Pre-service Innovative Teaching Methodologies
Participants Workbook
University of
Nairobi,
Kenya
St. John’s
Medical College,
India
0
January 2011
Health Care Providers train in professional schools to finally graduate and perform roles as health
care providers. Some become formal teachers in health care professional schools and are expected
to teach students the art and science of the provision of prevention, care and treatment. It is not
only knowledge but psychomotor skills, communication and attitudes that need to be learnt and
taught. Even nursery teachers require training and qualifications in education to teach and assist
their students to learn, but not an absolute requirement for teachers of health care professionals.
The goal of the teacher training is not to train special teachers but rather to enhance the
effectiveness of medical teachers, by showing different perspectives and approaches to what they
are already doing in order to benefit the student.
This collaborative effort between St. John’s Medical College, Bangalore, India and the University of
Nairobi, Nairobi, Kenya brings to Kenya a formal Teacher Training Workshop as a Trainer of Trainer
Workshop to enable UON improve upon the package and material gifted by St. John’s towards even
better future workshops for UON’s own faculty. It is our privilege and honor to share our teaching
experiences through this workshop with our colleagues in Kenya and thank you for the opportunity.
The package we gift to the UON includes teaching power points, activities, formats, participant’s
workbook, assessments and evaluations and, most importantly, our teaching learning methodologies
that we have evolved through the years. In no way are we the experts, but will certainly learn from
participants only to improve our own work as this workshop evolves.
The Teacher Training Workshop Team
Department of Medical Education
St. John’s Medical College, Bangalore, India
1
Contributors
We place on record all of the following for their contributions, past and present.
Drs. Swarna Rekha Bhat, Subash D Tarey, Sitalakshmi Subramaniam, Arpana A Iyengar, Suneetha
Nithyanandam, Arvind Kasthuri, Nachiket Shankar, Ishwara Bhat, Usha Kini, Sandhya Avadhany, V.
Balasubramanyam, John Stephen and Sanjiv Lewin
A special thank you for all the support and encouragement from the Director Rev Fr Lawrence
D’souza, the Associate Director Rev Fr Mathew and our Dean Dr. Prem Pais.
Any part of this Teachers Training Participant Workbook may be freely reproduced with the appropriate
acknowledgement. This publication is meant for private circulation only and is for non-profit, non-
commercial use specifically designed for use by the participants of the Teacher Training Workshop
Trainer of Trainers. The printing of this Participant Workbook was with the financial support of the
University of Maryland, School of Medicine, Institute of Human Virology – Kenya team, towards
providing assistance to the UON-St. John’s Teacher Training Workshop.
2
TABLE OF CONTENTS
Sl.
No.
Topic
Page No.
1
Principles of Learning
4
2
Taxonomy of learning and specific learning objectives
19
3
Teaching-learning methods 1: Seminar, symphosium,
panel discussion, role play
24
4
Teaching-learning methods 2: Lecture
27
5
Teaching-learning methods 3: Tutorial
37
6
Problem Based Learning
42
7
Teaching media: Visual aids
50
8
Evaluation 1: Principles of evaluation
70
9
Evaluation : Essay and short answer questions
79
10
Evaluation : Multiple choice questions
84
11
Item Analysis
92
12
Microteaching
96
13
Assessment of clinical competence
104
14
OSCE / OSPE
110
15
Medical Education Resources
125
3
PRINCIPLES OF LEARNING
Competency:
The teacher should be able to understand and relate learning theory and Bloom’s Domains
to educational events and be able to utilize principles of teaching and learning to plan and
implement activities to attain educational objectives.
Specific learning objectives:
1. Understands learning as a process and a product.
2. Conceptualize major Theories of Learning.
3. Differentiate between Pedagogy and Andragogy.
4. Recognizes the importance of Instruction in the Educational Spiral.
5. Understands Bloom’s Domains and is able to relate any instructional activity to the
domain/s it targets.
6. Is able to develop effective teaching and learning principles, which will ultimately lead to
attainment of educational objectives.
1. What is Learning?
Most of the standard textbooks on psychiatry define learning as a change in
behavior. Thus learning is an outcome of a process, an end product. However it should
be noted that conditioning which is also a change in behavior, might not necessarily
involve new knowledge. It is fair to comment that for learning to have occurred
experience should have been used.
Thus for a clear concept of “learning”, it is not enough to focus on overt change in
behavior only but also on how people understand, or experience and or conceptualize
the world around them. The focus is on gaining knowledge, ability and skills.
When asked, a number of adult students what they understood by learning, they
responded as follows;
 Learning as a quantitative increase in knowledge. Learning is acquiring information or
“knowing a lot”.
 Learning as memorizing. Learning is storing information that can be reproduced.
 Learning as acquiring facts, skills, and methods that can be retained and used as
necessary.
 Learning as making sense or abstracting meaning. Learning involves relating parts of
the subject matter to each other and to the real world.
 Learning as interpreting and understanding reality in a different way. Learning involves
comprehending the world by reinterpreting knowledge.
The first two categories mostly involve 'knowing that'. As we move through the
third we see that alongside 'knowing that' there is growing emphasis on 'knowing
how'. This system of categories is hierarchical - each higher conception implies all the
rest beneath it.
In these five categories learning appears as a process through which behavior
changes as a result of experience. One important issue is the degree to which a learner is
aware of the change that is taking place. Learning occurring in instructional setting is
more formal. Learning occurring in the society, family, and work groups is “informal”.
4
1.1 Task-conscious or acquisition learning.
Acquisition learning is continuous process and part of daily learning. It is “concrete,
immediate and confined to a specific activity” (Eg. driving a car, planning a holiday,
parenting or running a home).
1.2 Learning-conscious or formalized learning.
Formalized learning arises from the process of facilitating learning. It is 'educative
learning' rather than the accumulation of experience.
It is possible to think of the mix of acquisition and formalized learning as forming a
continuum.
2. Theories of learning:
The focus on process as to how learning occurs obviously opens up debates about
learning theories and ideas about how or why change occurs. In the following
discussions focus is five different theories.
2.1 Behaviorism
Behaviorism is primarily associated with Pavlov (classical conditioning) and with
Thorndike, Watson and particularly Skinner in the United States (operant
conditioning). Behaviorism is a worldview that assumes a learner is essentially passive,
and responds to environmental stimuli. The learner starts off as a clean slate (i.e. tabula
rasa) and behavior is shaped through positive reinforcement or negative reinforcement.
Both positive reinforcement and negative reinforcement increase the probability that
the antecedent behavior will happen again.
In his initial experiment, Pavlov used a metronome to call the dogs to their food
and, after a few repetitions, the dogs started to salivate in response to the metronome.
Thus, a neutral stimulus (metronome) became a conditioned stimulus (CS) as a result of
consistent pairing with the unconditioned stimulus (US - meat powder in this example).
Pavlov referred to this learned relationship as a conditional reflex (now called
conditioned response).
When an organism exhibits a behavior, and the consequences of that behavior are
reinforcing, it is more likely to repeat it. What counts as reinforcement, of course, is
based on the evidence of the repeated behavior. The schedule of reinforcement of
behavior is important for effective learning. Withdrawal of reinforcement eventually
leads to the extinction of the behavior. This is referred to as Operant Conditioning
(Skinner).
2.2 Cognitivism
The cognitivist revolution replaced behaviorism in 1960s as the dominant
paradigm. Cognitivism focuses on the inner mental activities. Opening the “black box” of
the human mind is valuable and necessary for understanding how people learn. Mental
processes such as, thinking, memory, knowing, and problem solving need to be
explored. Knowledge can be seen as schema or symbolic mental constructions. Learning
is defined as change in a learner’s schemata.
People are not “programmed animals” that merely respond to environmental
stimuli; people are rational beings that require active participation in order to learn, and
whose actions are a consequence of thinking. Changes in behavior are observed, but
5
only as an indication of what is occurring in the learner’s head. Cognitivists use the
metaphor of the mind as computer; information comes in, is being processed, and leads
to certain outcomes.
Many psychologists are not comfortable with behaviorism. There is too much focus
on single events, stimuli and overt behavior. Such criticism is especially strong from
Gestalt psychologists (Gestalt meaning configuration or pattern in German). For them,
perceptions or images should be approached as a pattern or a whole rather than as a
sum of the component parts. Such thinking found its way into psychoanalysis and into
the development of thinking about group functioning (perhaps most famously in the
work of Kurt Levin). It also has a profound effect on the way that many psychologists
think of learning. Where behaviorists looked to the environment, those drawing on
Gestalt turn to the individual's mental processes. In other words, they were concerned
with cognition - the act or process of knowing.
2.3 Humanism
Humanism, a paradigm that emerged in the 1960s, focuses on the human freedom,
dignity, and potential. A central assumption of humanism, according to Huitt (2001), is
that people act with intentionality and values. Humanists also believe that it is necessary
to study the person as a whole, especially as an individual grows and develops over the
lifespan. Hence study of the self, motivation, and goals is of paramount interest. In
humanism, learning is student centered and personalized, and the educator’s role is that
of a facilitator. Affective and cognitive needs are keys, and the goal is to develop selfactualized people in a cooperative, supportive environment.
Maslow’s Hierarchy of Needs has often been represented in a hierarchical pyramid
with five levels. There are four levels of lower-order needs (physiological), while the top
level is considered growth needs. The lower level needs have to be satisfied before
higher-order needs can influence behavior. The levels are as follows
1. Self-actualization - morality, creativity, problem solving, etc.
2. Esteem - includes confidence, self-esteem, achievement, respect, etc
3. Belongingness - includes love, friendship, intimacy, family etc’.
4. Safety - includes security of environment, employment, resources, health, property,
etc.
5. Physiological - includes air, food, water, sex, sleep, other factors towards homeostasis.
Humanists like Rogers believe that;
 Learning is self-initiated. Even when the impetus or stimulus comes from the outside,
the sense of discovering, of reaching out, of grasping and comprehending, comes from
within.
 Learning is pervasive. It makes a difference in the behavior, attitudes, and perhaps the
personality of the learner.
 The learner evaluates learning. He knows whether it is meeting his need, whether it
leads toward his goal, whether it illuminates the dark area of ignorance. The locus of
evaluation, we might say, resides definitely in the learner.
2.4 Constructivism
Constructivism is a paradigm that considers learning as an active, constructive
process rather than an acquisitive process. The learner is the constructor. He actively
6
constructs or creates his own subjective representations of objective reality. He links
new information to prior knowledge, thus mental representations are subjective.
Knowledge is constructed based on personal experiences and hypotheses of the
environment. Learners continuously test these hypotheses through social negotiation.
Each person has a different interpretation and construction of knowledge process. The
learner is not a blank slate but brings past experiences and cultural factors to a situation.
It asserts three major themes:
 Social interaction plays a fundamental role in the process of cognitive development.
“Every function in the child’s cultural development appears twice: first, on the social
level, and later, on the individual level; first, between people (interpsychological) and
then inside the child (intrapsychological).”
 The More Knowledgeable Other (MKO). The MKO refers to anyone who has a better
understanding or a higher ability level than the learner, with respect to a particular
task, process, or concept. The MKO is usually a teacher, coach, or older adult, but the
MKO could also be a peer, a younger person, or even computers.
 The Zone of Proximal Development (ZPD). The ZPD is the distance between a
student’s ability to perform a task under adult guidance and the student’s ability to
perform it independently. According to Vygotsky, learning occurred in this zone.
2.5 Social Learning Theory
Much learning occurs through observation of others’ behavior, attitudes, and
outcomes of those behaviors. “Most human behavior is learned observationally through
modeling: from observing others, one forms an idea of how new behaviors are
performed, and on later occasions this coded information serves as a guide for action.”
Social learning theory has sometimes been called a bridge between behaviorist
and cognitive learning theories because it encompasses attention, memory, and
motivation.
A primary focus is learning through social participation – that is, an individual is an
active participant in the practices of social communities, and in the construction of his or
her identity through these communities. The motivation to become a more central
participant in a community of practice can provide a powerful incentive for learning.
Students will have a desire to develop skills (e.g. literacy skills) if the people they admire
have the same skills. That is, they want to join the “literacy club” and will work towards
becoming a member.
3. Andragogy
A German teacher, Alexander Kapp, originally formulated the term andragogy in
1833. He used it to describe elements of Plato's education theory. Andragogy (andrmeaning 'man') could be contrasted with pedagogy (paed- meaning 'child' and
agogosmeaning 'leading')
In the minds of many around the adult education field, andragogy and the name of
Malcolm Knowles have become inextricably linked. For Knowles, andragogy is premised
on at least five crucial assumptions about the characteristics of adult learners that are
different from the assumptions about child learners on which traditional pedagogy is
premised.
1. Self-concept: As a person matures his self-concept moves from one of being a
dependent personality toward one of being a self-directed human being
7
2. Experience: As a person matures he accumulates a growing reservoir of experience
that becomes an increasing resource for learning.
3. Readiness to learn. As a person matures his readiness to learn becomes oriented
increasingly to the developmental tasks of his social roles.
4. Orientation to learning. As a person matures his time perspective changes from one of
postponed application of knowledge to immediacy of application. Accordingly his
orientation toward learning shifts from one of subject-centeredness to one of
problem centeredness.
5. Motivation to learn: As a person matures the motivation to learn is internal
4. Bloom’s Domains
There is more than one type of learning. A committee of colleges, led by Benjamin
Bloom, identified three domains of educational activities:
 Cognitive: Mental skills (Knowledge)
 Psychomotor: Manual or physical skills (Skills)
 Affective: Growth in feelings or emotional areas (Attitude)
Since the work was produced by higher education, the words tend to be a little
bigger than we normally use. Domains can be thought of as categories. Trainers often
refer to these three domains as KSA (Knowledge, Skills, and Attitude). This taxonomy of
learning behaviors can be thought of as "the goals of the training process." That is, after
the training session, the learner should have acquired new skills, knowledge, and/or
attitudes.
The cognitive domain involves knowledge and the development of intellectual
skills. This includes the recall or recognition of specific facts, procedural patterns, and
concepts that serve in the development of intellectual abilities and skills. There are six
major categories, which are listed in order below, starting from the simplest behavior to
the most complex. The categories can be thought of as degrees of difficulties. That is,
the first one must be mastered before the next one can take place.
4.1 The cognitive domain
The cognitive domain involves knowledge and the development of intellectual
concepts that serve in the development of intellectual abilities and skills. There are six
major categories, which are listed in order below, starting from the simplest behavior to
the most complex. The categories can be thought of as degrees of difficulties. That is,
the first one must be mastered before the next one can take place.
Category
Examples
Key Words
Knowledge: Recall data or Examples:
Describe
information.
features of pain. Quote
dose of aspirin. Name
causes of hematuria.
Comprehension:
Examples:
Understand the meaning, approach
Key
Words:
defines,
describes,
identifies,
knows,
labels,
lists,
matches, names, outlines,
recalls,
recognizes,
reproduces, selects, states.
Write
the Key Words: comprehends,
to
syncope. converts,
defends,
8
translation, interpolation, Explain the steps for
a
and
interpretation
of performing
instructions and problems. catheterization. Interpret
the CSF report.
Application: Use a concept
in a new situation or
unprompted use of an
abstraction. Applies what
was learned
in the
classroom
into
novel
situations in the work
place.
Examples: Use a manual to
start a dopamine infusion.
Calculate
mean
and
standard deviation of Blood
sugar values of your class.
Analysis:
Separates
material or concepts into
component parts so that its
organizational
structure
may
be
understood.
Distinguishes
between
facts and inferences
Examples: Analyze the data
obtained
by
history.
Differentiate
between
Pulmonary
TB
and
pneumonia.
Synthesis:
Builds
a
structure or pattern from
diverse elements. Put parts
together to form a whole,
with emphasis on creating
a
new
meaning
or
structure.
Examples: Write a project
on effect of smoking on
chest infections. Design a
protocol to study attitudes
to organ donation.
Solve the delays in dispatch
of X-ray reports
Evaluation:
Make Examples: Select the most
judgments about the value effective treatment for
of ideas or materials.
Shock. Choose a journal for
publication. Explain and
justify purchase of pulse
oximeters.
distinguishes,
estimates,
explains,
extends,
generalizes,
gives
Examples,
infers,
interprets,
paraphrases,
predicts,
rewrites,
summarizes, translates.
Key
Words:
applies,
changes,
computes,
constructs, demonstrates,
discovers,
manipulates,
modifies,
operates,
predicts,
prepares,
produces, relates, shows,
solves, uses
Key
Words:
analyzes,
breaks down, compares,
contrasts, diagrams,
deconstructs,
differentiates,
discriminates,
distinguishes,
identifies,
illustrates, infers, outlines,
relates, selects, separates.
Key Words: categorizes,
combines,
compiles,
composes, creates, devises,
designs,
explains,
generates,
modifies,
organizes,
plans,
rearranges, reconstructs,
relates,
reorganizes,
revises,
rewrites,
summarizes, tells, writes.
Key Words: appraises,
compares,
concludes,
contrasts,
criticizes,
critiques,
defends,
describes,
discriminates,
evaluates,
explains,
interprets, justifies, relates,
summarizes, supports.
9
4.2 The psychomotor domain
The psychomotor domain includes physical movement, coordination, and use of
the motor-skill areas. Development of these skills requires practice and is measured in
terms of speed, precision, distance, procedures, or techniques in execution. The seven
major categories are listed from the simplest behavior to the most complex:
Category
Examples
Key Words
Perception: The ability to
use sensory cues to guide
motor activity. This ranges
from sensory stimulation,
through cue selection, to
translation.
Examples: Detects nonverbal
communication
cues. Estimate where to
keep the stetho for
murmurs. Adjusts rate of
infusion to set value. Keeps
the patient at 45 degrees
to assess JVP.
Examples: Palpates
trachea. Asks the method
of tracheal tug. Volunteers
to elicit knee reflex. NOTE:
This
subdivision
of
Psychomotor is closely
related
with
the
"Responding
to
phenomena" subdivision of
the Affective domain.
Examples:
Performs
cranial nerve examination
as
shown.
Follows
instructions to elicit a
history of angina pectoris.
Respond to instructions on
hand-signals of instructor
while checking for eye
movements.
Examples: Use a pulse
oximeter. Record the blood
pressure. Dress the surgical
wound.
Key
Words:
chooses,
describes,
detects,
differentiates, distinguishes,
identifies, isolates, relates,
selects.
Set: Readiness to act. It
includes mental, physical,
and emotional sets.
Guided Response: The
early stages in learning a
complex skill that includes
imitation and trial and
error.
Adequacy
of
performance is achieved by
practicing.
Mechanism: This is the
intermediate
stage in
learning
a
complex
skill. Learned
responses
have become habitual and
the movements can be
performed with some
confidence and proficiency.
Key Words: begins, displays,
explains, moves, proceeds,
reacts,
shows,
states,
volunteers.
Key Words: copies, traces,
follows, react, reproduce,
responds
Key
Words:
assembles,
builds, calibrates, constructs,
dismantles, displays, fastens,
fixes,
grinds,
heats,
manipulates,
measures,
mends, mixes, organizes,
sketches.
10
Complex Overt Response:
The skillful performance of
motor acts that involve
complex
movement
patterns. Proficiency
is
indicated by a quick,
accurate,
and
highly
coordinated performance,
requiring a minimum of
energy.
Adaptation: Skills are well
developed
and
the
individual can
modify
movement patterns to fit
special requirements.
Origination: Creating new
movement patterns to fit a
particular situation or
specific problem. Learning
outcomes
emphasize
creativity based upon
highly developed skills.
Examples: Performs a CPR.
Inserts a central line.
Removes a foreign body
from eye.
Key
Words:
assembles,
builds, calibrates, constructs,
dismantles, displays, fastens,
fixes,
grinds,
heats,
manipulates,
measures,
mends, mixes, organizes,
sketches.
Examples: Treats
hypotension
during
a
procedure. Modifies ATT
on development of side
effects.
Examples: Constructs
a
new theory. Develops a
new and comprehensive
training
programming.
Creates a new surgical
technique.
Key Words: adapts, alters,
changes,
rearranges,
reorganizes, revises, varies.
Key Words: arranges, builds,
combines,
composes,
constructs, creates, designs,
initiate, makes, originates.
4.3 Affective Domain
This domain includes the manner in which we deal with things emotionally, such as
feelings, values, appreciation, enthusiasms, motivations, and attitudes. The five major
categories are listed from the simplest behavior to the most complex.
Category
Examples
Receiving Phenomena: Examples: Listen to others
Awareness, willingness to with respect. Listen for and
hear, selected attention. remember the name of
newly introduced people.
Responding
to
Phenomena:
Active
participation on the part
of the learners. Attends
and reacts to a particular
phenomenon. Learning
outcomes may emphasize
compliance
in
responding, willingness to
respond, or satisfaction in
responding (motivation).
