The education of dentists and doctors is embedded in the practices and mores of two large service activities, namely education and the care of patients. These dual strands are present at all levels of training and are not always compatible; they are also subject to rapid policy change that impacts on how medical and dental educators can teach; we are not Medicine and dentistry ❘ 425
Interrogating practice
• What aims underpin an undergraduate curriculum with which you are familiar?
• Do you agree with the emphases of the aims?
• Do you think the curriculum is organised in such a way that the aims are fulfilled/attainable by most students?
free agents. Other impinging matters include the unit of resource for clinical teaching and the difficulty of attracting doctors and dentists into clinical academic posts.
The General Dental Council (GDC) and the General Medical Council (GMC) have statutory responsibility for approving undergraduate/graduate entry courses and publish curriculum guidelines and recommendations. For dentistry the Quality Assurance Agency (QAA, 2002a) Subject Benchmark Statement is expected to be updated in 2007/2008, while the statement for medicine (2002b) will be sub- sumed into a new version of the GMC’s curriculum recommendations over a similar time-scale.
In 1993 the GMC set out radical and extensive requirements for undergraduate curricula. The updated GMC document, Tomorrow’s Doctors (2003), the outcomes of further consultation (GMC, 2006a), The New Doctor (GMC, 2005) and Good Medical Practice (GMC, 2006b), set the context and requirements for university medical curricula. Among newer expectations and recommendations are the encouragement of innovation around a core curriculum of skills, knowledge and attitudes taught in an integrated manner, interprofessional training and greater emphasis on reflective and ethical practice. Greater emphasis is also placed on learning and study skills, being curious and critical in approaching knowledge and acquiring understanding of underlying principles, concepts and mechanisms rather than the teaching and regurgitation of enormous amounts of material. This is compatible with contemporary understanding of how students and professionals learn (see Chapter 2), but also needs to be aligned with provision of high- quality and safe patient care. Today most UK schools have a ‘core plus options’ approach to curricula, and use case or problem-based methods of delivery (see section on PBL, p. 427). Some core skills and knowledge are now often taught with other healthcare undergraduates, including nurses, therapists and radiographers. Preparation for professional practice is emphasised. Assessment has generally lagged a little behind other curricular reforms.
Early this century the desire to change the demographics of medical student entry led to the creation of new medical schools and graduate entry programmes. These, pioneered in the UK by St George’s Medical School, University of London, attract graduates from higher education. With more mature learning skills these students pass through an accelerated programme. This, the merger of several London medical schools creating year cohorts of over 350 students, and the changing knowledge of undergraduates entering higher education, have challenged curriculum leaders to devise bespoke and effective solutions, including means of accessing patients or exploring effective alternatives (see sections on simulation and technology, pp. 436, 437).
The GDC radically revised undergraduate curriculum recommendations in the late 1990s, and further updated them in 2002; these recommendations brought an evolutionary shift. The GDC emphasised its desire to see educationally progressive ideas and improved methods of study incorporated into curricula that were also to exhibit reduced congestion and earlier patient contact. The GDC recommendations are more prescriptive of ‘essential elements’ than the medical equivalent. The composite recom- mendations of the GDC visits to dental schools provide a good summary of recent 426 ❘ Teaching in the disciplines
practices and indicate areas in which the GDC would like to see further movement, including working in a dental team and the further development of outreach teaching that makes use of learning technology (GDC, 2006).
Postgraduate training in the UK has been the subject of much recent change and scrutiny and has increasing impact on undergraduate education. There is growing concern for a more holistic view of undergraduate and postgraduate training and for a continuum of learning and updating extending until retirement. The vocational year for newly qualified dentists is a requirement prior to independent National Health Service (NHS) practice and specialty registers were established some years ago.
In postgraduate medicine several far-reaching and hugely challenging changes have occurred in political control and the structure of training. In 2005 the government set up the Postgraduate Medical Education and Training Board responsible for post- graduate training. In 2006, as a by-product of Sir Liam Donaldson’s ‘Unfinished business’
(DoH, 2002), Modernising Medical Careers (MMC) was born. MMC saw the creation of the ‘Foundation Programme’, encompassing the first two postgraduate training years and the specialist ‘run-through’ training programmes. These were competency based, educationally supervised and structured with defined outcomes. They promised to
‘improve patient care by delivering a modernised and focussed career structure for doctors’ (MMC, 2007a). The Tooke Report (MMC, 2007b) is likely to result in further change.
