases

·         Structured vivas *

·         Observed long cases - in examination setting,*   in practice setting

·         Standardized patients (SPs) - in examinations, in practice setting

·         Chart audit

·         Chart  simulated recall

·         Supervisor and peer review

·         Patient review

 

                 (* = in RACGP examination)

 

Written tests are used to assess the knowledge and problem-solving components of competence.  Objective tests such as MCQs have practical advantages,  but also have their limitations.  e.g. items usually assess only the recall of facts and the degree of cueing by having options available.  Current modifications include the use of clinically based stems or long menu type questions.  The added disadvantage here is the increased time needed for completion.

 

Clinical problem solving was initially measured with written patient management problems (PMPs) and modified essay questions (MEQs). Recently, Cambridge cases, which focus testing on key features within a clinical case, have been used.  The main advantage being the increased number of cases that can be undertaken in the same period of time as conventional PMPs and MEQs.

 

Computer-based tests are used to simulate clinical situations in PMPs’ Although currently used in RACGP examination, there are the same limitations as written PMPs as well as the additional problems associated with the more complex technology.

 

Clinical tests include the traditional unstructured clinical and viva voce examination, as well as the objective structured clinical examination (OSCE). With the traditional clinical examination efforts need to be made to reduce the variability in the tasks and the variability in marking.

 

Measures to improve the quality of this form of assessment are:

·         Test only those aspects of competence that cannot be measured by more objective     methods

·         Clearly define the attributes to be assessed

·         Ensure candidate performance is actually observed

·         Increase the number of cases

·         Reduce the variability of cases presented, e.g. use standardized patients (SPs)

 

The OSCE is not a method in itself, but is a flexible examination structure, which can incorporate a range of methods and clinically relevant tasks. The OSCE is not the answer to all our “assessment prayers” as it still has advantages and disadvantages.  If it is to be used there are definite guidelines which must be followed and care should be taken to ensure it is not modified into a completely different “beast”, where many of its advantages are lost?

 

In 1985, Norman et al reviewed the recent innovations in assessment and made some recommendations on the use of such methods to assess different areas of competence.  These are tabulated in Table 1.

 

 

SETTING STANDARDS

 

Standard setting is the process of determining the score required to pass a given examination.

 

Scores represent the medical correctness of a response or group of responses.  They are based on medical knowledge or expert judgment about medical correctness.  Scores may be dichotomous or continuous.  Dichotomous scores indicate correct responses and do not allow compensation, whereas continuous scores indicate a degree of correctness and do allow compensation.

 

Standards are the scores that separate passers from failers.  Standards may be relative or absolute.

 

Relative standards (norm referenced measurements) are established by the performance of the candidates.  In this case, the pass or cut off level is predetermined statistically, e.g. one or two standard deviations below the mean. Essentially, candidates compete with each other.  This approach is simple but has limitations in the assessment of clinical competence or performance.

 

Absolute standards (the criterion referenced approach) are where each candidate is assessed against standards decided prior to the actual examination.  In this case, the measurements entail a clear-cut statement of the minimum acceptable competence or performance of a candidate over a selected range of knowledge, skills and attitudes.  The pass mark is independent of the performance of the candidates. This approach is more complex and time consuming to implement.

 

The Angoff method and the Ebel method are two content-based methods used for setting absolute standards for written tests.  They are similar in that both approaches require a group of experts to review the test items and estimate how “borderline” candidates would perform on that item.  The Hofstee method is for use in performance based tests and uses a compromise between relative and absolute standards.

 

CRITERIA FOR AN EXAMINATION TO ASSESS CLINICAL COMPETENCE

 

The ideal examination would be to fulfill three main criteria:

·         Is it valid?

·         Is it reliable?

·         Is it practical?  (feasible)

 

Validity is ensuring that the assessment measures what it is supposed to measure.  There are a number of types of validity referred to in the literature.

 

Content validity, i.e., the test contains a representative sample of what is expected to be achieved, is of great importance.  This can be achieved by using a test matrix or blueprint as suggested earlier.

 

Construct validity is established by making inferences about phenomena, which can not be observed directly, from phenomena which can be observed directly.

 

Predictive validity refers to the relationship between the performance of candidates in an examination and their actual performance in subsequent practice.

 

Figure 8. Reliability and Validity
 

Reliability refers to the consistency and precision of the test measurements. (See Figure 8).  A variety of factors influence reliability including the candidates, the examiners and the patients/test materials.  Content specificity is an important concept in reliability.  It refers to tests of clinical competence which aim to assess clinical skills and clinical problem solving and the need for such tests to contain many samples of candidate performance to achieve an adequate level of reliability.  (Newble and Swanson,  1989;  van der Vleuten and Swanson, 1990)

 

In Table 2, the reliability coefficients for clinical examinations as functions of testing time and the number of examiners are demonstrated.  It shows that acceptable reliability coefficients can be achieved by increasing the number of cases and having a new examiner in each case.  The additional increase in reliability from having the new examiners per case is minimal. The question may be asked, “Do we need two examiners per case?”

 

Practicality refers to the restriction on available resources. Ultimately, there is always a compromise between the ideal and practical.

 

Fidelity is a term introduced into the medical literature by Shulman from Michigan State University.  The purpose being to establish examination settings resembling the actual situation in which the clinical performance takes place.