Examples: Participates in
class discussions. Gives a
presentation.
Questions
new
ideals,
concepts,
models, etc. in order to
fully understand them.
Know the safety rules and
practices them.
Key Words
Key Words: asks, chooses,
describes, follows, gives,
holds, identifies, locates,
names, points to, selects, sits,
erects, replies, uses.
Key Words: answers, assists,
aids, complies, conforms,
discusses,
greets,
helps,
labels, performs, practices,
presents,
reads,
recites,
reports, selects, tells, writes.
11
Valuing: The worth or
value a person attaches
to a particular object,
phenomenon,
or
behavior. This
ranges
from simple acceptance
to the more complex
state
of
commitment. Valuing is
based
on
the
internalization of a set of
specified values, while
clues to these values are
expressed in the learnerís
overt behavior and are
often identifiable.
Organization: Organizes
values into priorities by
contrasting
different
values, resolving conflicts
between
them,
and
creating an unique value
system. The emphasis is
on comparing, relating,
and synthesizing values.
Internalizing
values
(characterization): Has a
value
system
that
controls
their
behavior. The behavior is
pervasive,
consistent,
predictable, and most
importantly,
characteristic of the
learner.
Examples: Demonstrates
belief in the democratic
process. Is
sensitive
towards individual and
cultural differences (value
diversity). Shows the ability
to
solve
problems. Proposes a plan
to social improvement and
follows
through
with
commitment.
Informs
management on matters
that one feels strongly
about
Key
Words:
completes,
demonstrates, differentiates,
explains,
follows,
forms,
initiates,
invites,
joins,
justifies, proposes, reads,
reports,
selects,
shares,
studies, works.
Examples: Recognizes the
need for balance between
freedom and responsible
behavior. Accepts
responsibility for one’s
behavior. Explains the role
of systematic planning in
solving problems. Accepts
professional
ethical
standards. Creates a life
plan in harmony with
abilities, interests, and
beliefs. Prioritizes time
effectively to meet the
needs of the organization,
family, and self.
Examples: Shows
selfreliance when working
independently. Cooperate
in-group activities (displays
teamwork).
Uses
an
objective
approach
in
problem solving. Displays a
professional commitment
to ethical practice on a
daily
basis.
Revises
judgments and changes
behavior in light of new
evidence. Values people for
what they are, not how
they look.
Key Words: adheres, alters,
arranges,
combines,
compares,
completes,
defends, explains, formulates,
generalizes,
identifies,
integrates, modifies, orders,
organizes, prepares, relates,
synthesizes.
Key
Words:
acts,
discriminates,
displays,
influences, listens, modifies,
performs, practices, proposes,
qualifies, questions, revises,
serves, solves, verifie
12
Group work
5. Educational Spiral
The needs of the population determine the direction of professional health care
education. Depending on the population’s needs, learning objectives are framed. These
are then imparted to future professionals so as to further the cause of health care. At
the end of instruction, all subjects undergo an evaluation, which measures and assesses
the impact of instruction on learning of each learning objective, which may belong to
one or more specific domain of learning.
This is an evaluation of the professional learning and reflects the ability of the
health care professional to fulfill certain roles and responsibilities towards the
population’s needs and indirectly, the ability of teachers to impart the necessary
education to meet the said learning objectives. Usually all the domains of learning are
evaluated.
Often the main motivation factor in is external and e.g. an award of a degree. And
this leads to a paradox that if the evaluation focuses on a particular cognitive or
psychomotor knowledge, skill or attitude then student will strive to “learn” and
demonstrate only that specific knowledge, skill and attitude.
Hence, for successful attainment of pre-determined objectives, the evaluation
process must be comprehensive enough to designed to gauge whether set educational
goals are achieved or not. Redesigning of objectives and instructional methods is needed
if the outcomes of evaluation are not satisfactory.
An evaluation will also expose deficiencies in the instructional design, teaching
methods, learning methods and the process of evaluation itself thus providing valuable
feedback not only to students but also teachers and policy makers.
The educational spiral illustrates this concept to identify objectives based on needs
followed by designing evaluations then planning and implementing teaching learning
activities and finally implementing the planned evaluation to determine outcomes.
Population
Health Needs
13
6. Principles of Instruction
M. David Merrill 2007 developed some important principles of instruction, which
he has discussed in detail in an article.
6.1 Task-centered principle
 Learning is promoted when instruction is in the context of whole real-world tasks.
 Learning is promoted when learners are engaged in a task-centered instructional
strategy involving a progression of whole real-world tasks.
6.2. Activation principle
• Learning is promoted when learners activaterelevant cognitive structures by being
directed to recall, describe or demonstrate relevant prior knowledge or experience.
• Activation is enhanced when learners recall or acquire a structurefor organizing the
new knowledge, when this structure is the basis for guidance during demonstration, is
the basis for coaching during application, and is a basis for reflection during
integration.
6.3. Demonstration principle
• Learning is promoted when learners observe a demonstrationof the skills to be learned
that is consistentwith the type of content being taught.
• Demonstrations are enhanced when learners are guided to relate general information
or an organizing structure to specific instances.
• Demonstrations are enhanced when learners observe mediathat is relevant to the
content and appropriately used.
6.4. Application principle
• Learning is promoted when learners engage in application of their newly acquired
knowledge or skill that is consistent with the type of content being taught.
• Application is effective only when learners receive intrinsic or corrective feedback.
• Application is enhanced when learners are coached and when this coachingis gradually
withdrawn for each subsequent task.
• Application is enhanced when learners observe mediathat is appropriately used.
6.5. Integration principle
• Learning is promoted when learners integratetheir new knowledge into their everyday
life by being directed to reflect-on, discuss, or defend their new knowledge or skill.
• Integration is enhanced when learners create, invent, or explore personal waysto use
their new knowledge or skill.
• Integration is enhanced when learners publicly demonstratetheir new knowledge or
skill.
Group work
7. Effective learning
7.1 Prior knowledge
Prior knowledge gives a perspective and clarity to new learning. It is important
for teachers to review student’s prior knowledge and correct anomalies,
14
misconceptions and correct them so that proper integration of new learning can
occur.
7.2 Motivation and learning behavior
Motivation is the most important factor for assimilation of new learning to
occur. It also supports their continued engagement when difficulties arise.
Motivation may be influenced by a number of factors, such as students’ interests,
goals, and expectations. Finally, knowledge itself can be a powerful motivator – the
more students know, the more they want to know.
Motivation could be intrinsic or extrinsic. Intrinsic motivation arises from
expectations about the relevance and utility of learning experience in future. In
contrast extrinsic motivation involves rewards like getting good grades, completing a
degree course, or winning a quiz competition.
7.3 Organization of knowledge
Knowledge representations that accurately reflect the concepts, the
relationships among them and the contexts of use, enable students to retrieve and
apply knowledge both effectively and efficiently. Teachers should put emphasis on
organization of knowledge around core concepts that should guide thinking, logic
and reasoning process. It is important to identify and resolve issues of disconnected
information and inaccurate links.
7.4 Meaningful engagement
Meaningful engagement, such as posing and answering meaningful questions
about concepts, making analogies, or attempting to apply the concepts or theories
to solve problems, leads to more elaborate, longer lasting, and stronger
representations of the knowledge.
7.5 Component skills and knowledge
Many activities that faculty believe require a single skill (for example, palpating
an apex beat ) actually involve a synthesis of many component skills To master these
complex skills, students must practice and gain proficiency in the discrete
component skills. Organizing and integrating component skills, understanding their
context and their application to new contexts promotes acquisition of proficiency in
the targeted domain.
7.6 Goal-directed practice and targeted feedback
Goal-directed practice involves working toward a predetermined level of
performance and continually monitoring performance in relation to the defined
goals of instruction. Teachers have important responsibility to provide feedback. ).
Instructor feedback can come via formal and informal assessments
a) Feedback regarding students’ performance
b) Feedback should be timely, frequent, and constructive
c) Feedback should help students to incorporate it in future practice.
15
7.7 Self-directed learning
Students must become conscious of their own thinking processes. This is called
metacognition. Monitoring, evaluation, and reflection on their own performance by
receiving feedback will help developing metacognitive skills. Another way is to model
how teachers approach problems, question their strategies, and monitor their
performance. Students may be given definite guidelines on how to monitor and
evaluate their performance.
7.8 Social, emotional and intellectual climate of the classroom
Students are not only intellectual but also social and emotional beings. The
social and emotional aspects of the classroom climate affect students in ways that
can enhance or hinder learning. For example, students will be more likely to take
intellectual and creative risks if they feel supported and respected. By the same
token, when students fear ridicule or persecution, or feel marginalized or
stereotyped, they may disengage from classroom participation and learning
opportunities, or perform.
8. Effective teaching
Teaching is a complex, multifaceted activity, often requiring instructors to juggle
multiple tasks and goals simultaneously and flexibly and encouraging learners to think,
feel, and do (experience). The following set of principles can make teaching both more
effective and more efficient, by helping teachers create the conditions that support
student learning and minimize the need for revising materials, content, and policies.
8.1 Effective teaching involves acquiring relevant knowledge about students and using
that knowledge to inform our course design and classroom teaching.
Learning is affected by many qualities of the students like cultural and
socioeconomic backgrounds, disciplinary backgrounds, and students’ prior
knowledge (both correct and incorrect). Etc. Although one cannot adequately
measure all of these characteristics, an insight may help in planning (a) course
design, (b) student difficulties (c) instructional adaptations (d) instructional content.
8.2 Three major components of instruction: learning objectives, assessments, and
instructional activities.
Teaching is more effective and student learning is enhanced when a teacher
gives a clear idea about :
a) A set of learning objectives;
b) The instructional activities
c) The assessments (e.g., tests, papers
d) Targeted feedback that can guide further learning.
8.3 Expectations regarding learning objectives and policies.
Being clear about the expectations and communicating them explicitly helps
students learn more and perform better. Articulating the learning objectives gives
students a clear target to aim for and enables them to monitor their progress along
the way.
16
8.4 Effective teaching involves prioritizing the knowledge and skills we choose to focus
on.
Coverage is the enemy, so it is necessary for teachers to make decisions –
sometimes difficult ones – about what will be and will not be included in a course.
This involves
a) Recognizing the parameters of the course (e.g., class size, students’ backgrounds
and experiences, course position in the curriculum sequence, number of course
units)
b) Setting our priorities for student learning, and
c) Determining a set of objectives that can be reasonably accomplished.
8.5 Effective teaching involves recognizing and overcoming our expert blind spots.
Teachers cannot be their own students. And so they often skip or combine
critical steps when teaching. Students need instructors to break tasks into
component steps, explain connections explicitly, and model processes in detail.
8.5 Effective teaching involves adopting appropriate teaching roles to support our
learning goals.
Even though students are ultimately responsible for their own learning, the
roles teachers assume, as instructors are critical in guiding students’ thinking and
behavior. Effective teaching involves progressively refining our courses based on
reflection and feedback.
8.6 Teaching requires adapting.
Teachers need to continually reflect on their teaching and be ready to make
changes when appropriate (e.g., something is not working, try something new, the
student population has changed, or there are emerging issues in our fields.
9. Role of a teacher
In the current context of student centric activities for achieving learning objectives,
the role of teacher as a font of knowledge will diminish in future. However he will
continue to do multiple functions.
9.1 Manager
Planning, implementation and control of the educational process, which could be
as mundane as lesson planning to as elaborate as curriculum development. The
educational process is controlled by periodic evaluation to assess if educational
objectives are achieved or not. This activity generates feedback, which may lead to
appropriate changes in the curriculum and teaching methods.
9.2 Communicator
Verbal and non-verbal communications go a long way to make a teacher popular. It
facilitates transfer of information.
17
9.3 Self-learner
With recent explosion of information and availability of net, teacher has to be
abreast of latest developments in his area of instruction. This activity should be reflected
on the students so as to emphasize the importance of life long principle of self-learning.
9.4 Research worker
Through activities pertaining to a research based principles teachers can encourage
students to develop skills necessary for research but help students a spirit of enquiry,
fire their imagination, acquire a scientific temperament and become a rationally thinking
member of society.
9.5 Mentor
Students often bring personal, learning related and social matters to the teacher
with a hope that they will get some help. Good teachers always help students, motivate
them and help them to see their problems in perspective by giving a constructive
feedback.
9.6 Role model
Teachers, by their behavior attitudes and conduct are role models for the students
and may instill in students the virtue of hard work, ethical and moral principles, scientific
temperament, rational thinking, compassion, respect for human rights and freedom
apart from qualities which are so important to the fractionates of the healing profession.
18
TAXONOMY OF LEARNING
AND
SPECIFIC LEARNING OBJECTIVES
Competency:
The teacher should be able to frame sound specific learning objectives across all three
taxonomic domains.
Specific learning objectives:
Part I Educational objectives and Taxonomy
I. EDUCATIONAL OBJECTIVES
1. Define educational objective
2. Benefits of writing objectives
3. Describe the three types of objectives: Institutional, departmental and specific learning
objectives
II. Taxonomy
5. Define the terms cognitive, affective and psychomotor domains
6. Develop objectives in each domain
7. Formulate educational objectives in different levels of cognitive, affective and
psychomotor domains
Part II - III. SPECIFIC LEARNING OBJECTIVES
8. Define specific learning / instructional objective (SIO)
9. Describe the qualities of learner objectives
10. Identify the four elements of SIO
11. Formulate SIOs incorporating at least three domains
1. What is education?
Education is a process the main goal of which is to bring about a behavioural change
in the learner.Educational objective is defined as “what the student should be able to do at
the end of a learning period, that they could not do before”.
The educational process consists of three main steps referred to as educational spiral.
The components of the educational spiral include:
 Defining the educational objectives
 Preparing and implementing an educational programme
 Planning and Implementing evaluation
Population
Health Needs
19
2. Objectives
Benefits of writing objectives:
1. -------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------2. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------3. --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------2.1 It would be appropriate at this point to discuss what is relevant in the context of
needs of the society. It is useful to follow the concept of:
Must know – something which is common and important: example all undergraduate
students must know about leukemias.
Good to know – something which is important but not
common example it would be good for all undergraduate
students to know something about myeloproliferative
disorders
Nice to know – something that is rare but interesting.
Example UG students need not know about Hairy cell leukemia
Individual activity: Write the must know, good to know and nice to know areas on a
topic in your speciality at the UG level
Must know: ---------------------------------------------------------Good to know: -----------------------------------------------------Nice to know: -------------------------------------------------------2.2 Objectives can be of different levels
Institutional or General Objectives
This is a broad or general statement to describe an institution’s end product. These
objectives can be determined by the regulatory body (In India, Medial Councils of India,
University or the individual institution).
Example : The student should be able to recognize and treat all diseases that are
common.
20
Departmental or Intermediate objectives
Within the broad objectives of the institution the department has to develop a list of
objectives specific for the discipline concerned.
Example: The student should be able to recognize and treat common infectious diseases
occurring in the pediatric age group
Specific instructional objective or specific learning objective
Are statements that describe the performance of the learner expected to result from a
specific unit of teaching – learning activity
Example: the student should be able to list symptoms and signs of malaria
3. Blooms taxonomy of education objectives
The educational objectives are divided into three domains and in each domain different
levels of learning can be achieved.
The three domains are:
Cognitive – This refers to knowledge- domain of intellectual skills.
Example - the student should know the life cycle of the malaria parasite
Psychomotor – This refers to as domain of practical skills
Example – the student should be able to draw blood from a patient
Affective – this deals with attitudes and values
The domains depend on what the objective of the course / department is and it also
depends on what level the student is.
Example – the student should be able to communicate bad news to a patient’s
relative.
As an undergraduate student it is quite adequate for the student to list the steps in
resuscitation (cognitive domain)
As a postgraduate student or during internship the student should be able to
perform the steps of resuscitation (psychomotor domain).
In each of these domains increasingly difficult levels would be present and these
taxonomic levels will be discussed.
Individual activity: Write an example of an educational objective for each domain
a. The levels in cognitive domain
 Knowledge
 Comprehension
 Application
 Analysis
 Synthesis
 Evaluation
The levels may be simplified into three levels namely: recall, interpret and problem solve
21
Example
 Knowing the blood pressure range for a normal adult is recall - knowledge
 Identifying that a particular blood pressure reading is below or above normal is comprehension
 When seeing a patient with stroke – interpreting that the high blood pressure may
be the cause of stroke would be application
 To reason out the causes of pedal oedema in a elderly hypertensive patient is
analysis
 To propose appropriate treatment regimen for a patient with hypertension and
bronchial asthma is synthesis
 To justify the choice of therapy on the above setting would be Evaluation
3.2 The levels in psychomotor domain
 Imitate
 Control
 Automatism
With reference to CPR (cardiopulmonary resuscitation)
The student
 Will observe CPR being performed and perform on a mannequin is imitate
 Will perform under supervision is control
 Will practice the skill and perform with high degree of proficiency is automatism
3.3Taxonomic levels in Affective domain
 Receiving
 Responding
 Internalization
The steps would be
 Receiving – becoming aware of an idea
 Responding - willingness to accept the idea
 Internalize– Judgment whether the idea is worthy of accepting and ability to
conceptualize the idea
Example:
 The student should be aware of a child’s anxiety to undergo phlebotomy (receiving)
 The student should develop the ability to allay the anxiety (responding)
 This ability should become a habit whenever he /she deals with a patient
(internalization)
Group activity:
Given some objectives, state the domain to which they belong
Given are a list of objectives in the cognitive domain, identify the level of cognition
22
4. Specific Learning Objectives
4.1 The specific learning objective should have the following characteristics
Specific Is it precise?
Measurable - Is the objective quantifiable/ measurable?
Achievable -Are we attempting too much?
Realistic Are adequate resources available ?
Timed Is the time limit specified ?
4.2 Components of a specific learning objective(SLO) include:
Activity – What the learner is expected to do (Verb)
Content – describes the subject / object or those in relation to which the activity has to
be performed
Condition – under what circumstances should the activity performed or given what
tools/ equipment/ logistic
Criterion – define the desirable level of proficiency
Specific learning objective = Task + Criterion
Task consists of: Act, Content and Condition
Example:
At the end of the teaching –learning session, the student should be able to
demonstrate the technique of an intramuscular injection in the deltoid muscle of an
adult given a spirit swab, needle and a loaded syringe correctly 80% of times.
Activity: to demonstrate
Content:the technique of an intramuscular injection in the deltoid muscle of an adult
Condition:given a spirit swab, needle and syringe
Criterion: correctly 80% of times. (Correctly will have to be defined as correct location,
using asepsis, using a Z-technique, entry of the needle at perpendicular to the arm,
withdrawl prior to injection)
Group activity: Formulate specific learning objectives incorporating the four elements
of objective in each domain
Key points
 The components of the educational spiral
 Benefits of writing objectives
 The concept of must know, good to know and nice to know
 The levels of educational objectives
 The domains of educational objectives and the levels in each domain
 The characteristics and components of Specific Learning Objective
23
TEACHING LEARNING METHODS 1
SEMINAR, SYMPOSIUM, PANEL DISCUSSION, ROLE PLAYING
Competency:
The participant should be able to choose the appropriate teaching-learning method to fulfill
a student’s learning of a specific learning objective.
Objective:

