Date: 2023-12-06 

The Presentation

Pre-workshop reading 

Learning and teaching in the clinical environment

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1125480/ 

Kettle boiling 

The core case used for the session 

You are GP tutors. 

You have four medical students attending your practice. You are meeting them for the first time. Your goal is to plan the day and sessions. 

Outline of the day 

• Morning clinic with patients 

• Lunch 

• Tutorial 

Building empathy by activating prior experience and user profiling 

Personal prior knowledge 

Notes from the menti responses 

The responses provide valuable insights into the experiences and challenges faced by medical students during their transition to GP practice. By acknowledging these challenges and seeking to address them through targeted teaching strategies, we can create a more supportive and effective learning environment for their students.

• The initial transition from hospital to GP practice can be overwhelming and exciting. Tutors acknowledged the challenges and anxieties that medical students face when entering the GP setting, which is significantly different from the hospital environment.

• Active involvement in consultations and role-playing activities enhances learning. Tutors highlighted the importance of providing opportunities for students to actively participate in consultations and role-plays, allowing them to apply their knowledge and skills in a practical setting.

• Limited involvement in clinics can hinder learning opportunities. Tutors acknowledged that simply observing consultations without active participation can diminish the learning experience for students.

• Passive observation without opportunities for active engagement can hinder learning. Tutors emphasized that simply sitting in the corner of a room and observing consultations is not an effective learning strategy. Instead, students should be encouraged to engage actively, ask questions, and participate in discussions.

Social Learning Theory by Albert Bandura:

According to Bandura, individuals learn through observation and imitation. The transition from hospital to GP practice, with its different environment and patient interactions, presents a challenge for medical students. By providing opportunities for active participation in consultations and role-playing activities, tutors can foster observational learning, allowing students to observe experienced healthcare providers and emulate their behaviours and communication skills.

Constructivism:

Constructivism emphasizes that learners actively construct their own knowledge through experiences and interactions. By actively engaging in consultations and role-playing, students can actively construct their understanding of clinical practice, applying their knowledge and skills in a practical setting. This hands-on approach fosters deeper understanding and retention of information.

Building learner (or user profiles) to develop empathy 

User profiling is a helpful tool that educators can use to get to know their students better. This simple but powerful technique helps us understand student's perspectives and goals. By creating profiles, we can better tailor our teaching methods to student's needs and preferences.  User profiling also allows us to identify areas where students may need extra support. 

During the workshop, we created student profiles. We have included one example below (from Group 2) and made two profile statements. 

Workshop notes on student profile - group 2 

What is your student's name? And demographic details 

Michelle, 23 years old student.

White British.

Studying at QMUL

Live in Tower Hamlet

What are their needs? 

- Preparation for the real world of medicine

- first time in GP practice, may have never seen how a GP works before, exposure to the routine 

- Need experience in history taking in GP practice and focused examinations  

- Exposure to common GP presentations that may not be seen in hospital.

- feeling welcome by the practice

- being given time to ask questions

What are their pain points?

- stress of being a student and exam pressure, and passing each module/rotation.

- unsure about depth of knowledge needed.

- communication skills- maybe limited experience speaking to patients. Different communicating with patients in the community.

Write a few sentences to introduce the student in the first person (I am a….I need to ….I find this….I am hoping to…..)

Hello, my name is Michelle. I am hoping to learn as much as possible from this rotation. 

Michelle (Group 2)

 My name is Michelle, I am a 23-year-old medical student from the White British community. Currently studying at Queen Mary University of London, I'm eager to gain firsthand exposure to the daily routine of a GP practice and immerse myself in the real world of medicine. As a novice in this setting, I'm particularly interested in developing my history-taking and focused examination skills to effectively manage common GP presentations. I also hope to feel welcomed by the practice and have ample opportunities to ask questions, as I navigate the nuances of communication in the community healthcare setting. While the pressure of exams and the uncertainty about the required depth of knowledge can sometimes cause stress, I'm determined to embrace this rotation as a valuable learning opportunity and become a more confident and competent healthcare provider.

Fatimeh  (Group 3)

I am Fatimeh, a third-year medical student from a non-English-speaking country. As an international student, I'm eager to enhance my communication skills with patients and gain confidence in my clinical abilities. This rotation provides a valuable opportunity to expand my exposure to the diverse patient population and develop my diagnostic skills independently. However, the distance from the clinic and my financial constraints make participating in the full schedule challenging. I plan to find a balance that allows me to maximise my learning while managing my circumstances.