 

Table 1. Assessing different areas of competence

 

 

Global rating

 

MCQ

 

MEQ

 

PMP

 

Cambridge Cases

 

SPs

 

Patient Rating

 

Diect Observation

 

Mechanical Simulation

 

Knowledge

 

 

 

 

+ +

 

+ +

 

+

 

 

+

 

 

+

 

Interpersonal

 

 

 

 

 

 

+ +

+ +

+ +

 

History

 

 

 

 

 

+

+

 

 

 

Physical Examination

 

 

 

 

 

 

+ + +

 

+

+

Reasoning/Diagnosis

 

 

+

+

+

+ +

+

 

+

 

Management

 

 

+

+

+

+ +

 

 

 

 

Personal Qualities

 

+ +

 

 

 

 

 

 

 

 

 

Table 2. Reliability Coefficients for Clinical Examinations      

 

Testing Time

 

Number of cases

 

Reliability coefficient

 

 

 

Same examiner for all cases

New examiner for each case

2 new examiners for each case

2

 

4

0.45

0.69

0.76

4

 

8

0.47

0.82

0.86

6

 

12

0.47

0.87

0.90

8

 

16

0.48

0.90

0.93

10

 

20

0.48

0.92

0.94

20

40

0.48

0.96

0.97

 




OPEN FORUM

 

Q.    Please comment on standardisation feedback.  How can we improve?

 

A.   We need to run workshops such as this for our own local educators in our training program; we should know the dangers of bad feedback.  As a consequence, this will help the trainees.  The hard part is to standardize anything.  We should have clear criteria and clear guidelines.

 

A.   What assessment methods should we use?

 

A.  I encourage you to develop more assessment methods.  Don’t just use one that usually exists.  Develop one that suits your purpose.

 

Q   What tests psychomotor skills?

 

A   Physical Examination is the one that tests psychomotor skills specifically. We use real patients. We have 1 long case, 3 short cases and a practical procedure. For those who did not pass, we let them know what went wrong so that they can make changes. We provide preparation for the examination.  We don’t aim to fail people.  We aim to pass people.  If we could raise the standards of Family/ General Practice in Australia, so that 100% passed the exams, I would be happy because it could mean that we have raised the standards.  We have improved the levels of skills and understanding.  Therefore, we provide better patient care for the community. 

     

      Not all examiners are candidate centered.  The difficulty with this is that standardization of examiners needs to occur. We need to agree the level of candidate centeredness and ensure that everyone use the same yardstick.  We need to calibrate the examiners.

 

      Feedback is the food of champions.  The athlete has a coach who observes and gives three sorts of feedback: reinforces what the person is doing right; points out the things that are not being done right; and makes suggestions about how the incorrect performance can be remedied. 

 

Figure 9. Historical Perspective of Assessment Methods
 

REFERENCES AND SUGGESTED READING

 

Barrows, H.S.  and Tamblyn R.M., (1977) the portable patient problem pack. (p4)  A Problem-based learning unit.  Journal of Medical Education.  1,  79-80.

 

Bordabe, G.  and Page IO. (1987)  An alternative approach to PMPs: The ‘key features” concept, I.R. Hart and R.M. Harden. (Eds)  Further Developments in Assessing Clinical Competence. Montreal: Heal- Publications.

 

De Gaff, E. Post, G.J. and Drop, M.J.  (1987) Validation of a new measure of clinical problem solving.  Medical Education.  21, 213-218.

 

Newble D.,  Dawson, B.,  Dauphinee, D.,  Page G., Macdonald, M.,  Swanson, D., Mulholland, H., Thomson A. and van der Vleuten, C. (1994).  Guidelines for assessing clinical competence.  Teaching and Learning Medicine 6, No 3, 213--220.

 


Norcini, J.J., Meskauskas, J.A., Langdon L. O.  and Webster, G.D., (1986).  An evaluation of a computer simulation in the assessment of physician competence.  Evaluation in Health Professions.  9,  286-304.

 

Norman, J.G., Bordage, G.I., Curry, L., Dauphinee, DI, Jolly, B., Newble, D., Rothman, A., Stalenhoef, B., Stillman, P., Swanson, D.  and  Tonesk, X. (1985).  A review of recent innovations in assessment, In: Wakeford, R., Bashook, P., Jolly, B., (Eds).  Directions in Clinical Assessment.  Cambridge:  Office


of the Regius Professor of Physics.  Cambridge: University School of Clinical Medicine.

 

Norman, G.R., (1989).  Reliability and construct validity of some cognitive measure of clinical reasoning.  Teaching and Learning in Medicine.  1,  194-199.

 

Rethans, J., van Leeuwen Y., van der Vleuten C and Sturmans F.  (1990).  Competence and performance: two different concepts in the assessment of quality medical care.  Family Practice 7,  168-174.¨

 

SPEECH BY THE SECRETARY FOR HEALTH AND SOCIAL AFFAIRS OF THE GOVERNMENT OF MACAU,

AT THE OPENING CEREMONY OF“WORKSHOP ON FAMILY MEDICINEEDUCATION: CLINICAL TEACHING”

 

Gabinete Do Secretario Adjunto

Governo de Macau

 

 


At this moment, when this “workshop” is commencing its works, first of all and on behalf of the Macau Government.   I wish to extend my greetings to all its organizers and participants and to welcome all those delegates who have come from abroad, wishing them a pleasant and fruitful stay in this city which as a result of its uniqueness as a meeting point of various cultures has learned, throughout the many years it has experienced of acquaintances among different people, to be hospitable and generous.

 

 

Secondly, I would like to praise and applaud the initiative of the Macau Association of General Practitioners in promoting this Meeting in Macau, showing in this manner their determination for the improvement of the Macau Health System, through the development of Primary Health Care, and the particular, the reinforcement of Education of Health.