To define a Seminar, Symposium, Panel Discussion and Role Plays

To understand the differences, advantages and disadvantages of each of the above
as a teaching learning method
Problem: You have a task of teaching undergraduate students on a communicating to a
mother of an infant regarding routine immunization. You have been allocated a group of 15
students.
Question: What Teaching Learning Method would be considered convenient for your above
mentioned task?
Probable Answer: A Role Play session would probably be best to teach communication and
attitudes involved in counseling the infant’s mother.
Listening, questioning and speaking plays a large part in the learning process. This is
linked to theories of learning and many of the methods described here encourage this
process. Spoon feeding and ‘learning’ like rote like a parrot isn’t necessarily educative.
Theories of learning
Platts’ has written “When we speak, we have to go through a process of
reconstructing concepts stored in memory and this reconstruction is part of the learning
process and how we 'capture' knowledge. We can become aware of what we understand
well and what we are not sure of, what we need to understand better as well as to test new
thoughts and ideas. The feedback which we get from our peers and tutors helps to guide
our ideas and understanding. Feedback from oral presentations is more immediate and
varied than what we get from written work. We can also clarify, restate, and add extra
information and so on immediately. Speaking allows tutors to see we are making an effort
that we are going through the process of trying to learn. The silent student may well be
learning too, but it is not possible to tell if this is so or not. Students who talk make a more
positive impact on tutors because this is a form of feedback. It guides tutors to the kind of
24
help students need to progress in their studies. It makes them feel needed. Silent students
tend to make them feel frustrated.”
What is a Seminar?
Definitions vary extensively though it may be defined as a group discussion on a specific
subtopic related to a prior lecture/reading, held between students and a seminar tutor who
might or might not also have been the person who gave the lecture on the subject. The
similarity to a tutorial is obvious but traditionally a seminar differs in being more structured
with a ‘mini’ talk(s)/lecture(s) on subtopic/theme that leads into an interactive detailed
discussion among participants. Most definitions have common elements described below:

Small Group Learning Sessions (15-20 students with a facilitator/tutor)

Facilitator or Expert and advanced students that are well read on the topic for the
seminar

Presentations are briefly made on subtopics/themes by facilitator/expert or
participating students

Active learning and Interactive discussions follow

Duration 1-2 hours
What is a Symposium?
Quoting the Wikipedia web encyclopedia, “Symposium originally referred to a
drinking party (the Greek verb sympotein means "to drink together") but has since come to
refer to any academic conference, whether or not drinking takes place. In ancient Greece, it
was a forum for men to debate, plot, boast, or simply to party with others.”
In our academic context, it usually is a series of prepared talks/speeches made by
experts providing new information to a group and allows for updates on various issues
related to a topic. There usually is a controlled session between speakers or at the end of all
speakers where questions and answers are allowed from individuals directed to the
speakers.
What is a Panel Discussion?
A Panel Discussion is an activity where a number of panelist sit at a table facing an
audience and answer questions put to them by a facilitator/compare. It differs from a
symposium that consists of a series of prepared speeches, followed by questions and
answers. Panelist may present different views not always agreeing on the answer(s) to the
question(s) asked. The topic for the Panel Discussion is usually complex and requires
numerous panelists to answer all questions and cover all issues. Preparation is usually
individually by panelist and they usually hear others viewpoints during the session.
25
Traditionally, they remain sitting at the table when they speak into audio equipment. The
session is controlled by a compare who asks the questions to the panelist and keeps time to
allow all panelist to have equal time. The compare preferably should allow different views
from various panelists and must not be biased. The session ends usually with a
summarization of discussions and thanking the panelist. He or she could rephrase and
request for clarifications from panelist during the course of discussions. There is usually no
active audience participation.
What is Role Playing?
It is easier to keep talking during a teaching session, but it doesn’t always improve
learning. Thinking of activities that allow students to utilize their newly learned skills/
knowledge/attitudes improves learning. If these activities are realistic and the students have
to actively work rather than passively listen then it all adds up to better learning. Role
Playing is an audience involvement exercise where the audience members and/or the
presenter interact while assuming the attitudes and actions of others.
Teaching communication skills and practicing them under supervision and in low risk
situations are best examples of using Role Playing. In this method students act different
roles like in a drama based on an outline script. Other students systematically observe using
checklist the drama and at the end participate in active discussions on their observations. To
maximize participation, all students are divided into groups of three, two of whom perform
role plays with a third using an objective checklist as an observer. Roles may be changed
depending upon time available. The presence of large groups makes this more difficult to
use as a learning method since ideally all participants should have active roles in this
exercise.
If Expert Patient Trainers (EPTs) or Simulated Patients are available for such an
activity then this Role Playing would be an even more realistic learning experience. Expert
Patient Trainers or Simulated Patients may be actual patients or actors that have been
trained to present with specified clinical features that includes common realistic background
stories. When they are interviewed or counseled or communicated to by potential health
care providers in training, they would be expected to give specific objective feedback to the
trainee.
When would one choose to use the above methods as a T-L method?
Seminar: It is used for the cognitive/knowledge domain when in depth information on a
particular topic is required for improved student understanding. A small group of students
may nominate members to make targeted presentations to the group that leads to
interactive discussions.
Symposium: Rarely used for undergraduate teaching, this method is primarily a means of
dissemination of updated information by experts on specific subtopics related to a larger
26
theme of the symposium. Again here it is the cognitive/knowledge domain that is best
served.
Panel Discussion: Uncommonly used for undergraduate teaching, this method is a good
means to listen to different viewpoints/arguments of experts on answers to questions on
various aspects of a topic. The method targets the cognitive/knowledge domain
predominately.
Role Playing: A good method to teach Communication skills and Attitudes. Time is usually a
constraint especially when the group if large. Preparation of an objective checklist that
reflects specific essential learning objectives required at the end of the activity are a must.
The advantages of role playing are the provision of an opportunity, in a controlled situation,
to develop real communication skills and obtain constructive feedback from peers and
experts including potential patients. The situation is also emotionally laden and provides
experiences of empathy and the need for understanding. Major disadvantages are the need
for preparation time and need for active student involvement especially imagination.
Advantages and disadvantages of Small Group learning activities are tabulated below:
Advantages
Disadvantages
Permits active learning small group High cost in personnel and time.
dialogues between student-student and
student-tutor.
Allows evaluation.
Recommended Reading
1. Guilbert JJ. Educational handbook for health personnel. 6 thEdn. Geneva, World
Health Organization, 1998.
2. Medical Education: Principles and Practice. National Teacher Training Center,
JIPMER, Pondicherry, 1997.
3. Abbat FR. Teaching for better learning. A guide for teachers of primary health care
staff. 2ndEdn. Geneva, World Health Organization, 1992.
4. Exercises, seminars and tutorials. Department of Mathematics, University of York
website.
5. Platt MR. Seminars. Sussex Language Institute, University of Sussex website.
27
TEACHING –LEARNING METHODS 2
LECTURE
Competency:
The participant should be able to choose the appropriate teaching-learning method to fulfill
a student’s learning of a specific learning objective.
Objective:

To define a Lecture

To understand the differences, advantages and disadvantages of a Lecture as a
teaching learning method
There are various definitions of a lecture. The generic term is used to denote learning
that follows the ‘traditional’ model of a teacher-student relationship, where the teacher is
the ‘expert communicator’ of knowledge and the student the recipient. It is also described
as an exposition of a given subject delivered before an audience or a class, as for the
purpose of instruction.Another definition states that a lecture is an oral presentation
intended to present information or teaches people about a particular subject.
1. Introduction:
Lecture is the commonest method used in Teaching-Learning (T-L) activity in any
traditional medical school. Traditionally it is a teaching learning activity that involves at least
one teacher/facilitator that speaks (lectures) to a large group of students sometimes
assisted by the use of various media (Chalk board, Slides, Overhead Projectors, Power point
projections, etc.) at a scheduled time for a fixed duration of time. There is usually
inadequate time for interactions between teacher/facilitator and all students and it remains
a predominately didactic passive learning exercise. Entomologically, ‘to lecture’ means ‘to
read’ as was done in medieval times when learned persons read out manuscripts to an
audience who diligently took notes while listening. It could be defined in present times as an
exposition on a given subject delivered before an audience for the purpose of instruction. It
is seen as a concise method of introducing and explaining ideas which are of central
importance, and sometimes a method of helping students to understand quite complicated
ideas which are found in textbooks or research papers.
2. Lecture –as a “teaching learning tool”
Topics for a Lecture are usually from the cognitive (knowledge) domain as a Lecture on
Psycho-motor domain (skills) or Affective domain (attitudes )i is less likely to be effective
28
unless special audio-visual media or techniques (e.g. Role Play, Demonstrations, Video clips,
etc.) are utilized during the session.
EXERCISE 1
Choose which of the following learning objectives could be most appropriately taught using
Lectures in undergraduate medical training.
a)
Care in handling dissection specimens in anatomy [ ]
b)
Counsel pretest for an HIV diagnosis [ ]
c)
Describe the life cycle of Plasmodium malaria [ ]
d)
Interpret Arterial Blood Gas ABG results [ ]
e)
Discuss Tuberculosis Meningitis – Clinical Features, Investigations, Treatment [ ]
f)
Perform a Mantoux (Tuberculin Skin) Test [ ]
g)
Enumerate adverse reactions of commonly used antihypertensive medications [ ]
h)
Classify and describe mechanism of action of various antimicrobials [ ]
EXERCISE 2
List all possible advantages and disadvantages of a lecture session.
Advantages
Disadvantages
3. Attributes of a good lecturer:
EXERCISE 3
Before planning a lecture it would be well worth self-critically evaluating your lecture
performance against certain criteria. Enumerate attributes of a good lecturer:
29
4. Steps in planning a lecture:

