The previous chapter spanned a range of learning activities -- learning by doing, learning from text and computerised information bases, learning through discussion, and learning from presentations and mini-lectures. The criteria used for describing the learning as being in a clinical setting were (1) its direct relationship with the assessment and management of current patients and (2) its location within the concerns of the health care team responsible for those patients. This chapter covers a similar range of learning activities, but the mix is rather different because the focus is more on the acquisition of knowledge, skills and values needed for serving patients one will meet in the future than those which are one's current responsibility.
Although the teaching conference (sometimes called a grand round) is similar in many respects to the teaching rounds described above, the cases discussed are more likely to be recent than current and the majority of those present will have had no responsibility for those particular patients. Indeed the aims of such conferences are not always very clear.
Luce (1996), one of the few authors to address this issue, argues that if conferences are part of the formal postgraduate training programme their educational effectiveness has to be justified. His own department of plastic surgery has developed two forms of conference which are more consistent with principles of adult learning than the traditional variants. This involved distinguishing between (1) a cognitive conference based on prior study of assigned topics and readings in order to develop propositional knowledge and (2) an intuitive conference to facilitate ``the use of judgement or intuitive reasoning in problem solving''. The cognitive conference provides the focal point of a study programme in which faculty as well as trainees participate, one role of faculty members being to design questions on the reading appropriate for each level of trainee. The intuitive conference is based on four to six cases chosen from the week's theatre list. Each case is assigned to a senior resident and an independent consultant not involved with the patient are appointed as discussants. The consultant's role is to develop the presenter's reasoning through Socratic discussion. These conference formats have been developed over time by a series of critical reviews and modifications. The cases are chosen and assigned by the director of the resident training programme with educational needs in mind, not left to the choice of individual presenters or their supervisors.
Another approach to the development of cognitive knowledge used in many programmes of postgraduate education is the Journal Club. Evidence on their effectiveness was recently reviewed by Alguire (1998), who noted that a major goal was to teach critical appraisal skills as well as establishing a lifelong learning habit. Clubs with high attendance and longevity are characterised by mandatory attendance, availability of food, and renewed importance by the programme director. Residents who are taught critical appraisal report paying more attention to the methods and are more sceptical of the conclusions, and have increased knowledge of clinical epidemiology and biostatistics but studies have failed to demonstrate that these residents read more, or read more critically.
A more individualised approach which aims to link self-study with current clinical experience is advocated by Harden et al. (1996b,a) in an AMEE Guide on task-based learning. The term is used rather generically to refer to a curriculum of tasks designed to take advantage of the core learning opportunities of a particular rotation. More ambitious still is the use of an educational contract (Mahood et al., 1994), in which a resident agrees a complete 2-year schedule of rotations and educational activities, focussed on her or his unique needs and designed to meet both residency training programme objectives and individual resident-identified objectives.
The principle of finding the most appropriate trainers for each particular purpose is well illustrated by Dale et al. (1997). They noted weaknesses in house officers' communication skill and management of primary care type problems in emergency departments; so they developed a training course for them taught by General Practitioners. The programme involves weekly 1 hour small group sessions and a visit to General Practice. Evaluation is by feedback questionnaire, subjective tutor evaluation and SHOs were developing consultation and communication skills appropriate to A&E, getting support from and giving support to other colleagues (a reflection of the rather lonely and stressful job of an SHO in A&E), and learning about the management and treatment of primary care problems.
Another approach to inserting the teaching of clinical skills within a crowded postgraduate programme was developed in Canada by Chan-Yan et al. (1988). Its purpose is to provide an ongoing review of physical examination which can serve as a top-up for first year residents. The four month course is taught in three parts each week:
Further details are in the article. The course has received a positive evaluation from all those involved and undergoes continuing improvement in the light of feedback.
Two skill-based courses in surgery for residents have also been reported. Lossing et al. (1992) describe a technical skills course for first year residents in general surgery, which runs for 3 to 4 hours a week for 8 weeks and includes 2 `dry lab' sessions (suturing and stapling) and 6 `wet lab' sessions. Residents showed significant improvements on a technical test and were better prepared for starting theatre work. The second describes a 3-day introductory course in laparoscopic surgery (Mari et al., 1995), in which morning sessions pursued cognitive objectives using problem based learning and checklist construction with tutorial support and afternoon sessions were devoted to practice with pelvic trainers. As the technology of simulation develops further, the role of such skills courses is likely to expand (Derossis et al., 1998b).
In many countries lectures in postgraduate education are linked to preparation for College or Board examinations which test both knowledge and its use in clinical situations. Their effectiveness depends not only on the quality and timing of the lectures themselves but also on concomitant teaching in clinical settings and time for independent study. Systems tend to be demand led (or demand resistant) but are not easily evaluated as there are few volunteers for a control group.
The role of lectures in promoting clinical competence is somewhat indirect. Their outcomes are normally measured by knowledge-based examinations, with the application of that knowledge being revealed mainly in clinical settings. However, unless accompanied by private study, knowledge gains from lectures can be very low (Wigton, 1981a). An unusual though pertinent example of a controlled study comparing ``lectures only'' with ``lectures plus'' interventions is provided by Sulmasy et al. (1993) in the field of ethics education. This showed that following lectures by case conferences with an ethicist in attendance did not increase the knowledge gain but significantly increased house officers' confidence in handling ethical issues. Sulmasy et al. (1992) discuss the impact of such ethics training on the treatment of patients with `do not resuscitate' orders.
A later study by Sulmasy and Marx (1997) of a two year medical ethics programme for house officers, comprising monthly sessions alternating ethics morning reports with ``didactic conferences'' describes consequent gains in both knowledge and confidence, as well as high ratings by 96% of the participants.
Cordes et al. (1996) report the development, evaluation and further improvement of a management training strand for residents in general preventive medicine. The original version comprised special projects, coursework, committee participation, administrative and program assignments, a one month administrative rotation and community rotations with administrative elements. This was well received but a survey of graduates also elicited several suggestions for improvement and indications of which aspects of the course could be strengthened. This led to further rotations with professional manager mentors and a series of management seminars, later expanded with a 1-semester course targeting selected management competences.
A different kind of learning environment is provided by day-release courses for General Practice Registrars (Jenkins, 1994). This national system has significant local variation but is highly responsive to local demand. There is a great deal of groupwork and sharing of experience, as GP registrars are more isolated than those in hospitals. It also offers the opportunity to update on clinical areas neglected in their previous hospital-based training, to study consultation and counselling methods, and to address some management topics. The introduction of summative assessment will have affected these courses, but so far there is only anecdotal evidence of this.
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5.6 SummaryResearch into postgraduate teaching and learning in non-clinical settings mostly comprises evaluations of a wide variety of teaching innovations, rich in ideas but not necessarily generalisable. In particular we would draw attention to improving the learning benefits of departmental conferences, developments in self-directed learning (more prominent for CME), skill-based courses in surgery, the use of GPs to teach primary care to house officers in Accident and Emergency departments, a system for teaching clinical examination comprising both seminar and ward-based components, and confirmation that various types of ``lectures plus'' teaching are more effective than lectures only. Several departures from the standard lecture format have been positively evaluated, as have variations on case-based departmental seminars.
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