Asking questions – improving teaching

The advancement of learning through research, publishing and teaching, is the main business of higher education institutions and their faculties. In recent years, concern about the effectiveness of these activities has led to the generation of a profusion of composite ‘quality’ terms, for example; quality control, quality audit, quality assessment and quality assurance. These terms are all concerned with the degree of excellence it is possible to achieve and maintain to fulfill the institution’s mission statement and satisfy more detailed aims and objectives. Some are external assessments such as the quality audit carried out by the Higher Education Funding Council for England’s (HEFCE) Quality Assessment Division (QAD), and the Higher Education Quality Council’s (HEQC) Division of Quality Audit (DQA), both of which aim to ensure that institutions have appropriate quality control mechanisms in place. The HEFCE has a statutory obligation to assess the quality of teaching and learning in institutions for which they provide funding, and with the HEQC, it emphasizes the importance of obtaining student feedback as a means of improving education. Likewise, the Student Charter states that the quality of student feedback should be improved. Listening to the concerns of students at all levels, whether they are undergraduates, postgraduates or adults from special groups, is both a legal and a moral obligation.1 In the past, educational research in medicine has centred on learners from groups who were not considered to be the ‘norm’, for example, ethnic minorities, women or other educationally disadvantaged groups. Although the views of such groups are important, we must recognize that all learners are individuals whose different educational needs must be taken into account. There is evidence that educational institutions are changing their relationships with students in their efforts to meet these various needs. Now, the emphasis is on a partnership that involves two-way communication rather than one-way ‘broadcasting’. Attention has shifted from a ‘jug-to-mug’ concept of education to the education of the ‘whole person’ that encompasses knowledge and skills, psychosocial issues, professional values and attitudes, and ethical and moral development. The student, particularly at undergraduate level, is an individual with growing autonomy, whose variable learning capabilities need to be understood, and who thrives in an open and responsive education system. It is vital that adequate student feedback is obtained during evaluation and audit procedures so that new courses, teaching and assessment methods, and the use of new educational sites, can be evaluated and improved. Likewise, at postgraduate level, and during subsequent careers as general practitioners or hospital specialists, their involvement in educational decisions to improve clinical practice will help to ensure that levels of patient care continue to improve. In this issue of the journal, we include a collection of papers that show how information from students can improve course content, teaching skills, attitudes and relationships. These papers show that students are being taught in a variety of contexts, using many different resources and media, namely, in small groups, clinical skills laboratories, hospitals and the community, and through self-directed research, the Internet and topic-related lectures. The authors demonstrate that they are keen to know how teaching and learning is being carried out in many different locations, and how locations, teaching and assessment methods complement each other. The choice of appropriate investigative tools, for example, questionnaires, interviews, focus groups, video recordings and psychometric measurement scales, is crucial as a means of finding answers to their specific questions. The use of a single research method will rarely, if ever, provide all the answers they seek. One of the key themes to emerge in the papers is the importance of the humanistic side of a medical student’s learning, namely, an attempt at reuniting science and caring in medical curricula, a theme that Mark Albanese explores in depth in his commentary.2 Feelings associated with relationships are at the heart of humanistic attitudes, particularly when dealing with patients and their families. One of the most difficult things a medical student has to learn is coping with strong feelings and emotions.3 How do they learn to be knowledgeable doctors and at the same time remain compassionate and understanding? How do students relate to patients and their families in difficult and distressing situations? Using pre-and post-clinical experience questionnaires, Hajek et al. show that the primary concern of their medical students is learning to communicate with patients who are distressed or in pain. They intend to use their findings to fill a perceived gap in communication skills courses.4 In Australia, Crotty and colleagues demonstrate that students who learned about disabled patients in a clinical setting became aware that they are also people who have a key role in solving problems resulting from their disabilities. Findings will be used to help both tutors and students to reflect critically and analyse their experiences, and to learn to confront their emotions.5 But students frequently learn from the examples of their tutors. Maheux and colleagues used questionnaires to obtain student feedback, and interviews with tutors to examine the humanistic qualities of teachers in medical schools that have contrasting innovative and traditional teaching regimes. They suggest that tutors are important role models – both as teachers and clinicians – if students are to acquire the nurturing and humanistic attitudes needed by future doctors.6 Malik also emphasizes the quality of the tutor–student relationship in the evaluation of a tutor support scheme. He used several methods of data collection to show that the personal qualities and attitudes of tutors provide the key to a successful scheme.7 Being articulate, compassionate and understanding with people is not the whole story. Two papers examine students’ reading and writing skills. Chur-Hansen et al. used video-taped interviews with standardized patients, coupled with a relevant rating scale, to assess how well medical students from different ethnic backgrounds could produce accurate reports of patient interviews. Their findings strongly suggest that training in writing skills should be compulsory for all medical students.8 Hodgson and Thomson carried out an assessment of medical students’ reading habits. Their findings show that many students support the inclusion of humanities in their courses, for example through Special Study Modules, as a way of broadening, enlightening and inspiring interests outside medicine, and keeping in touch with the world at large.9 To return to the initial ‘quality’ theme – what do these and other similar papers contribute towards achieving and maintaining quality in education? First, all the authors have evaluated aspects of their courses by involving their own students. The purpose is to learn about their educational experiences and use them to improve and develop curricula. The importance of involving students in curriculum development cannot be over-emphasized. We need to know about such things as course content, organization, and the acquisition of clinical skills and professional attitudes. Not least we need to know about ourselves as teachers and clinicians. Are we the best possible role models for our students in any given situation? Second, the choice of data collection methods must be determined by the research question, size of respondent sample, and the context in which the education is taking place. Finally, ongoing evaluation and occasional in-depth research must accompany any new educational idea, method or practice. If education has the dynamic characteristics necessary for continuing growth, then all aspects of the curriculum should be included in an integrated evaluation programme. Giving students a voice in that programme is crucial if we are to achieve the quality of medical education that everyone wants for the future.