PREPARE THE CONTENT: The best way to plan is to write down the context of the
lecture. Nothing clarifies the mind more than putting pen to paper!
The lecture topic is placed in the centre of the paper (as indicated below) and the
main points to be made are written down .As the main ideas are identified, further
points will tend to branch out as you think more carefully about them. You may at
this stage find that you need to read around some of the ideas in order to refine
them or to bring yourself up to date.
Major health problem?
What is it?
Implications, Statistics
What does it do to you?
Community statistics
Definition, Etiology
Hypertension
Pathology, Complications
How to treat?
How to investigate?
Treatment,
Prevention
Approach, Investigate
30
EXERCISE 4
Tick which of these sub headings you would cover in each of your areas
Treatment of tuberculosis
Sub headings
Medical
Nursing
Pharmacy
Classification based
on mechanism of
action
Names
medications
Various
names
of
trade
Dose
and
frequency
of
administration
Treatment
regimens
Duration of therapy
Mechanism
action
of
Adverse reactions
Drug interactions
In addition to preparing the contents,while planning a lecture, the following need
consideration:
o List specific Learning Objectives
o Choose appropriate Method/Media
o Time management
31
5. DELIVERY of the Lecture:
The Lecture could be supported where feasible by using appropriate media visible to
all in the large room. Media used should be set up and tested prior to the students’ entry. A
pointer is useful for the large audience when using media. The media however should not
restrict the teacher/facilitator from moving around the room in an endeavor to ‘interact’ if
not make ‘eye contact’ with many more students in the audience. Most students have
listening durations of 15 to 25 minutes and thus the traditional one-hour Lecture usually
needs to be structured with activities, questions, tasks, humor or energizers for the students
around this time when attention wanes. Do something different every 15 minutes even if it
is pausing and moving to another part of the class!
o Induction ("get their attention.")
Induction of the topic needs to be integrated into the lecture plan that
reminds them of their past related learning or potential clinical experiences and
hence the relevance of the topic for the Lecture. Starting with a relevant
problem, question or controversy is a great way to induce the topic.
 Getting the student’s attention and showing the importance of the
lecture by a case study or story or anecdote or examples or
illustrations. One may ask the students what they already know on
the subject and why they feel it relevant.
 List Objectives or Outline of the Lecture explaining themes to be
covered that assists in understanding how each part of the lecture is
related.
o Body ("Tell them")
The main body of the lecture should be in an organized systematic order to
enable better learning and to maintain a logical flow. This should begin with
stating the objectives and end with a summarization of key elements of the
topic. Never forget to periodically allow interaction through questions or
allowing time for clarifications from the students present even soliciting for
questions.
 Determine how much detail is needed (must know, good to know,
nice to know!). Concentrate on facts that are essential to know and
need to be recorded, but allow additional facts that make the lecture
interesting.
 Present the facts and information in logical sequence. One can do
this verbally with the assistance of a handout, reading from a book
(student or facilitator), describing facts, using audiovisual aids,
showing models/equipment, demonstrating or even by case studies.
 Set an exercise that enables an active learning process during the
lesson during which one can use the handout or even a brief verbal
discussion/question and answer sessions during the lecture or
towards the end.
32
o Conclusion ("Tell them what you told them.")
 Summarize
the
lecture
repeating
knowledge/information/facts.


all
essential
Plan an Evaluation
o Pre and Posttest
o Feedback
Handout of lecture
o It could be all your slides on a six or three a side handout format. Would cost
money to copy for all but would be a permanent record for the student.
o It could be a guide for taking notes as shown below. The left side column is
the outline of the lecture and the blank space on the right side allows for
brief notes to be jotted down by the student. Adequate space needs to be
provided and using an A4 sheet with the outline topics/themes well spread
out to allow adequate space for writing is recommended.
Example of Handout as a guide for taking notes:
Tuberculosis Meningitis
Etiology
Pathogenesis
Pathology
Clinical Features
Symptoms
Signs
Investigations
Diagnosis Criteria
Differential Diagnosis
Treatment General
Specific
Prevention/Complications
33
6. Tips to make Lectures more interesting:
If one is keen on enhancing and mastering the art of lecturing, adding variations in the
manner and style of presentation, active participation and interaction with students and use
of audiovisual aids would be useful.
Informing students of the topic and other details including the schedule time and
venue prior to the session is a step.
Based on the specific learning objectives and past experiences or lessons learnt, a
brief pretest and posttest may be designed to encourage student preparation and attention;
however, time must be allocated for this exercise. Multiple choice questions (MCQs) would
be ideal and if case-based even more of a motivating factor. A simple clinical case scenario
followed by 4-5 MCQs may even suffice depending upon the topic for the lecture. The MCQs
in the pre and posttest are usually the essential learning or key learning points (“take home
message”).
The availability of a student handout may reduce the need for note taking that may
interfere with listening and understanding during the lecture. This handout may be a brief
outline of the topic preferably in the order of the lecture and may contain blank areas on
the paper to enable some note taking. There remains a difference of opinion if the handout
should be given prior or after the Lecture.
The teacher/facilitator is the backbone of a successful Lecture. An enthusiastic,
dynamic, excited, well prepared teacher/facilitator with a command of the language who
speaks clearly and adequately loudly for the student audience is a step towards a successful
Lecture. Talking at levels appropriate for the student assists them in better understanding
the subject. Changes in pace, pitch and tone during talking interspersed with interactive
questions keeps many students with you through the Lecture.
Challenging students with questions followed by positive reinforcement by praising
them for responses makes a difference. During the activity, periodic reviews keep students
in the know of where they are in the Lecture plan. Such attempts that increase interactions
through inbuilt stimulating question or problem solving allows an improved two-way
communication towards increased effectiveness and active learning. Questions may be
asked to the entire group for volunteers to answer or to specific students preferably called
by name. Repeating audience questions and responses loudly for all to hear allows all
present to follow the interaction. A student question is best referred back to the class for
potential answers/views though if time is critical may be directly answered by the
teacher/facilitator.
Using examples or leaning on student or personal experiences to illustrate key issues in the
Lecture aids in improving the method. Repeating key points in different ways and stressing
34
on important points allows you to lead students through the thought process as the Lecture
proceeds.
7. When things go wrong:
Teachers should consider dealing with strategies to deal with unexpected problems as a part
of their teaching skills. The problems are likely to fall into one of the following categories.
Kindly imagine if you were to face any of the mentioned problems during the lecture session
and make a note of your reaction or solution to the problems listed below:
Problems
Reaction/Solution
Defective audio-visual aid
Discontinuity in flow of thoughts
Running out of time
Student yawning/ sleeping before you
Unable to answer student queries
EXERCISE 6: Discuss as a group and mention if these statements are true or false:
a. A Lecture is appropriate for large group learning.[ ]
b. A Lecture allows for adequate interaction and clarification. [ ]
c. A Lecture that continues for 60 minutes nonstop is most effective.[ ]
d. A Lecture allows explaining and understanding complex ideas.[ ]
e. A Lecture is essentially an active learning exercise.[ ]
f. A Lecture is most inappropriate for medical teaching.[ ]
g. A Lecture is best attended if no handouts are distributed.[ ]
h. A Lecture allows teaching a complete detailed coverage of a subject topic.[ ]
i.
A Lecture is effective if no questions are raised during or at the end.[ ]
35
Recommended Reading
1. Abbat FR. Teaching for better learning. A guide for teachers of primary health care staff.
2ndEdn. Geneva, World Health Organization, 1992.
2. CashinWE. Improving Lectures. Idea Paper No.14, September, 1985; Kansas State
University’s Center for Faculty Evaluation and Development.
3. Sullivan RL, McIntosh N. Delivering Effective Lectures Paper #5, December 1996, USAIDJHPIEGO.
4. Guilbert JJ. Educational handbook for health personnel.6 thEdn. Geneva, World Health
Organization, 1998.
5. Medical Education: Principles and Practice. National Teacher Training Center, JIPMER,
Pondicherry, 1997.
6. Knight AB. Lectures: Organizing Them and Making Them Interesting. University of
Oklahoma Instructional Development Program, 2006.
7. David Newble, Robert Cannon, Fraia. A handbook for the medical teachers,2 nd edition,
MTP Press Limited



Key learning
Lecture is an effective tool to transmit information but is less effective in
promoting thought or changing attitudes.
An effective lecture session involves lesson planning and delivery skills.
Effectiveness of a lecture lies in “telling students what you are going to say, then
to say it clearly and then tell them what you have said”
36
TEACHING –LEARNING METHODS 3
TUTORIAL
Competency:
The Medical College teacher should be competent to conduct a small group discussion
using tutorial as a teaching-learning tool.
Specific Learning Objectives:
At the end of this session the MedicalCollege teacher should be able:

To recognize the role of a Tutorial as a teaching learning method in medical school

To discuss four steps towards a successful tutorial

To outline tasks required for students to be completed prior, during and after a
tutorial that enable active learning
1. Introduction:
EXERCISE 1:
You have been assigned to take tutorials for undergraduates in your Institution.
What is your concept of a tutorial?
A Tutorial is a small group learning method where students gather together usually
with a tutor to discuss, interact and clarify previously presented material in more detail
clarifying individual doubts. There usually is no lecture component during the tutorial as in a
seminar.
In the medical setting, it may be triggered using a clinical case presentation or
problem which is discussed piece meal to understand all aspects of etiology, pathogenesis,
diagnosis, care, treatment, complications and prognosis. These may occur once in a week or
a month. It allows for issues to be identified, raised and discussed clarifying for all
individuals in the small group. This allows a broadening of understanding of the subject and
an interactive setting allowing questions to be raised and answered. An exchange of ideas
between students and their tutor may also occur in this setting. Being a smaller group (than
for example during a lecture), it provides the opportunity for each individual to have say
without the intimidation a large group can present. These sessions encourage students to
develop their critical thinking and problem solving skills through discussion and expect
students to contest different points of view. Thus, the vital element is student participation
and interaction preferably following preparation prior to the tutorial. Tutorials may be
considered less formal than other classes such as lectures and seminars. The size of the
group may range from 5 to 30.
37
2. When would one choose to use a Tutorial as a T-L method?
When the student batch is small and resources adequate, then an identified key
concept topic may be best discussed for improved understanding by a small group using a
Tutorial format in the presence of a tutor. The topic may be an essential must know concept
where an in depth understanding is required. The small group discussion, especially with
adequate preparation, allows for active learning and understanding under the guidance of a
tutor or subject expert.
EXERCISE 2:Discuss advantages and disadvantages of tutorials
Advantages
Disadvantages
2. Tutorial as a teaching learning tool:
EXERCISE 3:Instruction
List the aims of a tutorial that implies active student participation:
Like lectures, tutorials are central to learning in medical school and they provide
opportunities to discuss different aspects of the course. It allows a self-evaluation on
understanding of key topics and concepts as well as a feedback for the tutor. It allows the
development and encourages problem solving and critical thinking skills through active
38
engagements during interactive tutorials supported by tutors. Students also have direct
contact with faculty that support student learning. Many would use a clinical problem or
even a clinical case presentation as an induction process for a tutorial that would lead to
application of the key concepts/issues/topic.
3. Four Steps towards a Successful Tutorial
EXERCISE 4:
Activity: You have been assigned to take a tutorial (you can choose a topic of your choice)
for 15 final year MBBS students. List out the plan you would use to conduct the tutorial
A successful tutorial needs good student active participation to be effective. Students
should be encouraged to follow a four step process towards this success.

Preparation:Students should be informed regarding the topic or case being presented
for the tutorial. This allows for required reading and note-taking for the tutorial. Issues
and questions are hence identified for clarification during the tutorials.
Note-taking:


As a student take notes, the habit of citing your source: Author, Title,
Date, Page must be inculcated.
 Students should note the essence, the idea or the issue rather than
writing everything.
 They should think about what they are writing – and if it make sense to
them?
 They should note what it is they don't understand and ask for
clarifications during a tutorial.
Reading: As a part of preparation, reading prior to the tutorial is important to maximize
the efficacy of a Tutorial as a Small Group Learning Method. Students should be
encouraged to read on the topic as it enables an identification of issues that need
further clarification with the assistance of the tutor and allows more active participation
in the small group discussions during a tutorial. It may be explained that there are
several reading techniques, one being the SQ3R method (Survey, Question, Read, Recall
39


and Review). A repeat reading following a tutorial will reinforce the learning process and
also encourages the completion of the process.
Observation/Listening/Recording: During a tutorial students need to listen carefully,
participate and observe all discussions occurring. When this process is backed by
recording issues, clarifications and views by note taking then the review of the topic at a
later date will be an easier task.
Participation: Students must be made to understand that their involvement contributes
to the group’s learning process during a tutorial. When they express their points of view,
accept listening to other’s views and act in appropriate and responsible manner the
learning is much improved. As successful small group is hence able to complete a given
task during a tutorial. Being able to participate actively in a small group involves
dynamics and an alert tutor who recognizes that many in the group may need
encouragement and opportunities to participate actively as this method isn’t routine in
high school/pre-university teaching.
Having had an insight to the components of a tutorial ask participants to complete the
following exercise:
EXERCISE 5: Which of the following statements are TRUE or FALSE regarding Tutorials?
a. A Tutorial is appropriate for large group learning.[ ]
b. A Tutorial allows for adequate interaction and clarification.[ ]
c. A Tutorial that is short, lasting 30-45 minutes, is ideal.[ ]
d. A Tutorial allows explaining and understanding complex ideas.[ ]
e. A Tutorial is essentially a didactic teaching-learning exercise.[ ]
f. A Tutorial is teacher centric.[ ]
g. A Tutorial is most effective if no questions are raised during the discussions.[
]
Recommended Reading
 Guilbert JJ. Educational handbook for health personnel. 6 thEdn. Geneva, World Health
Organization, 1998.
 University of Wales Institute, Cardiff website
 James Cook University, Discover Study Skills Online website
40
 Medical Education: Principles and Practice. National Teacher Training Center, JIPMER,
Pondicherry, 1997.



Key learning
Tutorials give an opportunity for active student participation, face to face contact
and purposeful activity
Tutorials demand an understanding of group dynamics and explores the skills of
managing a group
Stimulus material like a patient, X-rays, video, photographs or articles can add to
the effectiveness of a tutorial
41
PROBLEM BASED LEARNING
Introduction
In problem based learning (PBL) students use “triggers” from the problem case or scenario
to define their own learning objectives. Subsequently they do independent, self directed
study before returning to the group to discuss and refine their acquired knowledge. Thus,
PBL is not about problem solving per se, but rather it uses appropriate problems to increase
knowledge and understanding.
Group learning facilitates not only the acquisition of knowledge but also several other
desirable attributes, such as communication skills, teamwork, problem
solving,
independent responsibility for learning, sharing information, and respect for others. PBL can
therefore be thought of as a small group teaching method that combines the acquisition of
knowledge with the development of generic skills and attitudes. Presentation of clinical
material as the stimulus for learning enables students to understand the relevance of
underlying scientific knowledge and principles in clinical practice.
Objectives of PBL
Develop an ability to identify relevant health problems that warrant further
discussion or self-study within the context of a clinical scenario presented as a
"patient problem".
Develop an appreciation for the interrelated nature of the physical, biological and
behavioural mechanisms that must be considered with each health problem during
the process of generating a management plan.
Develop the knowledge base necessary to define and manage the health problems of
patients, including the physical, emotional and social aspects, within the context of
effective health care provision within society.
Reinforce the development of an effective clinical reasoning process including the
skills of problem synthesis, hypothesis generation, critical appraisal of available
information, data analysis, and decision making.
Cultivate the skills necessary to become self-directed as a learner, acknowledging
personal educational needs and those of group members, and making effective use
of available learning resources.
Function effectively as an active participant within a small group engaged in learning
and the provision of health care.
Recognize, develop and maintain the personal characteristics and attitudes
necessary for a career in the health professions including the following:
o
Awareness of personal assets, limitations and emotional reactions;
o
Responsibility and dependability;
o
Ability to relate to, and show concern for, other individuals; and
o
The evaluation of personal progress, that of other group members and
that of the group process itself.
The Process of Problem-Based Learning
42
A typical PBL tutorial consists of a group of students (usually eight to 10) and a tutor, who
facilitates the session. The length of time (number of sessions) that a group stays together
with each other and with individual tutors could vary. A group needs to be together long
enough to allow good group dynamics to develop but may need to be changed occasionally
if personality clashes or other dysfunctional behaviour emerges. Students elect a chair for
each PBL scenario and a “scribe” to record the discussion. The roles are rotated for each
scenario. Suitable flip charts or a whiteboard should be used for recording the proceedings.
At the start of the session, depending on the trigger material, either the student chair reads
out the scenario or all students study the material. For each module, students may be given
a handbook containing the problem scenarios, and suggested learning resources or learning
materials may be handed out at appropriate times as the tutorials progress. The role of the
tutor is to facilitate the proceedings (helping the chair to maintain group dynamics and
moving the group through the task) and to ensure that the group achieves appropriate
learning objectives in line with those set by the curriculum design team.
A 19 mo old breastfeeding child presents with excessive crying and tugging the
right ear since last night. There is a history of 3 days of high fever and coryza …..
Read the problem
Brainstorm hypothesize
Next page
Evaluate
Identify learning
issues
Return – Reread –
Report - Review
Research – learn (27 days)
Tutorial groups will meet for approximately two hours once a week or once every two
weeks. During each small group session, the student group will identify and prioritize a
number of learning issues/objectives. Students will be expected to spend four to six hours
each week on independent study outside the small group to research and elaborate upon
new information and concepts. As they return weekly to their small group, they will bring
this new knowledge and information to the group. With the assistance of a faculty tutor,
43
important issues and learning objectives will be further identified and discussed. Each week,
new information built into the original problem may be introduced by the tutor. Within
each block, a PBL group will likely encounter five or six problems.
Student Responsibilities in Problem-Based Learning
Problem-based learning is a student centred process and it is the responsibility of the
individual student to participate fully, not only for his or her learning, but also to aid the
learning of the others in the group. Although much of the student’s time may be spent
alone in the library or at the computer, the full benefits of PBL cannot be realized in
isolation.
Guide to Professional Behavior in Tutorials
(Courtesy of McMaster University)
 Respect
 listens, and indicates so with appropriate verbal or non-verbal behaviour
 verbal and non-verbal behaviour are neither rude, arrogant nor patronizing
 allows others to express opinions and give information without "putting down"
anyone
 participates in discussion of differences in moral values
 differentiates value of information from value of person
 acknowledges others' contributions
 apologizes when late or gives reason for being so
 Communication Skills
 speaks directly to group members
 presents clearly
 uses words that others understand
 uses open-ended questions appropriately
 identifies misunderstanding between self and others or among others
 attempts to resolve misunderstanding
 tests own assumptions about group members
 accepts and discusses emotional issues
 able to express own emotional state in appropriate situations
 non-verbal behaviour is consistent with tone and content of verbal communications
 verbal or non-verbal behaviour indicates that statements have been understood
 recognizes and responds to group member's non-verbal communication
 Responsibility






