Learning from uncertainty: a change of culture

There are around 16 000 hospital and other clinical staff involved in teaching medical students in the United Kingdom. Not all of these clinicians hold university or teaching contracts, many are honorary teachers involved as part of their clinical responsibilities to district or general hospitals. Many of these teachers are also responsible for supervising and teaching junior doctors in training for specialist posts, and some play a part in the continuing professional development of their hospital colleagues, of local general practitioners and in the education of other health care professionals. However, unlike their training colleagues in general practice or in nursing and the therapy professions, most clinical teachers in hospital have not received any formal preparation for their teaching roles. Medical students have expressed surprise and concern about this lack of preparation for something that is a central part of the activities of so many clinicians. The realization that, in the main, good teachers are made rather than born, is a helpful one for students to hold and one that many medical schools and postgraduate Deans are currently responding to with urgency. Teaching tomorrow’s doctors was the theme of the recent annual scientific meeting of ASME (the Association for the Study of Medical Education). A preliminary survey of medical schools and postgraduate deaneries has shown that considerable effort is being made to provide courses and other opportunities for hospital doctors to increase their awareness of educational approaches and develop their teaching skills. The range of content of these courses is wide and includes observation of teaching practice, reflective diaries, microteaching techniques and workshops on specific skills, such as giving feedback or appraising progress. Many of the courses or teaching support sessions provided will be linked to an accrediting process so that participants may benefit by having their learning recognized by their local university or by the Institute for Learning and Teaching (a recently established national body serving the training needs of higher education in general in the UK). But will providing courses on teaching skills or educational theory be enough? Georges Bordage from Chicago, Illinois in the United States, in the annual Lord Cohen Lecture, suggested that more would be necessary before teachers both in hospital and in the community are fully prepared for their educational tasks. He argued that medical teachers need to know not just about teaching skills, curriculum planning or assessment methods, but that they also need to know more about how students think diagnostically. He was especially concerned with how students (and this term includes doctors in training) use the information they obtain from the clinical history and subsequent investigations, in coming to a diagnosis and clinical management plan. Knowing more about what students are thinking when they are presenting a case to you, or about what they are thinking after a lecture will enable teachers to help their students learn better. A major implication of his argument is that the provision of teaching skills training is not sufficient preparation for effective clinical teaching. Medical teachers need to know more about the process of learning in particular contexts. His view is supported by other work from the US where Irby has suggested that the effective clinical teacher uses knowledge from four domains.1 These are knowledge of medicine as a broad discipline, encouraging integration of learning across a number of fields, knowledge of the principles of teaching and learning, specific knowledge of the teacher’s own speciality area, enabling case specific teaching and the development of teaching ‘scripts’, and knowledge of the learners for whom the teacher has responsibility. This last domain includes knowing about what students already know when they arrive for teaching, knowing about their motivation and interests, and knowing about the mistakes that they are likely to make at their specific stage of learning. For example, common errors made by students during their clinical training include overemphasizing positive findings, ordering too many investigations and incorrect interpretation of cues given by the patient.2 In Bordage’s experience, collecting too much information is another common error – thoroughness becomes the response to uncertainty. He used examples from recent research to show that effective clinical problem-solvers make use of strategies other than thoroughness to reach a diagnosis. These included co-selection of information, knowledge of discriminatory evidence and conceptualizing the patient’s problems through abstraction (a process called ‘semantic representation’).3 Changing teachers is about changing the clinical culture. Bordage argued that many clinicians are uncomfortable disclosing their uncertainties for fear of judgement or ridicule, and students learn this behaviour through role modelling and example. But for Bordage, expressing uncertainty is the best way of learning and teaching because it allows exploration of the cognitive processes involved in clinical decision making. Teachers need to ensure a safe environment for this to occur and be clear and persistent in their approach to dealing with issues that arise. His conclusion – that as teachers, we must know what our students are thinking, and as educators, we must use and gather evidence – reflects growing interest in best evidence medical education, and if adopted, should ensure that clinical teachers avoid the four cardinal sins of prejudice, hunches, opinions and guesses.4