Menti on user profile activity

Notes on the menti

• Profiling medical students is a valuable tool for understanding their needs and challenges. Participants recognise that profiles can provide insights into students' prior experiences, learning styles, and personal circumstances, which can inform more effective teaching strategies.

• Participants recognise that students may have external pressures, such as tight schedules or financial concerns, that could affect their ability to focus on learning. By understanding these factors, we can provide additional support or adjust their teaching approach to accommodate students' needs.

Humanism:

Our lived experiences as medical students can enhance our ability to empathise with students and provide personalised support. This aligns with humanist principles, which emphasize the importance of understanding the learner's emotional, social, and psychological factors. By connecting with students on a personal level, tutors can create a supportive and nurturing learning environment that promotes academic success.

Scaffolding:

Profiling can help tutors identify students' learning gaps and provide appropriate scaffolding to support their progress. This aligns with Vygotsky's concept of scaffolding, which refers to the support provided to learners as they move from the zone of proximal development (ZPD) to the zone of independent performance. By understanding students' current ability levels, tutors can adjust their teaching strategies to provide effective scaffolding and promote their learning.

Teaching in clinics

Planning a clinic with students

During our clinic learning encounter planning workshop, we considered a scenario in which a patient with COPD presented with a cough that had lasted for a few days. The brainstorming session revealed a wealth of potential teaching opportunities. Student feedback consistently underscores the value they place in patient encounters, and this scenario highlights the abundance of learning avenues that arise from patient interactions. However, along with these opportunities come challenges. Clinical teachers must effectively balance prioritising teaching topics, managing patient care, and nurturing a productive learning environment. Our session demonstrated how anticipation and planning can pave the way for enhanced student learning experiences. Throughout GREAT, we will delve into additional topics that empower clinical teachers to excel.

Common problems with clinical teaching (BMJ)

• Lack of clear objectives and expectations

• Focus on factual recall rather than on development of problem solving skills and attitudes

• Teaching pitched at the wrong level (usually too high)

• Passive observation rather than active participation of learners

• Inadequate supervision and provision of feedback

• Little opportunity for reflection and discussion

• “Teaching by humiliation”

• Informed consent not sought from patients

• Lack of respect for privacy and dignity of patients

• Lack of congruence or continuity with the rest of the curriculum

Case scenario 

A 65-year-old patient with COPD is attending the clinic. She has had a worsening cough for four days.

Workshop questions and answers to help plan a clinic teaching sessions

• What are the patients needs? Think biopsychosocial needs. Think about acute & chronic care.

  • To see someone appropriately qualified to deal with their presentation.

  • Feel heard and looked after.

  • Managing acute cough.

  • Enquire about ADLs / level of independence.

  • Medication review, preventative measures

  • Explore ICE.

  • Appropriate safety netting.

• Brainstorm learning opportunities when students are in clinics. What can they learn from the above patient?

  • History taking - cough / cardioresp presentations

  • Examination findings - ?wheeze / crackles

  • Measuring vital signs.

  • Management of unwell patient in primary care - knowing when to refer to secondary care.

  • Chronic disease management - PSO.

  • Motivational interviewing

  • PUNs and DENs

  • Prioritising, managing complaints simultaneously

  • Generating a reasonable set of DDx

• Before you start the clinic, you need introductions and prepare the students. How will you do this?

  • Brief them about patient.

  • Brainstorm - how the student plans on approaching the case.

  • Discuss patients possible agenda vs clinicians agenda.

• How do you prepare the practice and patients?

  • Posters / leaflets in practice ‘teaching practice’.

  • Text patient beforehand.

  • Discussion with admin team.

  • Gaining consent from patient.

  • Setting patients expectations - might be a longer consultation

• How will you involve the patient?

  • Shared decision making.

• How will you plan the debrief?

  • Go through hx / exam in a separate room (without patient).

  • I like, I wish, I wonder

Menti

Notes on the menti

• Patients can be valuable educators for medical students. They can share their experiences, perspectives, and insights, which can help students to better understand the patient's perspective and to develop their communication and empathy skills.

• It is important to think ahead and be flexible. Things don't always go according to plan in the consultation setting, so it is important to be able to adapt to unexpected situations.

Tutorials

Planning tutorials - anticipating challenges and opportunities 

The anticipation of challenges is rooted in proactive learning and risk management principles. By identifying potential issues, tutors can develop strategies to address them and ensure a smooth and productive learning experience.

Workshop questions and answers (collated)

• How can you make the tutorial authentic?