punctual
completes assigned tasks
presents relevant information
identifies irrelevant or excessive information
takes initiative or otherwise helps to maintain group dynamics
advances discussion by responding to or expanding on relevant issues
44
 identifies own emotional or physical state when relevant to own functioning or
group dynamics
 describes strengths and weaknesses of group members in a supportive manner
 gives prior notice of intended absence
 negotiates alternatives if unable to complete assigned tasks
 Self-Awareness/Self-Evaluation
 acknowledges own difficulty in understanding
 acknowledges own lack of appropriate knowledge
 acknowledges own discomfort in discussing or dealing with a particular issue
 identifies own strengths
 identifies own weaknesses
 identifies means of correcting deficiencies or weaknesses
 responds to fair negative evaluative comment without becoming defensive or
blaming others
 responds to fair negative evaluative comment with reasonable proposals for
behavioural change
PBL tutorial process
Step 1 Identify and clarify unfamiliar terms presented in
the scenario; scribe lists those that remain
unexplained after discussion
Generic skills and attitudes
Teamwork
Chairing a group
Step 2 Define the problem or problems to be discussed;
students may have different views on the issues,
but all should be considered; scribe records a list of
agreed problems
Step 3 “Brainstorming” session to discuss the problem(s),
suggesting possible explanations on basis of prior
knowledge; students draw on each other's
knowledge and identify areas of incomplete
knowledge; scribe records all discussion
Listening
Recording
Cooperation
Respect for colleagues' views
Critical evaluation of literature
The primary task of each problem is to
provide a springboard
learning,
not to
Self-directed
learning andtouse
of resources
make a quick diagnosis and work out a
managementskills
plan.
Presentation
Step 4 Review steps 2 and 3 and arrange explanations into tentative solutions; scribe
organizes the explanations and restructures if necessary
Step 5 Formulate learning objectives; group reaches consensus on the learning objectives;
tutor ensures learning objectives are focused, achievable, comprehensive, and
appropriate
Step 6 private studies (all students gather information related to each learning objective)
Step 7 Group shares results of private study (students identify their learning resources and
share their results); tutor checks learning and may assess the group
45
The Role of the Tutor
The role of the tutor is to facilitate the proceedings (helping the chair to maintain group
dynamics and moving the group through the task) and to ensure that the group achieves
appropriate learning objectives in line with those set by the curriculum design team. The
tutor may need to take a more active role in step 7 of the process to ensure that all the
students have done the appropriate work and to help the chair to suggest a suitable format
for group members to use to present the results of their private study. The tutor should
encourage students to check their understanding of the material. He or she can do this by
encouraging the students to ask open questions and ask each other to explain topics in their
own words or by the use of drawings and diagrams.
Questions Tutors May Ask
Appropriate questioning: Knowing how and when to ask appropriate questions is one of the
principle skills of a good tutor.
Questions may elicit a students' reasoning process. E.g: "What are you hoping to find
out?
What is the core information
A learning issue outside of this problem?
Emphasize open-ended questions to promote discussion rather than focusing on yes/no
type questions
Direct students along another path: Assume this is the situation ..., what do you need to
know?
Tutors must learn to tolerate silence. When communication stops or is at a stand still,
wait thirty seconds, someone is bound to talk.
Tutors should emphasize mechanisms and causes of patients' problems.
Explain and define medical terminology used.
Higher order questions. For example, in discussions of treatment it is more helpful to
ask "How do we decide what to do?” than "What is the best treatment?"
Other Helpful Hints
Do not be afraid to join the group as a participant.
Do not dominate the group with your opinions but rather facilitate the group dynamics.
Remind students of topics previously discussed but not fully understood.
Focus the group by introducing terms to describe what the discussion is about (e.g. body
image). Even better, help the students label the general principles themselves.
Before considering any intervention, ask yourself, "Will my comments help the students
to learn how to learn?"
Encourage the students to focus their discussion, rather than going off in all directions at
once. It may be helpful to get the group to construct “diagnostic grids” or “concept
maps” (see above).
Periodically remind students about how much they are learning. Be specific and give
examples.
46
Characteristics of a Good Tutor
A.
Knowledge
The tutor should have:
 An understanding of the overall goals for the teaching programme;
 An understanding of the objectives and logistics of the specific component of the
programme for which he or she is tutoring;
 A knowledge of various educational roles and an ability to use them
appropriately;
 A knowledge of the respective usefulness of various learning resources and
educational events;
 A knowledge of some basic principles and methods of evaluation;
 A knowledge of the steps necessary to promote problem-based learning, problem
solving and critical thinking in students;
 A knowledge about the rationale and techniques of self-directed learning;
 An understanding of the mechanics of group dynamics and the mechanics of peer
feedback;
B.
Personal Attributes
The tutor should demonstrate an acceptance of:
 the problem-based approach as an effective method for acquiring information
and for developing the ability to think critically;
 the self-directed learning approach, i.e. the student being primarily responsible
for the student's own education;
 the small group tutorial as a forum for integration, direction and feedback;
The tutor should fulfil responsibilities in the tutor role by:
 attending the orientation/training workshops and meetings;
 arranging his or her personal schedule during the teaching period in order to be
adequately available;
 being prepared to have individual meetings with students as required;
 supporting the efforts of the coordinators of the programme by ensuring that
student evaluations are completed, contacting planners about problems or
suggestions for improvement;
 coordinating student evaluation activities throughout the teaching period.
47
C.
Skills
The following skills are expected:
1.
Skill in facilitatory teaching, i.e.,





2.
asking non-directive, stimulating questions, challenging students as appropriate;
presenting consequences of student conclusions, opposing views, cues as needed;
indicating when additional external information is required;
referring students to resources as appropriate;
avoiding lecturing to the tutorial group unless an exception has been recognized,
justified, and agreed to be made.
Skills in promoting group problem solving and critical thinking by helping students:
3.
 to examine a range of phenomena, from the molecular level to the family and
community level;
 to assess/appraise critically evidence supporting hypotheses;
 to define issues and synthesize information.
Skills in promoting efficient group function by:
4.
 assisting the group to set early goals and a tutorial plan which may be modified
later including an organizational framework and an evaluation plan;
 sensing problems in tutorial functioning and helping the group to deal with them;
 making students aware of the need to monitor the group's progress;
 serving as a model to demonstrate productive ways of giving feedback.
Skills in promoting individual learning by:
5.
 helping students to develop a study plan, considering the goals of the student and
the programme;
 helping students improve study methods including the collection of appropriate
learning resources.
Skills in student evaluation and coordinating the evaluation of students by:





reviewing and clarifying programme goals with the tutorial group;
helping students define personal objectives;
helping students select appropriate self-evaluation methods;
reviewing learning achievement and ensuring that the student gets feedback;
preparing the evaluation report on the individual student learning progress,
including comments as to whether the student has or has not completed the
objectives of the programme.
PBL in curriculum design
PBL may be used either as the mainstay of an entire curriculum or for the delivery of
individual courses. In practice, PBL is usually part of an integrated curriculum using a
systems based approach, with non-clinical material delivered in the context of clinical
practice. A module or short course can be designed to include mixed teaching methods
48
(including PBL) to achieve the learning outcomes in knowledge, skills, and attitudes. A small
number of lectures may be desirable to introduce topics or provide an overview of difficult
subject material in conjunction with the PBL scenarios. Sufficient time should be allowed
each week for students to do the self-directed learning required for PBL.
Writing PBL scenarios
PBL is successful only if the scenarios are of high quality. In most undergraduate PBL
curriculums the faculty identifies learning objectives in advance. The scenario should lead
students to a particular area of study to achieve those learning objectives.
How to create effective PBL scenarios**Adapted from Dolmans et al. Med Teacher
1997;19:185-9
Learning objectives likely to be defined by the students after studying the scenario
should be consistent with the faculty learning objectives
Problems should be appropriate to the stage of the curriculum and the level of the
students' understanding
Scenarios should have sufficient intrinsic interest for the students or relevance to future
practice
Basic science should be presented in the context of a clinical scenario to encourage
integration of knowledge
Scenarios should contain cues to stimulate discussion and encourage students to seek
explanations for the issues presented
The problem should be sufficiently open, so that discussion is not curtailed too early in
the process
Scenarios should promote participation by the students in seeking information from
various learning resources
Assessment of PBL
Student learning is influenced greatly by the assessment methods used. If assessment
methods rely solely on factual recall then PBL is unlikely to succeed in the curriculum. All
assessment schedules should follow the basic principles of testing the student in relation to
the curriculum outcomes and should use an appropriate range of assessment methods.
Assessment of students' activities in their PBL groups is advisable. Tutors should give
feedback or use formative or summative assessment procedures as dictated by the faculty
assessment schedule. It is also helpful to consider assessment of the group as a whole. The
group should be encouraged to reflect on its PBL performance including its adherence to
theprocess, communication skills, respect for others, and individual contributions. Peer
pressure in the group reduces the likelihood of students failing to keep up with workload,
and the award of a group mark—added to each individual's assessment schedule—
encourages students to achieve the generic goals associated with PBL.
The above chapter is an adaptation of ‘The Queen’s Manual”, University of Queensland
49
TEACHING MEDIA
VISUAL AIDS
50
Great Visuals
Why
aids?
use
When you have attended presentations previously, what were the
supporting visuals that had most impact on you?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________
What
was
it
that
made
them
distinctive?
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________
visual Using appropriate audiovisual aids is a critical step in the training
process.
Audiovisual materials supplement training activities by highlighting
important points or key steps or tasks.
Because individuals have different styles of learning, using a variety of
audiovisuals allows the participant to receive information in different
ways and reinforces the learning process.
“I hear and I forget
I see and I remember…”
General
principles of
using visual
aids
Keep them “simple”
Size:
Visuals must be clear and large enough to be read by
the entire audience
Images:
Use pictures, graphs, or diagrams wherever possible –
this will avoid a mass of text
eMphasis: Use color to help emphasis
Pause:
Pause when you show a visual
Location:
Position visuals where everyone can see them
Eye contact: Face and address the audience
Visual aids can dramatically enhance and compliment one’s teaching
efforts when used effectively, and detract from such activity when
used poorly.
51
Black board /
White board
A writing board can display information written with chalk (chalkboard or
blackboard) or special pens (whiteboard). Although there usually are
more effective methods of transmitting information, the
blackboard/whiteboard is still the most commonly used visual aid. It is
especially useful for impromptu discussions, brainstorming sessions and
note taking.
Planning a session in which a blackboard/whiteboard will be used as a
teaching aid does not automatically indicate an entirely free form
session. A ‘Chalk Talk’ requires the same preparation and thoughtfulness
as a presentation developed with more advanced audio and visual aids. It
is still paramount to know the teaching objectives, the main ‘take home’
points for the audience and which concepts are likely to be most
challenging to communicate.
Black Board
White Board
Advantages
Disadvantages
/ Jot down what you think are three of the major advantages and three of
the major disadvantages of a black board / White board in medical
& teaching
Advantages
____________________________
__
____________________________
__
____________________________
__
Black Board
White Board
Advantages
Disadvantages
/ Advantages
&
 Readily available in most of
the lecture rooms
 Inexpensive
 Needs no electricity
 Sequential development of a
concept
can
be
done
effectively
 Easy to use (and misuse!)
 Darkening of the room is not
necessary
 The boards are suitable for use
by
both
trainers
and
participants
Disadvantages
_______________________________
_______________________________
_______________________________
Disadvantages
 Eye to eye contact is lost while
writing.
 It is difficult to write on the board
and talk to the participants at the
same time
 Advance preparation of material is
not possible
 Writing on the board is time
consuming
 The board cannot hold large
amounts of material and may
require continual erasing.
 The board can get messy
 There is no permanent record of
52
The boards are excellent for
brainstorming,
problem
solving, making lists and
other participatory activities
Black Board /
White Board
Tips for using a
Blackboard
/
Whiteboard
information presented
Is the blackboard/whiteboard a good teaching aid?
___________________________________________________________
___________________________________________________________
Like any other tool it is inherently neither good nor bad. The
effectiveness of the blackboard as a teaching aid depends on :
a) The purpose for which it is used
It is especially useful for impromptu discussions, brainstorming
sessions and note taking during case discussions…etc.
b) How effectively it is used
Effective use of the Chalk and board
Planning
 Have a clear purpose in mind.
For example, participants may be expected to note down what you
write, or the visual display may be intended to be there for a while
to provide focus for subsequent participant activity and discussion.
 Consider other ways of disseminating information.
It is often better to issue a handout containing information than to
write it up yourself for participants to note down. The use of
marker boards or chalkboards is probably best restricted to things
that emerge during a session, rather than the basic information on
which the session is based.
Pre-preparation
 Keep the board clean; if it is a blackboard, do not allow it to turn
into a grey board.
 Position it in front of the class so that all pupils are able to see
what is written on it
 Organize and practice chalkboard presentation in advance
 Prepare complex drawings in advance
Writing
 Write legibly and horizontally
 Write only the key elements
 Use bullets wherever possible
The time it takes to write long sentences can be irritating to
participants, especially if they're also trying to note the sentences
53
down themselves.
 Use chalk or pens that contrast with the background of the board
so that participants can see the information clearly.
 Use chalks and felt-tip pens of various colours
 On marker boards, use the right pens!
Pens need to be non-permanent and erasable! Also, the thickness
of the pens needs to be appropriate for the size of the room and
the maximum distance from participants' positions.
 Make text and drawings large enough to be seen in the back of the
room.
 Underline headings and important or unfamiliar words for
emphasis.
 After writing on the chalkboard or drawing some illustrations,
walk to the back of the class and look at your work. Read through
what you have written and quickly examine your illustrations. This
will help you to make corrections in case you have miss pelt some
words or put wrong information in the illustrations
 Normal handwriting is usually not suitable.
Unless you have a (fast) naturally attractive script, it's probably
better to use capital letters than 'joined-up writing' when using
chalkboards or marker boards. Ordinary script on prepared
overheads may indeed be easier to read than capitals, but the
same does not seem to apply to handwriting on boards.
Layout
 Use space wisely
Too many details are often a distraction and fail to assist the
audience in understanding the message
Depending on the situation, selective adding of information or the
intentional erasing of it, allows the visual aspects of the
information on the board to dynamically reinforce teaching points.
54
 Organize concepts by orchestrating the board
Placing ideas on the board in a way that is considered in advance,
but of which the audience members are not explicitly aware, is like
completing a puzzle before their eyes. Consider the scenario of
brainstorming a differential diagnosis for renal failure. Listing
diagnoses sequentially in the order in which they are volunteered
leads to a disorganized listing, even when comprehensive. But
creating multiple columns without stating explicitly why this is
being done challenges the group to figure out why the columns
are there to begin with. The label for each column slowly becomes
apparent for members of the group at different times during the
session, or later at time when the teacher turns to consider the
way of thinking about renal failure, arriving at the headings of prerenal, intra-renal and post-renal causes. In this instance diagnoses
are organized into a structure.
Drawing
 Use simple and clear illustrations, diagrams, pictures, graphs,
etc. You do not have to be an artist to illustrate some work on
the chalkboard. Practice drawing pictographs. Stick people,
simple objects and faces with different expressions can become
part of your repertoire
 If necessary, use the ruler, compass, or other devices in making
drawings
Arrows, circles, lines and lists
 Show your reasoning process
Arrows can help delineate a progression of disease much in the
way they are used in text figures and diagrams. By drawing these
in real time, the presenter is building and reinforcing the
relationships for the learners.
 Build structure into lists
If a long list is simply transcribed, the group will not think much
on the relationships between the data points in any organized
manner. But if the data are arranged in a particular way, it can
help teach an important concept of classification.
For example, one approach when creating an exhaustive
differential diagnosis is to place the diagnoses suggested by the
group on the board in a non-random order, such as putting the
more likely diagnoses on the top of the list and less likely ones
towards the bottom.
55
Other tips
 Do not talk while facing the board.
Do not block the participants’ view of the board; stand aside
when writing or drawing is completed.
 Allow sufficient time for participants to copy the information
from the board.
 Erase all irrelevant material
 Squeaky chalk is painful!
Most of us remember this from our schooldays. Breaking a stick
of chalk in two usually yields a chalk surface which writes more
freely.
 Don't erase too soon
Participants can feel manipulated if you remove information
from their view before they've had the chance to note it down
themselves, or at least complete their thinking about it.
56
Overhead
Projectors
Overhead
projector
Equipment
instructions
Although OHPs as a delivery tool are becoming less widely used, it can
still be a useful tool for two reasons:
 It is now possible to make some very high quality OHP material
by colour coping text, pictures, and diagrams onto acetate
 The OHP may give you a “safety net” should you not be able to
use alternatives like a powerpoint
Equipment use instructions
use
 The equipment must be
placed horizontally on a
stable platform like a table.
The screen must be vertical.
 Appropriately position the
OHP and using the mirror
adjustment ensure that the
right and left edges of the
screen and the upper and
lower edge of the screen are
parallel to each other
 Place
the
acetate
or
cellophane transparency on
the glass top
 Switch on the blower first and
then the bulb
 Get the image in focus on the
screen using the focusing
knob
 Commence the lecture
 Switch of equipment when not in use as the bulb can overheat.
Alternatively keep in standby mode where the blower is kept on and
the bulb is off
 Do not shift OHP when the bulb is on or the filament of the bulb may
break due to jerks during shifting. Keeping one or two spare bulbs in
the department is always a good practice.
 Let the appliance cool completely before putting away or when
replacing lamp
 The Fresnel lens and the bulb are the two important components of the
equipment. When the projector is not in use, it should be covered so
that no dust gets deposited on its lenses and bulb. Dust the projector
before and after use and occasionally clean the lenses with soft tissue
papers or flannel cloth available with the opticians.
 The mirror is also an important item to be taken care of so that
scratches are avoided.
57





