Theories about learning are ignored, misunderstood and misused in medical education- Janet Grant


 Medical Education Conference at UHS-II

Theories about learning are ignored, misunderstood
and misused in medical education - Janet Grant

Teachers should organize learning to suit learner’s stage of development

LAHORE: Dr. Janet Grant from UK was the first speaker in the plenary session on first day of the 2nd international conference on medical education organized by Council for Collaboration for Medical Education (CCME) at University of Health Sciences Lahore form October 29-31st 2015.  Topic of her presentation was Learning Theories, Curriculum integration and the Transition to Practice. This session was chaired by Prof. Sardar Fakhar Imam Vice Chancellor of Fatima Jinnah Medical University along with Prof. Kazi M. Saeed.

Dr. Janet Grant

Dr. Janet was of the view that theories about learning are ignored, misunderstood and misused in medical education. Medical educationists must understand nature of theories and evidence in education.  She pointed out that adult learning theory, active passive learning, and learning centered and experimental learning are not theories. Similarly Pedagogy, and ragogy, self-directed learning are just ideas but not learning theories.Learning in the way we practice is a good idea.  Similarly learning around a case is a good idea. Learning facts are rot learning which is bad. Facts prevent understanding, teacher lead instruction is passive. Long term memory is limitless. Facts in long term memory are key to learning.  Active efforts are needed to retain information in short term and still more efforts are need for long term memory. All effective learning is not visible. Learned knowledge, Janet Grant said is always changing. Technology does not change the way brain learns and solves problems. She then mentioned about communication, ethics and professionalism and said that knowledge gives freedom and liberties. Process of learning from others are observation and not theories.  Teachers should organize learning to suit learner’s stage of development. Reliance on technology can be a dangerous thinking. People need to learn basics in their own structure of basic and clinical sciences, she added.

Dr. David Taylor 

Dr. David Taylor from Liverpool UK talked about Residents as Trainers. Training, he said, was a continuous process and it should be a smooth transition from undergraduate to early clinical years. During early clinical experience we appreciate supervision. Then there is a time for reflection. We appreciate mentoring.  Responsibility with competence comes after appropriate training. For mentoring and supervision, residents are used as clinical teachers.

He opined that all doctors should be able to teach doctors, their families, and colleagues. It is time tested and it should be used effectively. Residents, he further stated, are more likely to spend more time with their juniors and it inculcates good practice.  Good Clinical Practice leads to improved skills and behaviour. It also results in better retention of clinical knowledge.

Prof. Ara Tekian

Prof. Ara Tekian’s presentation was on “Towards a Competency Based Medical Education: Implications for Curriculum and Assessment”.  He discussed in detail the competency based model, integrated organ system model, public dis-satisfaction with accrediting and quality of care, patient created demands and patient safety. Competence, Prof. Ara Tekian said is measured and assessed if the competency is observable.  Outcome based evaluationleads to competency based.

Speaking about levels of supervision Prof. Ara Tekian mentioned be part and observe, may act under protective or full supervision, may act under access to supervision if and when needed, may act unsupervised and finally allowed to act without supervision. He then emphasized the importance of Honesty, truthfulness, reliability. Competencies, Ara Tekian stated, must be clearly defined. It is better to define milestones for each competency. To integrate your competences, it requires robust work based assessment. One must be willing to incorporate new ideas, produce competent physicians based on competency. He further stated that competency based monitoring is important, timely, effective if applied at undergraduate and postgraduate level.  For all this provision of adequate resources and committed leadership is essential. Competency milestones are challenging, he concluded.

Dr. John Norcini

Dr. John Norcini spoke on Workplace Based Assessment. He discussed in detail the different challenges and opportunities in assessment, rational for work based assessment. Education and assessment needs, he opined, should be kept within range of patient problems. It is difficult to develop educational assessment material locally since resources are fragmented between specialties. Routine interaction between trainees and patients is beneficial.  Non experts can use check lists and provide feedback and guidance.  However, it misses some perspectives as compared to experts. It requires observation by an expert which allows the use of judgment.  Faculty development is essential. Students respect what you inspect. Provision of feedback in surgery, Dr. John Norcini said was limited.  Assessment provides feedback. Trainees needs to be assessed with more than one patient. Assessment should be by multiple examiners as examiners differ in stringency. Power of accurate observation is frequently called cynicism. It is essential to provide feedback to the trainees, create place for remediation, and develop evidence for dismissal. Quality, John Norcini said, depends on faculty development.