 

 

In fact, the Macau Association of General Practitioners is an effective member of WONCA since 1982, and it has been since its establishment a valuable co-operator of the Public Administration not only in the definition of the measures to be adopted in the health area by the government, but also, and mainly, in the field of professional training for human resources in the health system.

 

 

I would say that the success in the reform of Macau’s Health System, initiated about a decade ago with the implementation of Primary Health Care and the construction of the health centres network, is largely due to the enthusiasm and dedication that the general practitioners have given to the development of this area of Macau’s health system and which today has transformed into an essential component of such a system.

 

In fact, Macau’s public health system is an integrated system, in which the hospital’s activity is articulated with the activity developed by a network of eight health centres.

 

 

This network of health centres, without aiming to monopolize health assistance to the population and therefore allowing space for the role of the private component of the Territory’s health system, is nevertheless providing assistance, totally gratuitous, to more than seventy per cent of children in their first year of life, to sixty eight per cent of pregnant women and to about thirty per cent of the aged in the Territory of Macau.

 

 

Distributed through the various residential areas of the city of Macau and the two islands that constitute this Territory, the health centres carry out their activity based upon working teams and under the leadership of General Practitioners.

 

 

These centres prepare and execute a set of programs dedicated to the prevention of disease and promotion of health, like the programs of child health, women’s health and aged health, family planning of education for health.

 

 

They are also effective post-graduate professional training centres of General Practice and Family Medicine.

 

 

The health centres also provide nursing and medical assistance to those sick at home and those in homes for the aged.

 

 

 

 

It is natural that to make the development of this area of Macau’s health system possible - an area that today is a reality and to which the population has adhered - it was necessary to follow the investment in material means with another investment, absolutely indispensable for the achievement of the objectives defined.

 

 

I am referring to the investment in human resources namely, that applied in the training of General Practitioners.

 

 

To give a few examples, I would like to mention the creation of a professional statute for the general practitioners, such statute that since 1988, is fully equal to the statute of any other medical specialty; the introduction in Macau, in 1988, of Internship, as a compulsory professionalisation process for admission in the medical careers of the public health system, as well as specialized medical training also for the area of General Practice and finally to the establishment of on-the-job training for general practitioners with eight or more years of experience, a training that will provide them with admission and access to medical careers at the same level of training obtained in specialization internships.

The professional training of the human resources in the health system is in fact, the primordial and strategic objective of the government in this transition phase that Macau is undergoing.

 

The continuity, without interruption, of the instituted health system depends on the success that we obtained in the preparation of qualified staff and expert personnel who will guarantee the quality already achieved in the provision of health assistance to the population of Macau.

 

 

Professional training is one battle we want to win and the success of a workshop like this one organized by the Macau Association of General Practitioners will be a necessary and very initiative.

 

 

I am certain that from this workshop new and important contributions will result for the definition of the objectives and strategies that are to serve as guiding lines for the development of family medicine, and in particular education for health, not only in Macau but in the whole region of Asia Pacific.

 

Thank you very much.

WORKSHOP RESULTS

SMALL GROUP DISCUSSION (3)

CLINICAL TEACHING SKILLS; CLARIFYING AND FOSTERING LEARNING

 


 

DISCUSSION GUIDELINES

 

Using the video presentations as input as well as the experience of your group, discuss:

 

1.       To clarify and foster learning, what kind of questions and how much may such questions are asked?

2.       What is involved in constructive feedback?

3.       How will you foster the learner to self-critique?

 

 

GROUP I

Rapporteur:  Dr Irma Almeida

 

CLARIFYING AND FOSTERING LEARNING

 

Learning is clarified and fostered by three educational activities: asking questions, self-critique and feedback

 

ASKING QUESTIONS

 

Type of questions

·         Open ended questions : effective in bringing out trainees’ thinking and processing capabilities

·         Cascading question : one question lead to another,  can lead trainee to proper thinking

·         Direct question: process questions, conclusions must be justified.

 

The issue of divergent questions which gives patients the opportunity to tell their story in their own word versus convergent question which lead to short answers was also discussed.

 

The consensus of the group was that all these types of questioning can be used depending on the situation and the information desired and the purpose for which questioning is being used.  

Recommendations of the group about asking questions:

·         Teachers/trainers should learn not only cognitive questioning which lead to factual answers as shown by “Why do you think...?” but should utilize and be sensitive to the use questions about feelings which are directed towards the emotion and illustrated by  “How do you feel about...?”

 

The emotions however should never influence the objectivity of the trainers when asking questions of the trainees.

 

 

 SELF-CRITIQUE

 

The group feels that this is a new approach that can be utilized and should be related to the section on asking questions.

 

The general atmosphere however, should be interactive, friendly, and encouraging.

 

While Asians generally are modest and perhaps humble in giving an objective self-critique, things are changing and younger trainees can be quite objective.

 

FEEDBACK

 

The consensus of the group was a (formative) feedback somewhere in the middle of the course, because trainees can then have the chance to correct their mistakes and really learn.  Summative/terminal feedback provides little opportunity for trainees to improve. Its purpose is to assess whether the learner has achieved prescribed standards of pass or fail.

 

Feedback has three parts:

·         Compliment - good interventions  nurturing a good atmosphere - positive reinforcement

·          Critically discuss the weaknesses,

·          Constructive summary giving suggestions for improvement.

Someone suggested this be called the “Feedback sandwich”

 

The group recommends that when giving feedback:

·         The trainer/teacher should be familiar with the case, which is the basis of the feedback.

·         Be confrontational but not combative.

·         The trainer must be creative/innovative in bringing out situations where feedback is likely to be accepted.

·         A friendly atmosphere is very important for giving feedback.