Overhead
projector
Preparing
transparenciess








 Darkening the room is not necessary
 Switch on the OHP when you are ready to
show your first transparency, not before!
 Face the participants
 Read from the transparency, not from the
projection on the screen
 Do not block the screen
 Use a pointer
 Progressive disclosure
In this technique an opaque cover is used to
reveal one point at a time. This helps direct
attention to point being covered. However,
overuse of this technique can be quite
irritating to the participants and therefore
not recommended
 Overlays
This is useful to develop a complicated
drawing step by step. Each component of
the final picture is drawn on separate
sheets and superimposed on over the other
as the lecture progresses
 Switch off the projector when not
discussing an issue not on the transparency
Jot down what you think are three of the major advantages and three of
the major disadvantages of OHP
Overhead
projector
Using
the OHP
Overhead
projector
Advantages
Use clean transparencies
Use not more than 7 words per line
And not more than 7 lines per transparency
Use large lettering
Print text
Material can be Xeroxed from books and
journals into these acetate sheets.
Specially coated acetate sheets can be used to
take printouts ( in Black / White or colour )
using a computer and inkjet printer
Use a template while writing
Avoid smudges
Make graphics and drawings large enough to
be seen
Limit the information to one main idea
Lesson outline / number in the margin
Mount transparencies in frames
Notes may be clipped on to the mount
Place transparencies in sequence in a folder
&
58
Disadvantages
Overhead
projector
Advantages
Disadvantages
PowerPoint
&
Advantages
_____________________________
_____________________________
_____________________________
Disadvantages
_____________________________
_____________________________
_____________________________
Advantages
Disadvantages
 Face to face contact with
audience
 Effective in a fully-lighted
room; audience can follow
handouts or take notes
 Ability
to
modify
transparencies
during
presentations
 Sequence of material can be
modified during presentation
 Overlays can be used to
simplify complex information
into layers
 Diagrams / illustrations can be
easily copied from text books
and other resources
 Overhead projector is bulky and
heavy to transport
 Framed transparencies are bulky
and difficult to store
 Pages from books cannot be used
effectively without modification
since text will usually be too small
for audience to read.
 Overhead projection is perceived
as being "less professional" than
slides in a formal setting.
PowerPoint can be a powerful tool to help convey one’s ideas to an
audience. Many of us make regular presentations to our colleagues, to
our students and others. Power Point is a powerful tool, which when
used properly, can enhance the presentation and help the audience to
understand and remember the message.
However, when Power Point is misused it can detract from your
presentation and actually be a barrier to your communication. Knowing
some basic principles can make your presentation "shine" and help your
audience learn and remember the message you are presenting.
This session is not intended to be a "How To" on Power Point; one can
get all the help needed from the program itself. Simply turn on the
program and make good use of the "Help" function.
Here are a few pointers that will make your Power Point presentations
look great and get your message across.
59
Ten
Commandments
1.
Size really does matter
The reason for putting anything on the slide is that you want
the audience to read it. If “wanting the audience to read it” is
the objective, whatever you put on the slide should be readable
by the audience. Therefore if what you place on the slide is not
readable by the audience, it serves absolutely no purpose. Size
really does matter. Mentioned below are some principles about
font size for PPT slide design:
Use Font sizes in the range of 28 to 32 points. Anything smaller
may not be readable from the back of the room. A font size of
32 or more for titles and a font size of not less than 20 for other
text are recommended. If all your data won't fit on a slide at 20
-28 point, either condense your data or create another slide.
2.
Use “sans serif” typeface
Use just one or two fonts throughout your presentation. Use
large, bold type for titles and headings, plain text for the body
of your slides, and italics for highlighting. Color can also be used
for highlighting a point, but use restraint.
Use no more than three type sizes per presentation, or you'll
risk running into that "noise" issue. Use Standard fonts. Don’t
go for decorative fonts. They are too hard to read on a slide. Go
for one of the standard fonts, such as Arial or Helvetica (Sans
Serif), or Times New Roman (Serif). As a rule, the Sans-Serif
fonts are easier to read.
Avoid making all of your text bold. Text is only bold when it is
bolder than the text around it, relatively speaking. If you make
all your text bold, you have just created a heavier typeface!
Also, DON’T MAKE YOUR TEXT ALL UPPER CASE, AS TOO MUCH
OF IT IS TOO HARD TO READ.
3.
Do not overload slides
Don't overload the slide. If the gist of a slide can't be grasped in
seven seconds or less, it is a waste of time. Try splitting it into
two slides that deal with the same subject matter.
Don't write everything on the screen. Just illustrate the main
ideas.
60
4.
Use bullets, not numbers
Bullets and short phrases are more effective than sentences. If
you can shorten a point, then do so. A good guide is to use no
more than 5-7 bullets per slide, and no more than 5-7 words
per bullet.
Most often we put in some key points on the slide to guide the
audience about the talk. Bullets are used to separate and
highlight these various points. Do not use numbers if this is
your intention. Use numbers only when you are bringing about
the hierarchy in the points or when you are mentioning some
criteria for e.g. diagnostic criteria.
One concept/slide at a time is a good guide; or use progressive
disclosure slides (using animation) where the audience only
sees the point you are about to talk about.
5. Allow plenty of room around
Allow plenty of room around borders and illustrations. Keep all
objects at least a mouse pointer away from the edge
6. Follow “6 x 6 x 6” rule
The 6-6-6 rule: no more than six words per item, six bulleted
items per page and no more than six text pages in a row. The
audience will get bored if there are too many text slides in a
row. Add a picture, graph, illustration or an activity inbetween.
Often, even if you place just six lines, it can still appear
cramped ….Strive to place as little text as possible…make one
point …….one single point per slide!
61
7.
Choose color carefully
Be careful with the use of colour. A good guide is to use a deep
blue background colour, with white, yellow, or orange text and
lines.
White is dominant therefore it is good for highlighting text.
Due to the sensitivity of our eye, yellow letters will appear to
come forward; dark blues and deep reds will recede, so yellow
on blue, for instance, will make a slide that is easy to read.
Often, especially for scientific presentations a
background with black letters is best.
white
Whatever you choose, keep the same background throughout
the presentation for a consistent presentation.
8. Graphs / charts
Graphs are a great way to present a great deal of information
to your audience. It is much easier to view a graph than digest
a series of numbers in a table. But don’t do your graphs in
Excel and then import them into Powerpoint. Powerpoint has
a fantastic graphing program all of its own, and the graphs it
produces are more pleasing to the eye, behave better, and fit
into the look of your presentation. The graphing program built
into Powerpoint is very similar to the one in Excel, but it simply
works better.
9. Pictures & clip arts
We have about 40,000 cliparts. Occasionally you will find just
the right one for your presentation; one that hasn’t been used
to death by everyone else.
The right graphic can add impact to a slide, and if it is clear,
you audience will immediately understand its purpose, and it
will strengthen your presentation. Use the google or other
search engines on the internet tofind appropriate pictures and
illustrations.
Use graphs, clip art and photographs. Most people remember
what they see, better than what they hear. Studies show that
at least 50% of what an audience learns from a presentation
comes from visuals.
If you are including scans in your on-screen presentations, only
scan your images at the appropriate resolution. For example If your presentation will only ever be shown on a PC at SVGA
62
(800x600) resolution, don’t bother scanning anything higher
than 800x600 pixels.
To ensure that your pictures display well in slide show, rightclick on the picture, select "Format Picture...", go to the "Size"
tab, from the Scale area check the box labeled "best for slide
show", and set the resolution to match your system resolution
(available from the Display area of the Windows Control
Panel).
10. Be consistent
Remember, once you have made a design decision, you must
stick with it throughout your presentation. You must strive for
consistency in order to maintain clarity, and you do this
through repetition: Keep your headline in the same place on
each slide, repeat type selections, color and line rules, or you
will end up with a muddled mess.
Seven deadly sins
1. Slide Transitions and Sound Effects
Avoid slide transitions and sound effects. They become the
focus of attention, which in turn distracts the audience. Worse
yet, when a presentation containing several effects and
transitions runs on a computer much slower than the one it
was created on, the result is a sluggish. Such gimmicks rarely
enhance the message you’re trying to communicate.
However the animation could be used if it is done well and
designed specifically to bring out an important concept that is
being discussed.
2. Standard Clipart
Try to avoid using the standard “clip art”. Everybody has used
them and it could make the presentation uninteresting. Try to
find an interesting and importantly an appropriate photograph
or illustration instead. This could be obtained from various
sources of which the internet would be the easiest …the
google images for example.
3. Presentation Templates
As with the “clip arts” the standard templates could be boring
and sometimes come in the way of your material display. The
templates often contain distracting backgrounds and poor
color combinations. With a little imagination good
backgrounds could be created in the slide master. Create your
own distinctive look or use your company logo in a corner of
the screen.
63
4.
Text-Heavy Slides
Projected slides are a good medium for depicting an idea
graphically or providing an overview. They are a poor medium
for detail and reading. Avoid paragraphs, quotations and even
complete sentences. Limit your slides to six lines of text and
use words and phrases to make your points. The audience will
be able to digest and retain key points more easily. Don’t use
your slides as speaker’s notes or to simply project an outline of
your presentation.
5. The “Me” Paradigm
Presenters often scan a table or graphic directly from their
existing print corporate material and include it in their slide
show presentations. The results are almost always suboptimal. Print visuals are usually meant to be seen from 8-12
inches rather than viewed from several feet.
Typically, they are too small, too detailed and too textual for
an effective visual presentation. The same is true for font size;
12 point font is adequate when the text is in front of you. In a
slideshow, aim for a minimum of 28 point font. Remember the
audience and move the circle from “me” to “we.” Make certain
all elements of any particular slide are large enough to be
easily seen. Size really does matter.
6. Reading
An oral presentation should focus on interactive speaking and
listening, not reading by the speaker or the audience. Reading
text ruins a presentation. A related point has to do with
handouts for the audience. One of your goals as a presenter is
to capture and hold the audience’s attention. If you distribute
materials before your presentation, your audience will be
reading the handouts rather than listening to you. Often, parts
of an effective presentation depend on creating suspense to
engage the audience. If the audience can read everything
you’re going to say, that element is lost.
7. Faith in Technology
You never know when an equipment malfunction or
incompatible interfaces will force you to give your
presentation on another computer. Be prepared by having a
back-up of your presentation on a CD-ROM. It’s also a good
idea to prepare a few color transparencies of your key slides.
64
In the worst-case scenario, none of the technology works and
you have no visuals to present. You should still be able to give
an excellent presentation if you focus on the message. Always
familiarize yourself with the presentation, practice it and be
ready to engage the audience regardless of the technology
that is available.
Tips & Tricks
Turn off "Fast Saves" This will make your actual .ppt files
smaller. An extra tip to squeeze your powerpoint file even
smaller.... Choose "File", "Properties" and turn off the "save
preview image". This also speeds up saving the file, as
powerpoint does not have to make up the little image
preview
To copy an object on your page quickly and easily instead of
using cut & paste, try this instead. Select the object you
want to copy by clicking on it. Hold down the "CTRL" key on
the keyboard. Click (with the left mouse button) and drag
the object to the new position. Simple & quick. Now try it
again but press the "Shift" key at the same time as the CTRL
key, this will keep the objects aligned. Great for making
diagrams etc.
Quick Zoom.If you are lucky enough to be the proud owner of a
"wheel mouse" (wow!), then the following tips is just for
you. While you are editing your lovely presentation (in slide
view mode) simply wheel the mouse forward while pressing
the CTRL key. Instant zoom! To zoom into a particular
object, then select that object beforehand.
How can I go "back" in a slide show like I do in my browser?
The next slide/previous slide actions use the "slide show"
(one slide after another) metaphor, not the web-space
metaphor (where "back" means "the last slide I saw"). If
you're doing a kiosk style or self-running presentation, the
best thing to do is to put buttons on each slide that navigate
directly to the places they may want to go. To make a BACK
button:Draw a button (or use Slide Show/Action Buttons
and select the blank button, then draw it out on the screen
like you would a box). Select this button or graphic, and
then go to the Slide Show menu, select Action Settings, and
click the radio box marked "Hyperlink to:" and set it to "Last
Slide Viewed". This button will behave like the Back button
on your web browser. If you want this on all of your slides,
put the button on the Slide Master (View/Slide Master).
65
Getting ready
Preparing transparencies
Use clean transparencies
Use not more than 7 words per line
And not more than 7 lines per transparency
Use large lettering
Print text
66
Teaching-Learning Media – OHP 2 - Getting ready-Preparing transparencies…cont
Use a template while writing
Avoid smudges
Make graphics and drawings large enough to be seen
Limit the information to one main idea
Lesson outline / number in the margin
Mount transparencies in frames
Notes may be clipped on to the mount
Place transparencies in sequence in a folder
67
Teaching-Learning Media – OHP 3 - Getting ready
Equipment
Check the projector
Position (Screen / OHP / teacher)
Using the OHP
Darkening the room is not necessary
Switch on the OHP when you are ready to show your first transparency, not before !
Face the participants
Read from the transparency, not from the projection on the screen
Do not block the screen
68
Teaching-Learning Media – OHP 4 - Using OHP …contd
Use a pointer
Progressive disclosure
Overlays
Switch off the projector when not discussing an issue not on the transparency
69
EVALUATION 1: Introduction
Competency:
The Medical College teacher participant should be able to evaluate a medical
student’s knowledge, skills and attitudes comprehensively ensuring reliability,
validity and objectivity.
Specific Learning Objectives:
The Medical College teacher participant at the end of this session should be able to…..





