Career Focus

Thinking about teaching?

BMJ 1999; 318 doi: https://doi.org/10.1136/bmj.318.7196.2 (Published 29 May 1999) Cite this as: BMJ 1999;318:S2-7196
  1. Zoë-Jane Playdon, regional education adviser
  1. South Thames Department of Postgraduate Medical and Dental Education, London WC1N 3EJ

    Most medical teachers are not taught how to teach. Zoë-Jane Playdon writes about what you might learn from a programme of teacher training

    Consider the distinction between training and teaching. The concept of training has application when (a) there is some specifiable performance that has to be mastered, (b) practice is required for the mastery of it, and (c) little emphasis is placed on the underlying rationale. The typical term for the educational process by which people are brought to understand principles is teaching, for teaching - unlike training or instructing - implies that a rationale is to be grasped behind the skill or body of knowledge..1


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    If I ask someone how to do something and their answer begins with the words “Always and only,” then I know that I am in a training environment. The matter is not up for discussion, there are not exceptional circumstances; just do it and do it like this. Some of medicine is like this: the disposal of sharps, scrubbing up, keeping patient records. But to understand not just what is done but why it is done we must turn to teaching, to the rationale behind professional action.

    Summary points

    • Teaching requires a different methodology from training: teacher education is different from training the trainers

    • Teacher education for medicine should be in the context of patient care

    • Programmes should assist participants to formulate problems from their own experience rather than giving “10 top tips”

    • Causing distress in learners is unethical and never permissible

    • Don't settle for second best

    Teaching postgraduate doctors the sensitivity and discrimination required in the complex process of making clinical judgments cannot be done through the checklists and competence bases used in training. Action is provisional to the context in which the doctor must act, rather than being pre-specified. Discussing and exploring the reasons why a particular procedure has been chosen opens up the whole vista of medicine in all of its excitement, uncertainty, and possibility, which mere training can never do.

    Resources for teacher education

    • University departments of education are the main national resource for teacher education

    • Contact your local deanery to see what is on offer: South Thames offers a variety of programmes, including one to one observation and discussion

    • Reading that clinical colleagues have enjoyed includes:

      Holt J. How children fail. London: Penguin, 1964

      Holt J. How children learn. London: Penguin, 1967

      Neill AS. The new Summerhill. London: Penguin, 1992

      Kohl H. On becoming a teacher. London: Methuen, 1984

    So, what will you be taught on your teacher education course? How to say “Just do it” in a variety of ways - 10 top tips for trainers, in other words - or how to engage with postgraduate doctors, how to support their inquiry, and how never to dampen the enthusiasm that they bring into medicine?

    Doing it or only talking about it?

    Teaching, like medicine, is a practical activity. It is enacted in a lived daily context and has to do with interactions between people. Postgraduate medicine is learned, in the main, through “'the professional conversation,' the ongoing interchanges about patients, principles and procedures,”.2 which reflects on, and is part of, clinical practice. Teacher education is about how that conversation is carried out, what is actually said and done between postgraduate doctors and their professional colleagues, and the impact that this has on them. In mainstream teacher education this is often done by workplace observation, and a one to one, confidential “professional conversation” afterwards.

    To discuss education is a good thing, but to do nothing but discuss it is to present a limited experience at best and to miss the mark entirely at worst. In the past, at least one regional teacher education scheme for primary care put general practitioners through an extensive programme that included several workshops, a resource audit of the practice, videotapes of consultations, an interview - everything except whether the person concerned could actually teach. What does teaching accreditation mean if no one has ever seen you do it?

    There is a deeper problem here. If conversation about teacher education misses out its actual practice, then from where is it deriving its principles? If it is not observing real life interactions between postgraduate doctors and those from whom they learn, then how can it develop theories based on practice? Without such an approach - termed “praxis” - what is left is the so called “Academy,” the “production of alienated knowledge out of a denied labour process.”.5 Praxis takes the real life problems of patient care as its starting point. The approach of the Academy, however, is to impose abstract theory (such as learning styles or outcome measures) in a process that is at once unscientific and unhumanistic since it denies the daily work of medicine.

    Open discussion or not?

    If your purpose is to discuss the ins and outs of education, then is the discussion an open one? For example, consider the literature on appraisal, which says that it should be “characterised by mutual trust and respect, openness and a non-threatening atmosphere.”.4 While this may be true in some cases, in others the atmosphere may be better characterised as “overtly huggy-wuggy, secretly stabby-wabby.”.5 The unequal balance of power between employee and employer, the judgments that are being made, and their effects on the employee's career militate against openness.

    Contrast this with professional conversations in clinical care, where, if you are unsure about a particular aspect of a case, you may consult a specialist in that subject. While deferring to the specialist's expertise, you may also question it, and you will expect the specialist's answers to be convincing and thorough. The conversation will be between professionals who are different and equal. So, in your teacher education, the person teaching you should be able to answer any question you may raise, should be able to explain his or her reasoning, and should be able to respond helpfully to challenges that you may make. For example, a seminar on teaching might usefully focus on participants' own experiences in order to tease out and identify what counts as good teaching. The leader of the seminar should be able to assist participants to define problems from their own experience, to explore them, and to develop possible solutions, rather than to provide pat answers. As a participant, you should have a sense of authenticity, of engaging with your own experience, and discussing your practice with other practitioners equally engaged and equally concerned to find real answers to real questions.

    If, however, the seminar leader forces on to you old chestnuts such as “Learners have an attention span of 20 minutes” or “Learning objectives should be specific, measurable, attainable, realistic, and time bound,” then simply consider your own experience. Can you watch a play, listen to music, or read a book for more than 20 minutes? Can you ever be sure what it is that you are going to learn in the course of your daily clinical practice?

    Ethics or not?

    Teaching, like medicine, is a morally charged activity. Both operate to the fundamental ethical imperative to do no harm, and both recognise the potential danger of bad practice. Bad teaching makes dangerous doctors, since a young doctor who is unsure about an element of clinical practice but who fears that to ask will expose him to public humiliation is unlikely to make the inquiry. He may never ask, never find out, and become an inadequate practitioner. Bad teachers come between the learner and reasonable inquiry..6

    The same principle applies to your own education as a teacher. If the teacher education that you receive causes you to feel distressed then it is inadequate. Enforced participation in games, role playing, or videoing is unethical because, fundamentally, it breaches the principle of autonomy. In so doing, it disempowers the learners and dumbs them down into a position where they are no longer in control of their agenda.

    It is sometimes argued that putting people under pressure, making them stressed, and obliging them to do things against their will is good for them, and that such practices are justified on the grounds that medicine is, after all, a stressful profession. Ethically, this argument is as untenable as suggesting that forcing patients to undergo a medical procedure that they do not want is justifiable in their best interests. It is not. To make people act against their will is to do them harm, and intentional harm is never permissible, in education or medicine.

    The acid test for teacher education is to ask how you feel about it. If you hate it don't do it. If the discussion doesn't engage you or if the activity doesn't excite you then quit. If your teacher can't find creative ways of helping you to inquire into your professional practice as a teacher, if the best he or she can do is an uncomfortable exchange of views on “what went well and what went less well,” then ditch the teacher. There are other ways, other means, that draw from the richness of humanistic liberal education, from its history, its sociology, its psychology, and its philosophy. Training is all well and good in its place - on the production line, in the learning of simple repetitive tasks - but doctors are not trainers: they are teachers, with all the complexity and the fascination of what's difficult that that implies. Settle for no less when deciding on your teacher education programme.

    References

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