 

 

GROUP 2

Rapporteur:  Dr Wong Song Ung

 

ASKING QUESTIONS

 

The art of asking questions is of utmost importance.  The two Chinese characters for the word “Knowledge” literally means ‘learning to ask questions”

 

The types of questions are:

·         outcome versus process questions,

·         convergent versus divergent questions, and thinking versus feeling questions.

 

It is said that there are three types of teachers.

 

The three types of teachers are:

·         Those who only provide answers. 

·         Those who only ask question; and

·         Those who help the students to raise questions for themselves.

 

 

FOSTERING LEARNER’S SELF-CRITIQUE

 

Sometimes, what the teacher criticizes of the student’s consultation technique can be used by the student to develop his own critique technique.  The video clips provided some examples of this.

 

PROVIDING CONSTRUCTIVE FEEDBACK

 

General remarks:

·         It should be done in a friendly atmosphere during a protected time

·         It should be progressive and not be given at the end of the course when student would not be able to take remedial actions

·         It should begin with self-critique

·         It should be specific, non-judgmental and has       positive effect.

·         The teacher also needs feedback.

 

Making observations and comments on the video:

·         The student should have a go first in listing out is perceived strengths and weaknesses.  then the teacher gives his list.  These are compared.  Both the verbal as well as non-verbal components of the consultation should be critiqued.

·         The consultation may be expanded, following upon cues, asking questions such as “what if..”

·         The student would feel empowered to make effective changes if the teacher provides helpful and practical suggestions and alternatives.

 

CONCLUSIONS

 

There are basically two styles of teaching. One is the force-feeding approach such as the “Peking Ducks” are fed.  The other is as Master Confucius commented,  “That is the student is pointed out to one corner of a table, he should be able to figure out the other three.”

 

GROUP 3

Rapporteur: Dr Tito Lopes,  Jr.  

 

ASKING QUESTIONS

 

What kind of questions do we ask?  Mostly, we ask divergent (open ended) questions. These encourage the student to expand/improve on his thinking. Convergent (Close ended) questions are of limited use because they do not allow a more complete reply.

 

SELF- CRITIQUE

 

To encourage self critique, the trainer has to provide the following:

·         explain its importance in improving performance

·         develop a good trainer-trainee relationship

·         be willing to listen

·         be supportive

 

CONSTRUCTIVE FEEDBACK

 

Constructive feedback is dependent on the following dimensions for it to be effective:

 

·         Environment

-          time

-          place/setting

-          seating

-          personal space

-          eye contact

 

·         Student

-          personality

-          maturity

 

·         Teacher

-          honest

-          good finding

-          specific

-          link feedback to actual observation

-          “ dose given” is regulated

 

GROUP 4

Rapporteur:  Dr Chong Pak Yean  

 

 

ASKING QUESTIONS

 

·         What kinds? Mostly open ended/divergent answer.  They explore student’s thinking process.  They are also time consuming and the answers may be misdirected.

 

·         Close/convergent question requires a short answer and does not encourage the person replying to have much ground to cover.

 

·         The answer is to use both, depending on circumstances:

-          different student

-          different objective

-          different situation

-          different competence

-          different nature of the course

 

SELF-CRITIQUE

 

Asking the student to provide a critique of himself give the student some control of the situation.

 

-          Allow student express their thinking process

-          Encourage participation from the student

-          Consider:

-          level of competence

-          type of personality

-          cultural background

-          behavior

 

FEEDBACK

 

The following are strategies of a good feedback:

·         be concrete and specific

·         introduce feedback at the beginning of the course

·         provide feedback periodically so the student has a reminder on improving their performance

·         give solution: don’t confuse  the students with questions that can not be answered

·         encourage the student to do better

·         don’t neglect student’s strength: these should be positively commented upon too.

 

SYNTHESIS

by  Prof Goh Lee Gan

 

CLARIFYING AND FOSTERING LEARNING

 

Clarifying and fostering learning are important tasks in the educational process. They affirm what has been correctly learnt and correct misunderstanding and errors.  These tasks have to be handled sensitively in order not to destroy the learner’s self-esteem.

 

The presentations of the four groups to the questions in the discussion outline tell me that the basic principles shown in the video clips have been well internalised.

 

The following is an attempt to synthesise the thoughts of the four groups on the subject.

 

Learning is clarified and fostered by three educational activities: asking questions, self-critique and feedback.

 

ASKING QUESTIONS

 

The art of asking questions is of utmost importance.  What kind of questions do we ask?  Mostly, we ask divergent (open ended) questions. These encourage the student to expand/improve on his thinking. Convergent (Close ended) questions are of limited use because they do not allow a more complete reply.  There is yet another type of questions, namely, the feeling question as opposed to thinking question or question about observable things. “How do you feeling about …”

 

 

SELF-CRITIQUE

 

Self-critique is an useful instrument in fostering learning. The teacher can foster the spirit of self-critique by getting the learner to ask questions on how he or she can improve clinical performance and to be critical of his/her own progress.

 

 Here, the teacher-learner relationship is important.  The teacher must be supportive and constructive in order that self-critique is an effective tool. We also need to remember the culture dimensions because Asia is a bit more effacing and over critical of self.  However, one should also remember the behaviour from one generation to another does change.

 

GIVING FEEDBACK

 

Giving feedback helps the learner evaluate his learning. How much is he on target in his


learning? A feedback somewhere in the middle of the course is important because trainees can then have the chance to correct their mistakes and really learn.  Summative/terminal feedback provides little opportunity for trainees to improve. Its function is assessment of standards whether the learner has reached prescribed standards of pass or fail.