Identify challenges in existing evaluation systems
Recognize the position of evaluation in the educational spiral
To define the purpose of evaluation
Distinguish between formative and summative evaluations
Explain validity, reliability, objectivity and feasibility in relation to evaluation
1. Educational Spiral
It has been illustrated earlier that the health needs of the population that
determines the direction of relevant professional health care education. It is based on the
population’s needs that professional education identifies learning objectives necessary to be
learnt by professional students to fulfill the health care needs as care providers. Each
learning objective identified predominately belongs to a specific domain of learning and will
need to be measured and assessed to determine if they have been successfully learnt. This
is an evaluation of the professional learning and reflects the ability of the health care
professional to fulfill certain roles and responsibilities towards a populations needs. The
professional responsibilities are the competencies. However, the main motivation factor in
most cases is usually external and is the evaluation. If the evaluation asks the appropriate
question or demands a particular skill/attitude, then only will the student strive to “learn”
and demonstrate the specific knowledge, skill and attitude.
Hence, for successful learning of pre-determined objectives the evaluation must be
designed to capture the learning of the necessary learning objectives. If learning objectives
and evaluation outcomes that determines success or failure is determined then teaching
learning activities could be designed and chosen to maximize successful outcome
evaluations. An evaluation analysis could demonstrate if objectives were met by the
educational program allowing for modifications in teaching learning methods, educational
programs, teaching and learning styles a swell as provide students with necessary feedback.
As one can see below the educational spiral uses this logic to identify objectives based on
needs followed by designing evaluations then planning and implementing teaching learning
70
activities and finally implementing the planned evaluation to modify other areas or continue
with the same.
Population
Health Needs
Define
Learning
Objectives
Design
Evaluation
Plan and
Implement Teaching
Learning
Activities
Review
Educational
Process
Implement
Evaluation
2. Challenges in Evaluation:
As students and now as examiners, it should not be difficult to identify challenges, obstacles
and barriers to being fair to a student being evaluated.
Kindly list all possible barriers to a fair examination. Recollect your past theory, practical and
clinical examinations. Once completed, spend time suggesting potential solutions to
overcoming the barriers:
No. Obstacles/Barriers/Challenges
Solutions
71
3. Definition:
The process determining whether pre-determined educational objectives have been
achieved is Evaluation.
4. Wilkes’s Evaluation Cycle:
Wilkes described a simple Evaluation cycle which begins with the planning and preparation
of a Teaching Learning Activity that continues post activity with the collection of evaluation
data that is analyzed, reflected upon to re-plan and prepare the activity.
5. Purpose of Evaluation:
Evaluation not only assists us in assessing the performance of our students but also provides
feedback to teacher and the system in place. Tabulate in appropriate columns possible
purposes of evaluation.
Students
Faculty
Curriculum
6. Planning an Evaluation:
Assume that you are to plan an evaluation of a class of 30 students in your subject. Answer
these questions below as a part of the planning of an evaluation. After this individual
exercise, you may want to share and discuss your answers with your group.
 What is the purpose of your evaluation (Pass/fail? Ongoing feedback?)?
……………………………………………………………………………………………………………………………….
 Whom are we evaluating (Student? Teacher? Method/System)?
………………………………………………………………………………………………………………………………
72
 Who will collect and analyze data (Teacher? Student Peers? HOD or Dean’s Office) ?
……………………………………………………………………………………………………………………………….
.
 Who will see the results of the evaluation (Teacher(s)? Student(s)? Guardian?
Dean/HOD?)?
……………………………………………………………………………………………………………………………
7. Kirkpatrick’s Hierarchy:
Kirkpatrick, D.L. (1998) Evaluating Training Programmes - The Four Levels. 2nd Ed
Results
Patient
Outcome
Behaviour
Changes in
Professional
Practice?
Learning
What Knowledge, skills
and attitudes have
been acquired?
Reaction
What was the Learner’s
reaction to the activity?
Activity (Drill):
We have taught a session on the early diagnosis of Tuberculosis using Sputum Microscopy to
a class of health care providers. The following evaluations were conducted. Kindly write the
appropriate Kirkpatrick type for each of the proposed evaluations listed below.
Evaluations conducted
No.
1
2
3
4
Kirkpatrick’s Level Type
Immediate post test MCQs
The number of patients diagnosed early
over the next 6 months is compared with
the numbers last 6 months.
The participant is referring many more
patients
for
sputum
examination
compared with Chest X-Rays than was
previously
A post session performa is distributed that
asks for a grading of the session (5 point
grade from useless to useful)
73
8. Types of Evaluation:
For all practical purposes there are two evaluation types: Formative and Summative.
8.1 Formative/Feedback Evaluations:
These evaluations are usually confidential and allow the student alone to
access his or her progress through an assessment. It is ideally continuous or
frequently periodic during the period of training to capture true progress of the
student’s learning. It may monitor and evaluate small portions of an entire learning
probably focusing on key essentials. It enables students identify strengths and
weakness and areas that need additional efforts, not only by the student but by the
faculty. The faculty in turn through these formative evaluations monitors their
student’s performances and learning enabling them to prioritize certain areas or
even change teaching learning activities/methodologies to improve learning. It
usually is not designed to add on to a summative evaluation that determines pass or
failure, or success or failure of the student. Formative evaluations are not designed
to compare students but to evaluate student’s individual learning against achieving
identified learning objectives.
8.2 Summative/Certification Evaluations:
Summative or Certification evaluations have the specific objective of
determining if a student should pass or fail a course and is usually conducted at the
need of all learning activities. It may however be broken up to be administered
periodically and cumulative marking or grading that determines success or failure.
Here, student performance may be compared against each other to be ranked
though it may also be designed to decide if the student has acquired a predetermined level of knowledge/ skills/ attitudes. It usually is not confidential and
decides promotion or the need to repeat the training. It is relatively infrequent.
Activity (Drill):
The following evaluations were conducted. Kindly write the appropriate Type of Evaluation
(Formative or Summative) for each of the evaluations listed below.
Evaluations conducted
No.
1
2
3
4
Type of Evaluation
Final
MBBS
Medicine
Examination
Prelims for Final MBBS students
Surprise Class Quiz
Institute
Subject
Prize
Examination
74
9. Characteristics of Evaluation:
Good evaluation requires certain characteristics described below.
9.1 Validity = “truly measures what it is intended to measure”
The cornerstone of evaluation is validity.
If a competency required for a medical graduate is the ability to manage a normal
pregnancy, then one specific learning objective required would be that the student
should be able to determine gestation by palpation of the uterus.
If one gives a short answer theory question on Uterine Height it would allow the
student to write down all steps of how to do it and also describe how to interpret
the palpation findings. However, if one was to evaluate this learning objective being
primarily a psychomotor skill “palpation”, the actual observation by an evaluator of a
student demonstrating the actual palpation of a uterus and then interpreting his or
her findings would be a true measure of the ability to determine gestation by
palpation of the uterus.
The observation of the palpation of uterine height and its interpretation is certainly
“truly measuring what it intends to measure” and is valid compared with the short
answer question.
xxx
xxx
9.2 Reliability = “consistency of results”
If a competency required for a medical graduate is the ability to recognize
and initiate management of life threatening cardiovascular events in children with
cyanotic congenital heart disease, then one specific learning objective required
would be that the student should be able to diagnose a cyanotic spell of cyanotic
congenital heart disease.
To evaluate this objective one may set a question asking the student to
describe features of a cyanotic spell. Incidentally, the students have similar
terminology (Cyanotic Spell) in Breath holding spells as well as in Cyanotic Congenital
heart disease. The majority of students write well describing a cyanotic spell due to
Breath holding spells and very few write about Cyanotic Heart Disease’s Cyanotic
spells. There was “consistency of results” hence reliable (most wrote on Breath
holding spells!), but the question isn’t valid (for we meant to measure cyanotic
Congenital Heart Disease but didn’t measure what we intended to measure!).
75
The question to describe a cyanotic spell is certainly reliable but not valid. A
modified question to describe clinical features and initial management of a cyanotic
spell in Cyanotic Congenital Heart Disease may make it not only reliable but also
valid.
xxx
xxx
9.3 Objectivity = “Concordance between examiners”
If questions (theory or oral) are left inadequately structured then there are many
areas open to subjective interpretation not only by students but also evaluators.
A theory question asking a student to write a short note on the Appendix could
be used a s an example. The student may describe the gross anatomy and
histiology, even drawing a diagram and labeling the parts. Another student may
describe the gross anatomy, histiology and describe the applied anatomy of
appendicitis without a diagram. Who gets more marks? Similarly, evaluators may
expect different areas to be covered in the answer and differ from each other in
their independent evaluation of the same answer paper. A question as describe
above doesn’t have Objectivity for it allows poor “concordance between
examiners”. If the question is modified to describe the gross anatomy (0.5);
illustrate and label the relations (1.5); illustrate and label the histiology (1); and,
an applied aspect of the Appendix (2), it may improve the objectivity of the
question. A key outlining the expected answers and the breakdown of marks
would further improve objectivity. The student knows what to write and the
evaluator knows how to score an answer.
Ask the student the question and the student will answer! No guessing required!
An evaluation is to measure what the student has learnt, not what a student is to
guess what the evaluator wants!
xx x
x
x
x
x
x
x
9.4 Feasibility = “Ease of implementation”
One may have large number of students required to be evaluated and few
faculty. One needs to strike a balance between what is ideal and what is possible,
practical and pragmatic (ease of implementation). If we have a large number of
learning objectives to be evaluated, one may have to prioritize further and
choose a few that become essential requirements for your evaluation. You may
utilize different evaluation methods to achieve this feasibility such as
76
OSCE/OSPEs that don’t always require professional manpower to assess as long
as the manpower are trained in the specific OSCE/OSPE and have integrity.
9.5 Relevance = “Appropriateness”
If the Learning Objectives are appropriate for the level of student being trained
then the evaluation will probably be appropriate hence relevant.
During a viva asking an undergraduate medical student to read successfully a MRI
of the brain may not be appropriate and relevant. However, a Chest X-Ray with a
large pleural effusion could be considered appropriate and relevant.
Activity (Exercise):
The following evaluation methods were used to evaluate students. Kindly review each
method listed below and determine the strength (on a grade 0-5; 0 being poor and 5 being
excellent) of each of the tabulated characteristic.
Evaluation conducted
No.
1
Characteristics
Excellent)
Valid
of
Evaluation
Reliable
(Poor
0-1-2-3-4-5
Objective
Traditional
Essay
Question
Multiple Choice Question
Traditional
Clinical
Bedside Examination
Traditional Viva voce
Practical
Examination
with structured questions
and a model answer key
2
3
4
5
Key Learning





Evaluation determines what most students perceive as essential and priority
learning.
Evaluation evaluates if pre-determined learning objectives have been achieved or
not.
Evaluation not only assists a student in learning but guides a teacher in teaching
learning.
Evaluation may be Formative or Summative.
Evaluation must be valid, reliable, objective, feasible and relevant.
77
Session Self Assessment (True or False):
Serial
No.
1.
2.
3.
4.
5.
Statement
True
False
Comment
Evaluation must primarily assess the teaching of
predetermined specific learning objectives.
Summative evaluation assists a student in
modifying learning behavior during the training
course.
The consistency of results defines Validity.
Objectivity is when there is concordance
between different examiners.
Reliability is that the question truly measures
what it intended to measure.
78
EVALUATION 2
ESSAY AND SHORT ANSWER QUESTIONS
Competency:
The Medical College teacher participant should be able to evaluate a medical
student’s knowledge, skills and attitudes comprehensively ensuring reliability,
validity and objectivity.
Specific Learning Objectives:
The Medical College teacher participant at the end of this session should be able
to…..






List domains where Essay and Short Answer Questions are of relevance
Describe types of Essays and SAQs
Describe the role of Essays in Evaluation
Recognize poor Essays and Short Answer Questions that have poor
characteristics of Evaluation
Describe methods of scoring Essays
Construct Essays and SAQs
1. Kirkpatrick’s Hierarchy of Evaluation (Kirkpatrick, D.L. (1998) Evaluating Training
Programmes - The Four Levels. 2nd Ed).
Theory assessments are required to assess what Cognitive and Knowledge aspects
have been learnt or acquired. This assessment of Learning in the Kirkpatrick’s
hierarchy requires theory questions such as Essays and Short Answer Questions.
Results
Patient
Outcome
Behaviour
Changes in
Professional
Practice?
Learning
What Knowledge,
skills and attitudes
have been acquired?
Reaction
What was the Learner’s
reaction to the activity?
2. Characteristics of Evaluation:
Good evaluation requires certain characteristics described below. Even Essays and
SAQs need to have these characteristics to be “good” evaluations. Below are reminders of
the characteristics.
79
2.1 Validity = “truly measures what it is intended to measure”
xxx
xxx
2.2 Reliability = “consistency of results”
xxx
xxx
2.3 Objectivity = “Concordance between examiners”
xx x
x
x
x
x
x
x
2.4 Feasibility = “Ease of implementation”
2.5 Relevance = “Appropriateness”
3 Evaluation Methods
Activity:
Kindly spend the next 1-2 min thinking of all evaluation/examination/assessment
methods one has experienced or heard of and share them with the group when
asked. It may be a good idea classifying them into domains – Cognitive (Knowledge),
Psychomotor (Skills) and Affective (Attitudes). You may want to jot them down in the
table below:
Cognitive (Knowledge)
Psychomotor Skills
Affective (Attitudes)
4 Miller’s Pyramid
Miller’s Pyramid illustrates the hierarchy of learning psychomotor skills that also
requires the acquisition of cognitive knowledge that is the stepping stone to actually
skill acquisition. If one is to evaluate if the necessary knowledge is acquired even for
80
a psychomotor skill acquisition then we may utilize theory questions to assess this
aspect.
Does
Shows
How
Knows How
Knows
5 Cognitive (Knowledge) Assessments
They may be written or oral. Essays, SAQs and Multiple Choice Questions MCQs
would be examples of written assessments. Viva voce (by word of mouth) would be
an oral assessment of knowledge or cognitive.
6 Why Essays?
In the previous section we have seen how existing Essays have major drawbacks in
terms of characteristics of evaluation. They have poor validity, reliability and
objectivity. The question therefore is why do we need Essays for Evaluation?
7 Types of Essays
a. Structured Essays
Eg. Pulmonary Tuberculosis: Etiology, Pathogenesis, Clinical Features and
Management (1, 3, 3, 3 marks)
b. Modified Essay/Patient Management Problem
Eg. A 19 year old presents with chronic cough, persistent fever, weight loss and
hemoptysis. The person works in a government hospital as a ward boy. On
examination, he is emaciated, febrile and has bronchial breathing with
crepitations in the area of the right upper lobe of the lung.
 What is the possible differential diagnosis? (1 marks)
 Discuss the etio-pathogenesis of the commonest one? (1,2 marks)
 What are the laboratory investigations required to confirm the commonest
possible according to the National Program? (2 marks)
 What are the clinical features that differentiate the differential diagnosis? (2
marks)
 Plan and discuss treatment of the commonest diagnosis. (2 marks)
8 Types of Short Answer Questions SAQs
a. Completion type
Eg. A preterm newborn is born before……..weeks.
Eg. Label the ECG shown below: ECG tracing….
Eg. Name the enzymes in the biochemical cycle drawn below…..
81
b. One best response type
Eg. A 2 yr old child weighs 8 kg and has bilateral pedal edema. What is her IAP
PEM classification?
c. Open SAQs
Eg. Enumerate 3 causes of massive splenomegaly.
Eg. Enumerate 3 common side effects of Phenytoin.
Activity (Individual and Group):
Individual Task:
Construct
1. Structured Essay Question and/or a Modified Essay Question
2. Construct an appropriate Model Answer
3. Short Answer Question
Group Task:
4. Choose 1 of each from your group’s individual creations to present
a. Structured Essay/Modified Essay
b. Model Answer
c. Short Answer Question
9 Guidelines for Scoring Essays
a. Model Answers: Each structured or modified essay should have a skeleton model
answer with marks designated to improve objectivity between examiners who
correct the answers.
b. Scoring vs Grading Scheme: Essays may have clear structured model answers
allowing for scoring however when organization of thoughts and description of
concepts is involved then grading may be a more realistic.
c. Score Answer by Answer: When you have a series of answer sheets before you, it
is ideal to complete assessment of one question at a time rather than one paper
at a time. It allows a more objective assessment for all students being assessed.
d. Conceal identity: Being blinded to name, sex and institute improves objectivity.
e. No choice: Essays should preferably never have a choice to enable being fair to
all students participating in the evaluation.
f. Shuffle answer scripts between questions: Simply allows less bias and more
objectivity.
82
g. Average scores of at least 2 examiners: This method allows more objectivity and
if the difference between examiners scores is unreasonable as defined earlier a
third evaluation may be required.
h. Adequate time for evaluation: Some universities don’t allow too many answer
sheets being corrected within a time slot by an examiner. This allows more depth
of evaluation and being just to the student.
i. Don’t form a judgment of a student on the basis of only one question: By
shuffling papers and concealing identity much of this factor is limited.
Key Learning