  • Based on a real-life case from emis or personal experience in a hospital

  • Not just regurgitating guidelines but focusing on one area of DM

  • Linking to exam and real-life scenarios

  • Role play and asking learners about their experience with diabetes

• What are likely compelling CKD topics?

  • Learning needs that are likely to appear in exams.

  • Interesting cases such as kidney-pancreas transplants and teaching OSCE exam

• Are there potential tensions that could arise?

  • Wrong knowledge pitch or giving too much information

  • Short of time or pitching at too high or low level

  • Keeping students engaged for 90 minutes or disagreement by the learner

• What are the potential trade-offs you will have to make?

  • Only able to focus in-depth on one particular topic

  • Deciding which area to focus on ahead of time

  • Knowing students' pre-existing knowledge or where to draw the line.

• What are the potentially surprising or counterintuitive moments?

  • Students might know more than the trainer or disagree with you.

  • They might be too rigid in following the guidelines or have different views.

• What are the potentially difficult or confusing to understand topics?

  • Numerous medication options or the difficulty in getting some of them

  • Motivational interviewing or clarifying mechanisms of diabetes

• Are there moments when they are likely to go off track?

  • Students have queries about other types of DM or other topics.

  • When students are tired or bored

The questions and answers above highlight two key themes that are relevant to planning tutorials: authenticity and potential challenges.

Authenticity aligns with constructivist learning theories, emphasising prior experience and active learning in constructing knowledge. By grounding the learning experience in real-world contexts, tutors can facilitate deeper understanding and engage students more effectively.

Authenticity

Authenticity is crucial for providing a meaningful learning experience. By drawing on real-life cases, experiences, and examples, tutors can connect the material to students' lives and make it more relatable. This can be achieved through role-playing, asking students about their experiences, and linking the material to exams and real-life scenarios.

Authenticity also involves focusing on specific areas of interest and incorporating engaging teaching methods. By selecting topics that are likely to appear in exams and incorporating interesting cases and interactive activities, tutors can keep students engaged and motivated.

Potential Challenges

While authenticity is important, it is also essential to anticipate and address potential challenges that may arise during tutorials. These include:

• Knowledge pitch: Providing too much or too little information can lead to confusion and disengagement. Tutors need to gauge students' pre-existing knowledge and tailor their explanations accordingly.

• Time management: 90 minutes is a limited time frame, and it can be difficult to cover all the material effectively. Tutors need to prioritise key topics and ensure that their explanations are concise and engaging.

• Student engagement: Keeping students interested and motivated throughout the tutorial can be challenging. Tutors need to use a variety of teaching methods and incorporate activities that allow students to participate actively.

• Student disagreement: Students may have different opinions or perspectives on the material. Tutors need to be prepared to handle disagreements respectfully and encourage open discussion.

Planning tutorials - using GNOME

Task: Plan a tutorial on diabetes for year 3 medical students. Use the GNOME format.

The GNOME framework, a straightforward yet powerful tool, guides educators in devising effective teaching encounters. It encompasses fundamental pedagogical principles, ensuring alignment with learning goals and student needs.

Collated responses from the workshop groups 

Goals

• Guide students through an annual review of diabetes, covering diagnosis and management.

• Enhance students' understanding of the diagnostic process in diabetes, including eliciting salient history and ordering appropriate tests.

• Promote students' grasp of basic pathophysiology of diabetes and its impact on patients.

Needs Analysis

• Identify students' pre-existing knowledge and expectations regarding diabetes.

• Assess students' understanding of the diagnostic process and pathophysiology of diabetes.

• Align learning objectives with the medical student's curriculum and exam requirements.

Outcomes

• Students will be able to diagnose new cases of type 2 diabetes mellitus (T2DM).

• Students will gain an understanding of key aspects of diabetes management.

• Students will be able to explain diabetes to laypeople.

• Students will be able to explain general principles of diabetes management.

Methods

• Pre-meeting form to gather students' learning preferences.

• Case-based teaching approach to simulate an annual review of diabetes.

• Active discussion on diabetes management strategies.

• Role-playing activities to practice diagnostic skills and patient communication.

• Access to additional learning resources, such as CKS links and slides.

• Assignment of a presentation on a diabetes-related topic for the following session.

Evaluation

• Pre- and post-tutorial quizzes to assess retention of information and understanding.

• Feedback session following the role-playing activity to identify key learning points.

• Review of original learning objectives and learner feedback to assess satisfaction and comprehension.