 

Feedback has three parts:

·         Compliment - good interventions  nurturing a good atmosphere - positive reinforcement

·          Critically discuss the weaknesses,

·          Constructive summary giving suggestions for improvement.

 

This has been dubbed the “feedback sandwich”

 

Recommendations on giving feedback were given by one of the groups and these bear repeating:

·         The trainer/teacher should be familiar with the case, which is the basis of the feedback.

·         Be confrontational but not combative.

·         The trainer must be creative/innovative in bringing out situations where feedback is likely to be accepted.

·         A friendly atmosphere is very important for giving feedback.¨

 

 

 

WORKSHOP RESULTS

SMALL GROUP DISCUSSION (4)

SMALL GROUP TEACHING


 

DISCUSSION GUIDELINES

 

Using experience of your group, discuss:

 

1.  What are the skills necessary for effective facilitation of small group discussion?

 

2.  What are the skills necessary for an effective presentation- e.g. a 10 minute talk?  Illustrate this with a presentation of your group’s choice.

 

 

 

GROUP 1

Rapporteur:   Dr Carlos Canhota

 

SKILLS NECESSARY FOR FACILITATION

 

There are three sets of factors in the small group discussion. The facilitator needs skills to deal with these factors

 

The facilitator factor

 

The facilitator needs personal skills.

 

He:

·         has a strong commitment to lead,

·         is able to define clear goals (objectives) and standards,

·         is able to provide information to the group,

·         is sensible to the needs of  the group,

·         involves  the whole audience actively in the discussion, 

·         is very sensitive to the individual level of participation,

·         ensures optimum participation,

·         modulates discussion,

·         is receptive to all the feedback coming from  the group.

 

The audience factor

 

The facilitator needs to study the audience and be skilful in improving the participation level of the audience.

 

He:

·         encourages commitment,

·         clarifies their tasks in the discussion,

·         encourages interaction and cooperation  in group work,

·         acknowledges and makes use of the diversity of gift, strength, characteristics and culture in the audience, and

·         encourages feedback to the facilitator.

 

The physical environment factor

 

The facilitator needs the skills of handling the physical environment.

 

The following are important rules of thumb.

·         Circular arrangement of participants to provide eye contact,

·         Size of the group:  ideal is   6-12

 

 

GROUP 2

Rapporteur:  Dr Luke Tsang

 

EFFECTIVE FACILITATION: DO’S AND DON’T’S”

 

Facilitating skills

 

Facilitating skills can be grouped into those that are related to the facilitator and his/her personal attributes, and facilitating skills related to group dynamics.

 

Attributes of a facilitator

·         Sense of humor,

·         Has respect of all members of the group,

·         Enthusiasm,

·         Flexibility, and

·         Sensitivity to  the different reactions of each  member

 

Process skills of facilitator

·         He/She must involve all the members in a discussion.

·         He/She needs to focus on the discussion.

·         He/She needs to set the task and the goal of the group.

·         Interprets and reports back to the group.

·         Summarizes for the group,

·         Needs to co-ordinate the output of group members go  in different  directions, and

·         Time conscious.

·         He/She should act only as facilitator but not as a resource person to avoid conflicts of role.

·         He/She should not dominate the group discussion.

·         He/She should not dampen the enthusiasm of the group (Sarcasm).

·         He/She should not allow views and attitudes to be demeaning to the members of the group sharing the task. 

 

Group Dynamics

 

Positive group dynamics

·         The group needs an ice breaker.  A time to get to know one another, otherwise, there’ll be a lot of inhibited exchanges. The ice breaker puts everyone in contact with others. 

·         The group can have a rotating facilitator. This is positive because different members can anticipate at different times as facilitator.

·         Group members need to be honest, direct and have mutual respect the one for the other.  

 

Negative dynamics to avoid

·         Many work groups are stalled by members who are not comfortable in expressing themselves.

·         If the roles are fixed, some in a passive and others in a dominant role, the group dynamics will not be conducive to good participation.

·         If there are unresolved conflicts of interest within a group, then the group dynamics will suffer. 

·         Productivity will be diminished if the group is not genuinely interested in the topic under discussion.

·         If the background of the group is too diverse, this would also create problems.

 

 

GROUP 3

Rapporteur:  Prof John Richards

 

“C-ING THE WAY AHEAD IN SMALL GROUPS”

 

Discussion centered on the qualities necessary for good facilitation of small groups, and it emerged that most of these could be identified with the letter C. From this developed the concept of C-ing the way ahead.

 

A good facilitator must be a:

 

COMMUNICATOR. This requires someone who speaks clearly and listens carefully, someone who can interpret ideas for others and ensures that everyone understands and there is no ambiguity.

 

CLARIFIER. Although we may use the same words we do not always give them the same meaning.  A further adjunct to good communication is therefore someone who is a clarifier.

 

COORDINATOR.  This means someone who can ensure that the discussion does not get sidetracked and that those who wish to have a say, get an opportunity to do so.  There is also a need to bring together the many threads of a discussion.

 

CONTROLLER. This complements coordination.  The facilitator must maintain order, steer the discussion in profitable directions and control disruptive elements, namely, those who seek to dominate the conversation or intimidate or embarrass others.  Timing is also important.

 

CONCILIATOR. Often there are several in a small group who hold very strong views.  Sometimes these can not be reconciled, but often a good facilitator is able to act as a conciliator and help each to find common ground, which may serve as the basis for a measure of agreement.

 

CUER.  Here, we are looking for someone who has skills to encourage the right person to contribute at the right time, having subtly identified the tenor of that person’s likely contribution. 