Dr. Mowadat H. Rana from Pakistan was the last speaker in this session. Keeping up his tradition of selecting an innovative topic for his presentation, this time he spoke on “Putting Cartbefore the Horse: Frame Factors in Integration”. He was of the view that we look better at psychological and social factors as compared to other colleagues. Speaking about physical frames and settings, Dr. Mowadat Rana said that setting in which educaiotn takes place is changing. Referring to the economic frame, he said that now whosoever has got money was establishing a medical or dental college in the private sector and many of them have no medical educaiotn background. Medical educaiotn in Pakistan, he said, was going to be a big issue in the days to come. He laid emphasis on establishing Health Promoting Hospitals, prevention of diseases which was missing from our medical education today.

The second plenary session was chaired by Prof.  Hamid Mahmood Butt. Prof. Rukhsana Zuberi from AKU was the first speaker and she talked about preparing the students for the real World. Talking about integrated practice and integrated curriculum, she referred to the seamless weaving together of knowledge in patient centered care. She reminded the audience that almost 80% of our medical graduates are going to settle in General Practice and only 20% will become specialists. Hence they need to be trained in basic services, ethics, psyche and culture. She emphasized the importance of integrated services, patient care, professionalism, advocacy, pedagogy, team work, research, communication skills. They should have knowledge for critical thinking. Education and teaching should be integrated between cognition, knowledge, skills, and attitude and there should be integrated assessment. At present most of the students learn for tests and faculty teaches to the Test. What students will do to the patients if curriculum is integrated? Assessment should be at workplace, wards, in the Operation Theatre, in Emergency, community, at primary, secondary and tertiary care level.  She also referred to case based discussions, scenario based problem solutions, teaching and assessment integration.

Dr. Gominda Ponnamperuma from Sri Lanka discussed feasibility of running an integrated curriculum in South East Asia. He said that we should teach theory first and then expose the students to practice in basic sciences and clinical sciences. Speaking about   integration of soft skills and disciplines, he said, it can be realized through feasibility, practicability and cost effectiveness, teaching and learning assessment. Number of trained staff, staff and students support system were available. Nature of the contents material is dependent on the organizational framework of the institution. Educational environment including educational facilities were available. Educationists as leadership was the most important.  He then spoke about the body systems, current theories, PBL, Human life cycle, core clinical problems, EPAs, multidisciplinary teaching and training and felt that there will always be a way out for the problems.

Continuing Dr. Gominda said that we often hear that students are not reading. They like activity based teaching. Theory should always follow practice. The common criticism against integration is that students can pass withoutachieving 50% in each subject. In integrated curriculum while teaching cardiovascular diseases one should teach them the related physiology and anatomy. He then laid emphasis on documentation of curriculum, role of other disciplines and peer review of contents. All this should be planned properly and it should match with available resources. It should be in the existing system and should be integrated.

Dr. Madewa Chandratilake also from Sri Lanka made a presentation on Culture related dilemmas faced by medial students in Asia, their effects and lessons for medical educators. He emphasized the importance of professionalism, empathy,emotional engagement, open communication and patient centered, patient autonomy which were the most prevalent cultural and ethical issues. Speaking about the cultural theories he said that it was a fact that sometimes the patient dies before knowing their diagnosis.

 Council for Collaboration in Medical Education organized an international conference on Medical Education at UHS
last month. Photograph shows from (L to R) Prof. Aslam VC UHS presenting memento to Prof. Majeed Chaudhary 
extreme left and to Prof. Fareed Zafar on extreme right. Picture also shows Prof. I.A. Naveed, Prof. Majeed
Chaudhary and 
Prof. Junaid Sarfraz presenting mementos to Prof. Lubna Baig and other guest speakers. 

Prof. Lubna Baig from Jinnah Sindh Medical University Karachi in her presentation asked whether integrated curriculum can raise the standard of medical educaiotn in Pakistan. Our target, she emphasized, should always remain better patient care. We need high quality of medical educaiotn but it does not happen like that. There are various steps in integration of curriculum. She referred to the role of PM&DC, World Federation of Medical Educaiotn, Higher Educaiotn Commissionof Pakistan and said that faculty must take ownership of the curriculum issues. Institutions have the mandate from the community to produce competent doctors but are we fulfilling this mandate given to us by the community, she asked?

Prof.Khalid Masood Gonda Director CPSP Regional Center Lahore highlighted the salient features of electronic logbook introduced by CPSP from supervisor’s perspective. CPSP he said, has set up one of the best residency programme with adequate monitoring. CPSP has fourteen regional centers. Currently 22,421 postgraduates are enrolled which are being supervised by 3152 supervisors at two hundred seventy eight institutions. In the past there were lot of shortcoming which lead to poor training. Now the report is submitted by the supervisor to the CPSP after every three months, 75% of supervisors have logged in and 27% are giving regular feedback. Majority of the trainees have logged in. This is a better monitoring system and was also user friendly and it is good for developing countries, he added.

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