Menti 

Notes on the menti

• The focus of the tutorial: The response highlights the importance of defining clear learning objectives and selecting relevant topics for tutorials. This aligns with the principles of goal-setting and specificity in educational theory, which emphasise the need to establish clear learning goals and tailor teaching strategies to address those specific objectives.

• Authentic structure: The response suggests incorporating authentic learning experiences, such as using patient cases and role-playing scenarios. This aligns with situated learning theory, which advocates for connecting learning experiences to real-world contexts to enhance understanding and retention.

• Flexibility: The response acknowledges the need for flexibility in tutorial delivery to accommodate unexpected events or student needs. This aligns with the principle of adaptability in educational theory, which suggests that effective teaching should be able to adjust to changing circumstances.

What stood out - whole session

Behind the scenes - by RA 

Despite LY's absence from Session 1, I adapted the remote delivery and implemented parts of team-based learning.  However, an initial oversight prevented participants from editing the Google Doc, which was rectified.  More prominent, clearer fonts would enhance the readability of Google Docs.

The extended breakout sessions effectively managed the flow of the session.  A mentimeter was utilised after each session and yielded insightful responses. The ability to revisit each question would be beneficial.

Asynchronous teaching addresses timing constraints. Authenticity was fostered by incorporating Year 3 as an example. Prior knowledge activation and user profile exploration facilitated empathy with students, empowering us to plan for their learning effectively.

Collating notes and adding personal reflections enriched my understanding of the topic and evaluated my learning. Capturing information is indeed valuable for this purpose.

Here is my GNOME 

Goals

• To enable educators to plan effective learning encounters that meet the needs of their students.

Needs

• Equal talk time: Ensures that all participants can share their ideas and perspectives, promoting active engagement and inclusive learning.

• Psychological safety: Create a supportive environment where educators feel comfortable asking questions, sharing their thoughts, and taking risks without fear of judgment or ridicule.

Outcomes

• Empathise with students to understand their needs using personal experience, student handbooks, and user profiles: Fosters a deeper understanding of student learning styles, backgrounds, and motivations, enabling educators to tailor their teaching approaches accordingly.

• Understand and apply learning needs analysis: Equip educators with the tools to systematically assess student learning needs, identify improvement areas and guide effective interventions.

• How to Plan for Introductions: Develop a comprehensive approach to planning initial encounters with students, creating a positive and engaging learning environment from the outset.

• How to Plan for Teaching Patients in Clinics, including Common Problems: Provide educators with strategies for incorporating real-world patient scenarios into their teaching, enhancing the authenticity and relevance of learning experiences.

• How to plan for tutorials by understanding and anticipating challenges, opportunities and using GNOME structure: Equip educators with the skills to effectively design and structure tutorials, anticipating potential challenges and opportunities, and utilizing the GNOME framework to ensure a clear and organized approach.

• Understand the authenticity of the teaching activity: Promote a shift towards authentic learning experiences that align with real-world applications and challenges, enhancing student engagement and motivation.

• How to transform passive observations to active observations: Encourage educators to move beyond passive observation of student learning and engage in active observation, using questioning and feedback techniques to promote deeper understanding and critical thinking.

• Know Ausubel's theory of meaningful learning and constructivism: Equip educators with a strong foundation in learning theories, Ausubel's concept of meaningful learning and constructivism, ensuring that teaching approaches align with principles of effective learning.

• Understand the knowing-doing gap and apply the 'How' approach: Bridge the gap between theoretical knowledge and practical application, emphasizing the "How" approach to teaching, which focuses on providing students with the tools and strategies to apply their knowledge in real-world settings.

• Explore kairos for unplanned moments: Encourage educators to recognise and capitalise on unplanned moments in the classroom, using kairos to introduce spontaneous opportunities for learning and engagement.

Methods

• Breakouts in small groups: Divide participants into small groups to facilitate active discussion, collaboration, and brainstorming, fostering a sense of community and ownership.

• Using Google Docs to share thoughts and complete tasks: Utilize collaborative document sharing to encourage group work, enhance communication, and provide a shared platform for documenting ideas and findings.

• Large group discussions: Facilitate large group discussions to share insights, collectively synthesize information, and engage in critical thinking exercises.

• Mentimeter to capture thoughts and complete surveys: Utilize Mentimeter to gather real-time participant feedback, assess understanding, and identify areas for additional discussion.

Evaluation

• Using Mentimeter - what stood out: Evaluate the effectiveness of the training through Mentimeter surveys, asking participants to reflect on the key takeaways and identify the most valuable aspects of the learning experience.