 

CATALYST. The role of a cuer merges with that of the catalyst, someone who can take an idea and use it to stimulate other ideas - like the single match that may light a thousand candles?

 

CONTRIBUTOR. It is expected that not only should small group facilitators bring the above skills to the discussion but they should also be contributors, introducing ideas and information on their own behalf.

 

COMFORTER. There will sometimes be those who feel pained that their ideas are not accepted, and those who feel slighted.  Both should seldom occur in a well run discussion, but when it does, it is important that such people feel adequately supported and that they do not lose their self-esteem.  A good facilitator will recognize the development of such problems and do whatever is necessary to minimize them. 

 

COUNSELLOR. Occasionally, comfort alone is not enough and so the facilitator may need to be also a counsellor.

 

 

COMPARING PRESENTATIONS

 

A comparison of the advantages and the disadvantages of the lecture compared with the small group were made.

 

Lecture

 

Advantages

·         many  learn at one time

·         light on teaching time

·         non-threatening

 

Disadvantages

·         little interaction

·         little feedback

·         little flexibility

·         Sharing of knowledge of only one person

 

 

Small group discussion

 

Advantages

·         much interaction   

·         much feedback

·         sharing of knowledge of all participants

·         very flexible

 

Disadvantages

·         few learn at one time

·         heavy on teaching time  

·         threatening to some

 

Making a meal of the lecture

 

There was also an account of the qualities required of a lecturer presented by John Richards under the title, “Making a meal of the lecture” or a “Recipe for a good lecture.”

 

Recipe

·         It is important to know in advance who will be dining i.e., who will constitute the audience. 

·         One must also know how much the diners have consumed already and how well this has been assimilated. 

·         One should try to determine how hungry they are for what you have to offer.

·         The speaker also has to decide how many courses are going to be provided.

·         The menu must be attractive so that as many as possible will be enticed into partaking.

·         The meal itself must be easily digestible so that no one suffers from mental indigestion. 

·         Usually it should start with an appetizer to give a taste of things to come and stimulate the appetite. This means introducing the subject in a manner designed to attract attention.

·         The main course should be easily identifiable and memorable for its distinctive flavor and be genuinely nutritious.

·         At the end, the participants must feel replete but not surfeited i.e., satisfied but not overloaded.

·         The desert gives the summary, conclusion, important take home messages.

·         The meal must meet the needs of as many consumers as possible, but it must not be too bland.  It may even help if at times it is a little spicy.

·         The speaker must not be long-winded and even more importantly should not suffer from verbal diarrhea, a condition that seems to be endemic in some places.

·         There should always be an opportunity to ask for second helpings, should people feel that they have not had enough: i.e., there is a question time.

·         When the meal s over, the consumers must be able to demonstrate that what has been taken in is really absorbed, so that in the future it is not merely regurgitated, and that there is real growth as a result.

·         Most speakers also welcome feedback.

 

An observation

The lecture is like a miniskirt: not too long, not too short, but must cover the subject.

 

 

GROUP 4

Rapporteur: Dr Ying Hua Shieh

 

FACILITATION OF SMALL GROUP DISCUSSION

 

Success factors

·         Usually a round table.

·         Not too many in the group.

·         The facilitator does not dominate.

·         All have equal opportunity to express their views.

 

EFFECTIVE PRESENTATION SKILLS

 

Success factors

·         Rehearse presentation.

·         Familiarize topic and audience.

·         Choose appropriate language.

·         Link audience with their pre-existing  knowledge.

·         Have concise objectives and summary points

·         Have appropriate timing.

·         Be focussed.

·         Repeats main message in the conclusion.

 

Long or short it must have the necessary parts: ”A sparrow is small but all the parts are there.”

 

Success factors

·         Beginning or starter: use a cartoon, music or a picture

·         Content:  be relevant, properly packaged (gift wrapped),  involve the audience,  adapt to the audience where needed as the presentation unfolds

·         Ending: have concise summary and have take home messages

·         Audiovisual usage: be concise, uncluttered relevant, and use appropriate font size.

 

SYNTHESIS

by  Prof Goh Lee Gan

 

FACILITATION OF A SMALL GROUP DISCUSSION

 

All the four groups presented very useful points on


the skills necessary for facilitating a small group discussion. Attention needs to be paid to the facilitator, the audience and the physical environment. An innovative way of looking at the facilitating  skills is presented by Group 3 who has a set of 10 words beginning with “C” to describe these skills: communicator, clarifier, coordinator, controller, conciliator, cuer, catalyst, contributor, comforter, and counsellor.

 

 

PRESENTATION SKILLS

 

The skills required in a lecture were highlighted. Group 2 noted the parallel between preparing a successful lecture and preparing a meal. A knowledge of the audience is important. At the end of the presentation, the audience must feel replete and not surfeited.

 

The importance of structuring it as beginning, body and end was noted by more than one group. Concise summary and take home messages are important.

 

There is also a need to pay attention to  audiovisual usage. Finally, rehearsal is all important. ¨

 

 

 

 

 

 

 

 

 

 

 

SUMMARY AND CONCLUSIONS

 


The Workshop on Clinical Teaching held in Macau on June 15-17 provided a forum for sharing the what, how and why of teaching and learning clinical medicine. The Workshop will be remembered for the keen enthusiasm of the participants in grappling with the issues of clinical teaching and the warm hospitality of our hosts, the Associaocao dos Medicos de Clinica Geral de Macau.

 

Plenary papers

 

The plenary papers addressed the role of the clinical teacher, the educational planning necessary in clinical teaching, and assessment of clinical performance.