In coming years with increasing clinical responsibilities being given to allied healthcare professionals, the further development of interprofessional practice, the shift to primary care, the growing use of evidence-based practice, enhanced use of technology, and more specialities entering the postgraduate preserve, the role of dentists and doctors will continue to evolve. All these developments have implications for undergraduate curriculum design, teaching, workplace learning and assessment. Among possibilities on the horizon are national undergraduate exit assessment and a national core curriculum.
PROBLEM-BASED LEARNING
Problem-based learning is an idea that has had currency since the 1960s (Neufeld and Barrows, 1974), but was not widely used in medical and dental education in the UK until the mid-1990s. It is now an element in many UK medical and dental undergraduate curricula, in some cases being the main organising principle and pedagogical method.
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Interrogating practice
Are you familiar with national recommendations for undergraduate and postgraduate training operating in your country and speciality?
Problem-based learning (PBL) takes many forms, but there are really only two types of pure PBL – the short case version and the progressive release version. The short case format is generally used in courses designed for school leavers; the progressive release version for graduates or more mature students. Both versions use the same underlying principles (see below).
In the short case format, students are given a short trigger (e.g. a clinical case, a photograph, a newspaper or journal article), usually no more than a page long.
In the progressive release version, the facilitator gives the students a much longer scenario in stages (see Figure 26.1). Students discuss each stage fully, before moving on to the next part of the scenario. Key to the process is the ‘inquiry strategy’ where students have to decide what history, examination, investigations and treatment would be appropriate, prior to receiving the results of their inquiries (i.e. students are required to think like doctors).
An example(each paragraph is a separate trigger and the whole PBL is much condensed):
Michael Hennessy, a 55-year-old architect, presented to his GP with stomach pain.
He said he had been violently sick the night before after attending a celebration dinner with some friends at a local curry house.
Students hypothesise possible causes and suggest questions to ask Mr Hennessy which would help them distinguish between their hypotheses.
Mr Hennessy explained that the severe pain lasted for about five hours and then slowly subsided. He felt perfectly healthy again after a good night’s sleep.
He put it down to ‘something he ate’. He admitted that the same thing had happened a few days before, but the pain had not lasted for quite so long.
When asked where the pain was, he pointed to the epigastric region and right hypochondrium. He described the pain as colicky and griping and it seemed to move around to his back. He had taken paracetamol and that had helped the pain somewhat.
Students debate how this information has helped them and suggest what examination the doctor might carry out.
Mr Hennessy’s height was 178cm and his weight was 105kg. His oral temperature was 36.6oC. Dr Oshima, the GP, noted that his sclerae were yellow, though there was no pallor of the conjunctivae. There were no signs of chronic liver disease. His mouth was dry. He had tenderness in the right upper quadrant of his abdomen and Dr Oshima could not press too deeply here. There was no 428 ❘ Teaching in the disciplines
Case study 1: Problem-based learning – progressive release version
demonstrable rebound tenderness. There was no organomegaly or ascites. Bowel sounds were present. Mr Hennessy’s blood pressure was 130/90mmHg, and his pulse rate was 80 beats/minute. Dr Oshima asked Mr Hennessy to provide a fresh urine sample. The sample was dark brown in colour. Asked about his stools, he admitted that he had noticed they had been a bit paler than usual.
Students discuss the implications of the new information and suggest investigations which might be carried out. They discuss the relevant anatomy of the hepatobiliary tree, jaundice and the significance of the results.
The students are then supplied with the results of relevant investigations including blood tests and an ultrasound scan; they discuss the significance of these findings and suggest what further action should be taken.
An ERCP was arranged which confirmed the presence of several small stones in the common bile-duct.
The students compare and contrast the techniques for detecting stones. They discuss informed consent for ERCP and suggest treatments.
A sphincterotomy was performed to remove the stones.
The students discuss what they know about the procedure, alternatives and prognosis.
The case would then develop further with such complications as a post-operative infection, recurrence of the gallstones or perhaps a subsequent infection with hepatitis. At each stage, the students draw up a list of topics to research and feedback on. A single case usually spans three tutorials, and may be up to 20 pages long, depending on its complexity.