 

The family medicine teacher is a role model, motivator, knowledge and skill disseminator, assessor, and researcher. Clinical teaching is a challenging job. It is also a rewarding one.

 

Educational planning is planning learned experiences that the trainer wishes the learner to be exposed to in order to achieve learning goals. It puts the syllabus into operation.

 

Educational planning can be looked upon as trying to help the learner arrive at an intellectual or skill destination. The logical questions to ask then are: “Where are you now and where do you want to go?” (aims and objectives); How are you getting there? (the methods of learning), and “How do you know you have arrived? (assessment).

 

“Where are you now?” is an important question for the clinical teacher to establish before he draws up the teaching plans because the postgraduate doctor, unlike the undergraduate doctor does not start with a clean mental slate. The clinical teacher needs to plan the learning experience to continue from what he already knows.              

 

To be effective, educational planning needs to be adult learner oriented, and has to link objectives or aims, methods and assessment together. Other considerations are sequencing, course co-ordination and administration, allocation of time, resources and technical support, as well as providing a good learning environment. Educational planning for clinical teaching needs to consider also special procedures and techniques.

 

Assessing clinical performance is different from assessing clinical competence. Clinical competence is what the doctor is capable of doing and clinical performance is what the doctor does in real clinical practice. There is a need to be clear what we are assessing.

 

Assessing clinical performance can either focus on process or outcome or both. Assessing clinical competence can be formative or summative. The former is assessing whether the learner has succeeded in learning. Summative assessment is assessing if the learner has attained the standards set by an examining body. If the learner attains and exceeds the standards set, he passes.

 

The ideal examination should fulfil the three main criteria of validity, reliability and feasibility.  Multiple assessment methods are now available that suit special needs. A text matrix needs to be developed to test the broad clinical skills. The areas of clinical competence that are tested include: history taking, physical examination, diagnostic acumen, treatment personal qualities, and interpersonal skills. It is also established that it is more reliable to have a new examiner for each case then for the same examiner to examine all the cases. Two new examiners are better than one if the cases are few in number; there is a trade-off depending on what is feasible.

 

Needs assessment and learning plans

 

The first workshop examined the assessment of the learner’s needs and also how to involve the learner to develop individual learning plans. There is consensus that the teacher needs to gather information about the learner’s level of skill including cognitive and psychomotor skills at the beginning of training. There is also a need to gather information about the learner’s own learning objectives.   The methods used can be one or more of the following: interview, answering a questionnaire on confidence checklist, and a problem solving exercise either a written or a computer based exercise.

 

In developing plans for learning there is a need to define mutually acceptable goals and give the learner autonomy where appropriate but not to the extent of jeopardising the course content. Chart reviews, a log-book to monitor progress, self-critique, peer review and constructive are instruments that can be used to define the needs on which to base plans for learning.

 

Ground rules should be established on the standards to be achieved and these should be mutually accepted through negotiations and should not be unilaterally imposed.  

 

Teaching consultation skills

 

The consultation is the cornerstone of care of patients. The skills to be learnt are many.  They include: interview skills, relating skills to develop and maintain the doctor-patient relationship, examination skills, management skills and counselling skills.

 

The teaching of consultation skills involves observation of the consultation process and giving appropriate feedback. The latter must be done in a diagnostic and non-judgmental way. Also, the teacher should encourage self-critique in the learner as a means for improving performance.

 

Observation on the learner’s skills may be obtained by using: direct observation at the bedside, one way mirror, video and simulated patients as evaluator. A checklist is useful in facilitating the observation process.

 

The video is a powerful instrument for teaching consultation. It can record events to be analysed later.  The rules of etiquette in commenting on one’s presentation on the video needs to be followed. The person videod should be asked to critique themselves first before others give their comments. "How do you feel about your performance?” is a good opening question. The teacher should encourage self development by asking questions like, “ What do you think could have done instead?”

 

 

Clarifying and fostering learning

 

Clarifying and fostering learning are important tasks in the educational process. They affirm what has been correctly learnt and correct misunderstanding and errors.  These tasks have to be handled sensitively in order not to destroy the learner’s self-esteem.

 

Learning is clarified and fostered by three educational activities: asking questions, self-critique and feedback.

 

Asking questions

 

The art of asking questions is of utmost importance.  What kind of questions do we ask?  Mostly, we ask divergent (open ended) questions. These encourage the student to expand/improve on his thinking. Convergent (Close ended) questions are of limited use because they do not allow a more complete reply.  There is yet another type of questions, namely, the feeling question as opposed to thinking question or question about observable things. “How do you feeling about…”

 

 

Self-critique

 

Self-critique is an useful instrument in fostering learning. The teacher can foster the spirit of self-critique by getting the learner to ask questions on how he or she can improve clinical performance and to be critical of his/her own progress.

 

Here, the teacher-learner relationship is important.  The teacher must be supportive and constructive in order that self-critique is an effective tool. We also need to remember the culture dimensions because Asia is a bit more effacing and over critical of self.  However, one should also remember the behaviour from one generation to another does change.

 

Giving feedback

 

Giving feedback helps the learner evaluate his learning. How much is he on target in his learning? A feedback somewhere in the middle of the course is important because trainees can then have the chance to correct their mistakes and really learn.  Summative/terminal feedback provides little opportunity for trainees to improve. Its function is assessment of standards whether the learner has reached prescribed standards of pass or fail.

 

Feedback has three parts: compliment good interventions nurturing a good atmosphere to provide- positive reinforcement; critically discuss the weaknesses; and constructive summary giving suggestions for improvement. This has been dubbed the “feedback sandwich”.

 

Recommendations on giving feedback bear repeating: the trainer/teacher should be familiar with the case, which is the basis of the feedback; be confrontational but not combative; the trainer must be creative/innovative in bringing out situations where feedback is likely to be accepted; and a friendly atmosphere is very important for giving feedback.

 

 

Facilitation of small group discussion

 

Attention needs to be paid to the facilitator, the audience and the physical environment. An innovative way of looking at the skills needed is presented by Group 3 who has a set of 10 words beginning with “C” to describe the skills: communicator, clarifier, coordinator, controller, conciliator, cuer, catalyst, contributor, comforter, and counsellor.

 

 

Effective presentation

 

The skills required in a lecture were described. Group 2 likened preparing a successful lecture to preparing a meal and preparing a lecture. A knowledge of the audience is important. At the end of the presentation, the audience must feel replete and not surfeited.

 

 

The importance of structuring it as beginning, body and end was noted by more than one group. Concise summary and take home messages are important. There is also a need to pay attention to  audiovisual usage. Finally, rehearsal is all important.


 

 

 


 

 

THE WORKSHOP IN A NUTSHELL

 

·         The teacher is a role model, motivator, knowledge and skill disseminator.  assesor and researcher.

 

·         Educational planning can be looked upon as trying to help the learner arrive at an intellectual or skill destination. The logical questions to ask then are: “Where are you now and where do you want to go?” (aims and objectives); How are you getting there? (the methods of learning), and “How do you know you have arrived? (assessment).

 

·         Assessing clinical competence is different from assessing clinical competence. Assessing clinical performance can be process or outcome or both. Assessing clinical competence can be formative or summative. In summarive assessment, the examination should fulfil the three main criteria of validity, reliability, and feasibility.

 

·         The teacher needs to gather information about the learner’s level of skill including cognitive and psychomotor skills at the beginning of training.

 

·         In developing plans for learning there is a need to define mutually acceptable goals and give the learner autonomy where appropriate but not to the extent of jeopardising the course content.

 

·         The teaching of consultation skills involves observation of the consultation process and giving appropriate feedback. The latter must be done in a diagnostic and non-judgmental way. Also, the teacher should encourage self-critique in the learner as a means for improving performance.

 

·         Learning is clarified and fostered by three educational activities: asking questions, self-critique and feedback.

 


·         The facilitator needs the skills of a communicator, clarifier, coordinator, controller, conciliator, cuer, catalyst, contributor, comforter, and counsellor.

 

·         Preparing a successful lecture is like preparing a meal. A knowledge of the audience is important. At the end of the presentation, the audience must feel replete and not surfeited.  It must be structured to have a beginning, body and end. Concise summary and take home messages are important. There is also a need to pay attention to  audiovisual usage. Finally, rehearsal is all important.


 

 

 

 

LIST  OF PARTICIPANTS

 


GROUP I

 

Facilitator:  Dr. Chan Nang Fong (Singapore)

Members:    Dr. Carlos Canhota (Macau)

                    Dr. Reyaldo A. Olazo (Philippines)

                    Dr. Zunilda Bustami (Indonesia)

                    Dr. Bee Horng Lue (Taiwan)

                    Dr. Hyun Lim Choi (Korea)

                    Prof. Goh Lee Gan (Singapore)

                    Dr. David Chao  (Hongkong)

                    Dr. Cheang Seng Ip  (Macau)

                    Dr. Irma Almeida  (Macau)

                    Dr.  Mardiani Oemar (Indonesia)

 

 

 

 

 

 

 


GROUP II

 

Facilitator:  Dr. Eileen Tse (Hongkong)

Members:    Dr. Ryuki Kassai (Japan)

                    Dr. Luke Tsang  (Hongkong)

                    Dr. Neil Spike  (Australia)

                    Dr. Wong Song Ung  (Singapore)

                    Dr. Li Ning  (PRC)

                    Dr. Chau Chi Hong  (Macau)

                    Dr. Maria Dillard Fonseca (Macau)

                    Dr. Celeste Goncalves (Macau)

                    Dr. Young Sik Kim (Korea)

 

 

 

 

 

 

 

 

 


GROUP III

 

Facilitator:   Dr. Maria Augusta Drago (Macau)

Members:    Prof. Wesley Fabb  (Hongkong and                           Australia)

                    Prof. John Richards  (New                                          Zealand)

                    Dr. Linda Hui  (Hongkong)

                    Dr. Meng Chih Lee  (Taiwan)

                    Dr. Ying Hua Shieh  (Taiwan)

                    Dr. Cynthia Lazaro-Hipol                                                (Philippines)

                    Dr. Mohd Shajahan (Malaysia)

                    Dr. Zorayda E. Leopando                                                                (Philippines)

                    Dr. Tito Lopes Jr. (Macau)

                    Dr. Eddie T. Chan  (Hongkong)

                    Dr. Bina Kurup (Singapore)

 

 

 

GROUP 1V

 

Facilitator:  Dr. Winnie P. Siao  (Philippines)

Members:   Dr.  Chang Pak Yean  (Singapore)

                   Prof. Bong Yul Huh  (Korea)

                   Dr. Fong Hou Heng (Macau)

                   Dr. Shih-Tzu Tsai  (Taiwan)

                   Dr.  Sugito Wonodirekso (Indonesia)

                   Prof. Anthony Dixon (Hongkong)

                   Dr. Kamil Ariff (Malaysia)

                   Dr. Jorge Leitao Pereira  (Macau)

                   Dr.  Jose Batista Pereira (Macau)

                   Dr. Sylvia Achmad (Indonesia)

                   Dr. Lindsey Knight (Australia)