Students enjoy this way of learning. They are in control and decide what to research, and because they all research every learning issue, the debate during feedback is often at a very high level and enormously stimulating for the staff to listen to. The different members of the group bring different experiences to the tutorial, depending on their background knowledge. They feed off each other’s skills and knowledge. This form of PBL mirrors real life, albeit in slow motion, and helps the students to think clinically, learn medical terminology and interpret clinical data (especially since they are supplied with real lab reports, radiological tests, photomicrographs and patient discharge summaries). At the same time, the students learn their basic science through these ‘real’ cases. Although their learning is less detailed, it is much more relevant, deeper and more lasting.
Students have a problem knowing whether or not they have learnt enough in PBL. They only really find this out when they are assessed. But it is the cases, not the assessment, that drives the learning. The assessment defines the depth of their learning. By asking searching questions where students have to reason and apply their knowledge, they learn to reach beneath the trivial detail and get at the underlying concepts. That is what PBL is all about. And it’s great fun.
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(Professor Peter McCrorie, St George’s Medical School, University of London)
Boud and Feletti (1997) provide an excellent review of the range and variations of the different models of PBL. Among the most distinctive aspects are:
• learning and teaching stems from, and comes after, exposure to a scenario or trigger (the ‘problem’) which is presented without prior detailed teaching of all the material involved;
• students, not the teacher, make the immediate decisions about what they will research/learn in relation to a scenario;
• a non-didactic tutor/facilitator;
• interrogation of clinical and non-clinical subject matter;
• students report back and discuss their findings.
Teachers starting to use PBL often find they need to develop new skills. The following guidelines are useful pointers. The facilitator:
• is not there to lecture. The facilitator keeps the process true, guides but never leads the students (avoiding misinformation), and (in many versions) assesses performance;
430 ❘ Teaching in the disciplines
PBL 1: case begins Self-assessment
Share knowledge
PBL 3 case epilogue PBL 3 report back
PBL 2 report back PBL 2 case continues
Self-directed learning Group define learning issues
Self-directed learning
Share knowledge Group define learning issues
Share knowledge
Figure 26.1 PBL at St George’s
• establishes or reiterates group ground rules when taking a new group;
• assists students to fulfil their roles, but does not usurp their positions;
• assists in creating an exploratory and non-threatening learning environment;
• ensures that students feel able to question and query each other, using an appropriate manner;
• encourages students to use and formally evaluate a wide variety of information sources, including the internet;
• assists students to present cogently;
• asks students periodically to summarise a case or aspects of it;
• at the end of each problem asks students to evaluate how they tackled the problem and suggests how the process could have been more effective;
• gives feedback to the students about their performance in a specific, constructive manner (generally within the group setting).
No matter what version of PBL is used, it is important to train staff and students in its usage, provide adequate tutorial and study rooms and ensure that learning resources are available. Like other teaching modes, PBL requires assessment methods appropriate to the expected learning outcomes and suitable evaluation (see Chapter 14). Time is needed for curriculum planning, writing, updating, and rewriting problems and assessments, and developing supporting tutorial material.
In Case study 1 the author refers to the perceived benefits of PBL. Much research into its impact has been conducted. Early classics still worth consulting include: Schmidt et al.,1987; Norman and Schmidt, 1992; Vernon and Blake, 1993; Albanese and Mitchell, 1993. Challenge and counter-challenge are still occurring and more recent pieces worthy of consideration include: Dolmans (2003); Dolmans and Schmidt (2006); and Neville and Norman (2007).
There is some evidence that:
• PBL students take more of a deep approach to learning (see Chapter 2);
• students on traditional curricula tend to score slightly higher on conventional tests of knowledge, but PBL students retain their knowledge longer;
• students perceive PBL as more clinically relevant and rate their programmes more positively.
Medicine and dentistry ❘ 431
Interrogating practice
• Make a list of pros and cons about PBL that you think are important.
• If you use PBL now, what do you think of the way your school uses it: does it maximise its potential benefits? Why/how might that be different?
• If you do not use PBL, could you introduce it into any teaching you are connected with? Is the effort likely to be worth the rewards?