Essay and SAQs must be valid, reliable, objective, feasible and relevant.
Modifying Essays and SAQs predominately improves objectivity.
Session Self Assessment (True or False):
Serial
No.
1.
2.
3.
4.
5.
Statement
True
Fals
e
Comment
Traditional Essays major drawback is the poor
objectivity.
Model answers are designed to assist students
write appropriate answers
Patient Management Problems are suggested
Essay modifications.
Essays and SAQs are the keys to evaluation of
Psychomotor skills.
An essay is a written composition with a focused
subject of discussion.
83
EVALUATION 3
MULTIPLE CHOICE QUESTIONS
Competency:
The Medical College teacher should be able to construct suitable single response multiple
questions using the guidelines suggested for their proper construction.
Specific Learning Objectives:
At the end of this session the Medical College teacher should be able to:
 Recognize the role of multiple choice questions as a tool of evaluation.
 Compare and contrast the features of descriptive and multiple choice questions.
 Listthe types of multiple choice questions.
 Enumerate the components of multiple choice questions.
 Construct single response multiple choice questions using prescribed guidelines for their
proper construction.
 Construct single response multiple choice questions that test application of knowledge
rather than recall.
 Explain the importance of validation.
1. Introduction
Multiple choice questions (MCQs) are now widely used for formative evaluation and for
selection purposes, though less often for summative evaluation. The use of MCQs in itself
does not guarantee a more valid or reliable evaluation system, although it may make it
more objective. As with any other instrument of evaluation, guidelines for construction of
MCQs’ are related to the development of educational objectives and defining levels of
learning for each objective. Flawed MCQs interfere with accurate and meaningful
interpretation of test scores. Therefore, in order to develop tests that are reliable and valid,
MCQs must be constructed that are free of such flaws. This chapter provides an overview of
established guidelines for writing effective MCQs.
84
2. Comparison between descriptive questions and MCQs
An awareness of the inherent defects in the system of written evaluation based on the
conventional essay and short answer questions has led to an increased use of MCQs in
medical education.
Exercise 1: Please fill in the table below that compares the characteristics of descriptive
questions and MCQs’.
Characteristics
Descriptive Questions
Multiple Choice Questions
Ease of setting the exam
Ease of grading
Grading time
Grade consistency
3. Types of MCQs
As many ten formats of MCQs’ were used earlier. These have now been reduced to five,
which are most widely used in national and international examinations.
3.1 Single best response type
This is the most common format.
Example
Direction: Please tick the correct answer (√)
The movements of pronation and supination take place at which joint?
a. Elbow
b. Wrist
c. Radio-ulnar √
d. Mid-carpal
3.2 Matching type
This type of MCQ consists of two lists, namely premises and responses, which need to
be matched. The direction for this type of MCQ needs to be more detailed. Usually the
number of responses should be more than the number of premises to minimize guessing.
Example
Direction: Match the following sites of absorption in the gut (premises) with the nutrients
absorbed at each site (responses)
Premises
A) Jejunum
B) Terminal ileum
C) Colon
Responses
(A) 1. Calcium and folic acid
(C) 2. Water and electrolytes
(B) 3. Vitamin B12 and bile acid
( ) 4. Polysaccharides
( ) 5. Glycerol
85
3.3 Multiple completion type
This requires higher levels of cognition then mere recall of facts. The stem is followed
by four completions, one or more of which are correct. The direction should be clearly given
at the beginning of any section in which this format occurs. The code of response is usually
standard to avoid confusion.
Example
Direction: Each of the following statements given below has one or more correct answers.
Answer in the space provided using the following key.
a. Only if 1, 2 and 3 are correct.
b. Only if 1 and 3 are correct.
c. Only if 1 and 4 are correct.
d. Only if 4 is correct.
e. All four are correct.
Claw hand is seen in the following conditions: (b)
1.
Klumpke’s paralysis
2.
Erb’s paralysis
3.
Ulnar nerve injury
4.
Radial nerve injury
3.4 Multiple true or false type
In this format, the student is instructed to separately respond to each of four or five
choices. Each of these choices can be individually true or false and are not interdependent.
Example
Direction: To each of the alternatives of the item below you are to respond TRUE OR FALSE
Bipolar neurons are found in the
1. Retina
2. Taste buds
3. Organ of Corti
4. Olfactory epithelium
T / F (T)
T / F (F)
T / F (F)
T / F (T)
3.5 Relationship-analysis type
This type of MCQ is very useful to test higher levels of cognition as the candidate has
to decide whether each individual statement is correct, and then determine their causeeffect relationship. Here each item consists of an ‘assertion’ (statement A) linked to a
‘reason’ (statement B) by the connecting word ‘because’. The student has to decide
whether the assertion and reason are individually correct or not and if they are both correct
whether the reason is the correct explanation of the assertion.
86
Example
Direction: Each question given below consists of two paired statements A (assertion) and B
(reason) connected by the term ‘because’. Mark the appropriate answer using the key given
below.
A. If both assertion and reason are true statements and the reason is the correct
explanation of the assertion.
B. If both assertion and reason are true statements and the reason is not the correct
explanation of the assertion.
C. If the assertion is true and the reason is false.
D. If the assertion is false and the reason is true.
E. If assertion and reason are both false.
Assertion: Saturday night palsy causes wrist drop
Reason: The muscles of the flexor compartment of the forearm are paralyzed. (C)
4. Components of an MCQ
 Each MCQ is called an item.
 The instruction given for writing the MCQ is called a direction.
 Each question (item) has a stem followed by a series of responses.
 The correct response is the key and the incorrect responses are distracters or
alternatives.
Example
Tick / encircle the correct answer - DIRECTION
The site of action of anti-diuretic hormone in the kidney is - STEM
a. descending limb of loop of Henle
b. ascending limb of loop of Henle
c. distal convoluted tubule
d. collecting tubule – KEY
DISTRACTORS
ITEM
5. Guidelines for framing single best response MCQs
Characteristics of effective MCQs can be described in terms of the overall item, the
stem, and the alternatives. The educational objectives and the MCQs that accompany those
objectives should target all levels of learning appropriate for the given content. The
guidelines mentioned below should be viewed as best-practice rules and not absolute rules.
In some circumstances, it may be appropriate to deviate from the guidelines. However, such
circumstances should be justified and occur infrequently.
Item




Relate items to instructional objectives.
Test at same level of learning as objectives are designed to assess.
Write items to reflect different levels of learning.
Direction should be clear.
87
Stem
 Provide a complete statement.
 Include only relevant information.
 Contain as much of the item as possible in the stem.
 Keep stems as short as possible.
 Ask for the correct, not “wrong” answer. If the “wrong” answer is asked for or
“except” is used it needs to be highlighted.
 Avoid absolute terms such as “always”, “never”, “all”, or “none”.
 Avoid imprecise terms such as “seldom”, “rarely”, “occasionally”, “sometimes”, “few”,
or “many”.
 Avoid cues such as “may”, “could” or “can”.
 Define eponyms, acronyms, or abbreviations when used.
Alternatives
 Keep options grammatically consistent with the stem.
 Write incorrect options to be plausible but clearly incorrect.
 Link options to each other (e.g., all diagnoses, tests, treatments).
 Write distracters to be similar to the correct answer in terms of grammar, length, and
complexity.
 Avoid “none of the above” or “all of the above”.
 Place options in logical order (e.g., numerical, chronological).
 Write options to be independent and not overlapping.
 Vary position of keyed responses.
Exercise 2: Given below are single response MCQs that have flaws in their construction. Can
you spot the flaw and improve upon their construction?
1. The stylopharyngeus muscle is a derivative of the following pharyngeal arch:
a. 6
b. 4
c. 1
d. 3
2. A chest radiographic finding of left upper lobe collapse is _____.
a. hyperlucency of the upper and lower left hemithorax.
b. elevation of the left diaphragm.
c. when the mediastinum shifts to the right.
d. posterior displacement of the minor fissure.
3. What is the average effective radiation dose from chest CT?
a. 1-8 mSv
b. 8-16 mSv
c. 16-24 mSv
d. 24-32 mSv
88
4. All the following are true regarding cytotrophoblast except:
a. situated outer to syncytiotrophoblast
b. pale staining
c. mono-nucleated
d. retain individual cell membrane
5. The axis artery of the upper limb is formed by:
a. 4th cervical intersegmental artery
b. 5th cervical intersegmental artery
c. 6th cervical intersegmental artery
d. 7th cervical intersegmental artery
6. An otherwise healthy 28-year-old woman presented with a two-day history of cough,
fever and shortness of breath. What is the most likely diagnosis?
a. tuberculosis
b. community-acquired streptococcal pneumonia
c. varicella pneumonia
d. blastomycosis
Exercise 3: Please construct a single best response MCQ using the guidelines mentioned
above. Before constructing the MCQ, kindly state the specific learning objective that the
question is testing.
6. Testing application of knowledge rather than recall
The stem is generally longer when application of knowledge is being tested as opposed
to recall of an isolated fact. To test application of knowledge, clinical vignettes can provide
the basis for the question, beginning with the presenting problem of a patient, followed by
the history (duration of signs and symptoms), physical findings, results of diagnostic studies,
initial treatment, subsequent findings, etc. Vignettes do not have to be long to be effective,
and should avoid verbosity, extraneous material and “red herrings.” Vignette items are
generally felt to be more appropriate because they test application of knowledge and thus
improve the content validity of the examination.
Example:
Item measuring recall
Erb’s paralysis occurs due to an injury to the:
a. upper trunk of the brachial plexus
b. middle trunk of the brachial plexus
c. radial nerve
d. ulnar nerve
89
Item with a vignette measuring application of knowledge
Soon after a difficult delivery, a neonate was found to have an abnormality of the left upper
limb on testing for Moro’s reflex. The arm was held close to the body, with the forearm
pronated. No other abnormality was observed. The most likely cause for the neonate’s
symptoms is injury to the following structure on the left side:
a. upper trunk of brachial plexus
b. lower trunk of brachial plexus
c. radial nerve
d. ulnar nerve
7. Validation
An important step in the formulation of MCQs is the process of validation. Validation is
mandatory at two stages:
Pre-validation: It is the process to which an MCQ is subjected prior to administering in an
examination.
Post -validation: It is the analysis of the item after it has appeared in an examination (Item
analysis).
Both tests are equally important in ensuring that the item is valid.
7.1 Pre-validation
The item that has been constructed is subject to scrutiny by 3 or 4 experts in the subject
before administration in an examination. The following aspects need to be looked into:
i. Relevance with respect to the learning outcomes.
ii. Whether or not the item has been constructed according to the guidelines
mentioned above.
iii. A decision as to which of the alternatives is the correct one, and confirmation that it
is the only correct response possible.
iv. An estimate as to the level of cognition being tested by the item and the level of
expected difficulty.
7.2 Post-validation (Item analysis)
Statistical analysis of items to check that they are effectively evaluating student
learning is called item analysis. Details of this process are beyond the scope of this
workshop. Item analysis provides answers to the following questions:
i. Were any of the items too difficult or easy?
ii. Do the items discriminate between those students who really knew the material
from those who did not?
iii. Were the distracters effective or not?
90
Key learning







MCQs have a definite role in formative evaluation and selection examinations.
MCQs have certain advantages over descriptive questions chief amongst which are increased
objectivity and decreased grading time.
The types of MCQs include single response, matching, multiple completion, multiple true or
false and relationship analysis types.
The components of an MCQ include a direction, stem, alternatives, distracters and key.
Guidelines need to be followed for the proper construction of MCQs.
It is possible to test application of knowledge, in addition to recall, using single response
MCQs’.
Validation of MCQs is an essential process and consists of pre-validation and post-validation.
Suggested reading
Internet
• www.bradfordvts.co.uk/.../guidelines%20for%20preparing%20good%20MCQs.ppt
• www.tss.uoguelph.ca/tli/tli04/presentations/jbarth.ppt
• cstl-pti.semo.edu/.../Multiple%20Choice%20Test%20Item%20Analysis.ppt • www.arrs.org/uploadedFiles/.../writingMultipleChoiceHandout.pdf
• www.ascilite.org.au/conferences/perth04/procs/pdf/woodford.pdf
• www.journalofeconed.org/pdfs/.../48_57Buckles_win06.pdf
• www.aishe.org/events/2006-2007/conf2007/.../paper-53.pdf
Books
• Medical Education – Principles and Practice, 2nded, NTTC, JIPMER.
• Medical Education Technology, MEC, St. John’s Medical College.
91
ITEM ANALYSIS
Competency:
The teacher should be able to analyze the responses to a series of questions designed to enable
the modification of the questions following the item analysis if required.
Learning Objective
The Participant should be able

to defend the rationale behind an item analysis

to perform an item analysis

To interprete calculated values

to apply an item analysis
What is item analysis?

Item analysis is the process of analyzing the performance of a multiple choice item
after it has appeared in a question paper

Pre- validation: the process in which the MCQs are validated by subject experts and
by administering the MCQs to a small group of students

Post validation: validation of the MCQ after its administration to the students as a
test. This procedure is known as item analysis.
Why item analysis?

To determine whether the item is of appropriate level of difficulty for the batch of
students tested

Whether the item is capable of discriminating between the knowledgeable and the
ill-informed students.

It is used to analyse the effectiveness of distracters
What are its uses?
Item analysis provides answers to the following questions.

How difficult / easy is the given item?

Can it discriminate between the knowledgeable and ill –informed students?

Are distracters serving their purpose effectively?
92
How is item analysis performed?

Score the test for all students

Rank the students in the order of merit based on their test scores

Take the bottom third as low achievers and the top third as high achievers

Prepare a table for each item as follows
Example: Item no 15
Options
A
B
C
D
No response
Total ( N)
Key (Correct response ) C
No. selecting the option against
High achievers
Low achievers
5
5
30
10
nil
50
10
10
10
10
10
50
For calculation of indices, although it is simplistic to divide into two halves, top 50% and
bottom 50%, statistically it has been proven to be more accurate to use the top 27% and
bottom 27% which represent the high and low achievers.
Difficulty index:
Is indicated by symbol ‘P’ is calculated by the formula
P = H+L X 100
N
H is the number of students answering the item correctly in the High achiever group
L is the number of students answering the item correctly in the low achiever group
N Total number of students in the two groups (including non-responders)
Difficulty index is the proportion of total students in the two groups who have answered the
item correctly. It is expressed as a percentage.
Difficulty index 30 – 70% are acceptable
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50 – 60% are ideal
>70% are very easy
< 30% are difficult
Discrimination index:
is indicated by the symbol ‘d’, calculated by the formula
d = H-L X 2
N
It is a measure of the ability of an item to discriminate between knowledgeable and illinformed students, important when items are used for selection of students as in an
entrance examination. It is expressed as a decimal
d 0.25 – 0.35 are good
> 0.35 are excellent
<0.2 are poor
Negative discrimination index indicates a defective item or wrong key
The distracter effectiveness:
Any distracter in the item which has not attracted even 5% of the total response is a nonfunctional distracter
Group activity:
To calculate the difficulty index, discrimination index in the given situations
Creation of item banks:

Item analysis is used to bank tested MCQs with known and consistent levels of
difficulty and discriminating power, free of constructional errors and having
functional distracters.

Item card: is a record on one side of the full item, the correct answer, the source of
the item, the ability being tested and the broad and specific areas to which the item
belongs. On the reverse side of the item card is a record of the difficulty and
discrimination indices of the item. If the item has been used more than once, all the
indices should appear in order to test for consistency.

From the item bank, appropriate number of items from various subject areas of
appropriate levels of difficulty and discriminating capacity can be selected.
94

Items which are easy can be included in the beginning of the question paper as
morale booster. Very difficult items are often nondiscriminatory. Defective items
may be rewritten

Use of item analysis following a test as a part of formative evaluation enables the
teacher to determine areas which require reinforcement and emphasis
Key message:

Item analysis is important for better learning, better teaching and better evaluation
95
MICROTEACHING
Competency: The Medical College teacher shall learn about the important teaching skills to
be a good teacher and imbibe some of these skills in the microteaching session.
Objectives:
At the end of this session the participant shall be able to:
1.
2.
3.
4.
5.
List the important teaching skills
Understand the concept of microteaching
Describe the process and cycle of microteaching
Plan and participate in a microteaching lesson incorporating the teaching skills
Organize microteaching sessions in parent department
Definition of teaching skills
Teaching skills include all behaviors of the teacher, both verbal and non-verbal, which
maximizes pupil learning.
Enlist important teaching skills
1. Attitude And Preparation–The most important requisite!
One has to enjoy teaching to be a good teacher. Sincerity and commitment to
teaching is the most important prerequisite to becoming a good teacher . Humility and
willingness to learn coupled with thorough preparation before a class is required.
Depending on the powerpoint presentation for your class is not suitable- one should have
mastered the topic beforehand.
2. Organizing the content
Logical sequencing of the topic so the topic can be easily understood
- Establish clearly, in advance, the major point or points you wish to communicate
- Establish links between ideas.
- Obtain information from pupils about their knowledge, experience, and interest to
guide your planning.Your explanation must appeal to your class.
- Decide the means by which explanation is likely to be effective.
- Be flexible. Be prepared to modify your plans in the light of feedback from pupils
96
during the lesson. Adapt to pupil needs.
- Be brief. Think how much you recall after 10 minutes.
3)Creating set for introducing the lesson
Arouse interest by relating to previous learning/ establish relevance of the class to
clinical situation
4) Specifying objectives
Establish clearly the specific learning objectives of the session. This should include
what you think is the ‘must know /take home message’ for the class. By doing so it draws
the students’ attention to the relevant points as they appear in the course of the class.
5) Explaining
This is the main body of the session.
Ensure the following:

Clarity

Continuity with beginning and ending statements

Cover essential points

Simple

Use examples if possible
6) Using teaching aids
Choose beforehand the most appropriate one for the topic eg blackboard, powerpointetc
Familiarize yourself with its use.Don’t depend only on the AV aid- it may fail- have a back up
plan!
7)Stimulus variation
Studies have shown it is very difficult to hold the attention of the class for long without a
change in sensory stimuli. Therefore it is necessary to incorporate these stimuli in order to
secure the attention of the class. These stimuli include:
-
Movements eg to the blackboard., between the students etc. do not stick to one
place!
Gesturing to indicate shapes, concepts etc
97
-
Facial expressions to indicate emotion etc
Changing the pace of the presentation, voice modulation to emphasize points
Pausing – a sudden pause in the presentation grabs the attention of the class
Change interaction style
8) Questioning
Solicit questions from the pupils. Ask specific questions to highlight important points and
also as means of stimulating the class. Reward pupil effort by appreciating correct answers
like saying ”very good” or “that’s a good answer”. This encourages the students to
participate actively participate in the class.
9)Promoting pupil participation
This includes questioning and organizing activities like group activities, role plays, inter
student discussions, student presentations . Promotes Self learning by the student
10) Achieving closure of the lesson
It is important to summarize the key learning points at the end of the class. Relate them to
the learning objectives projected at the beginning of the class.
Also, link the learning points to future learning in the form of additional reading/literature
/next class/student assignments
11)Management of the class
Any class is a mixture of fast and slow learners, and of orderly vs disorderly/ distracting
students. The test of the teacher lies in ensuring that even the slow learners learn and to
ensure discipline while at the same time maintaining a friendly,student friendly
environment in the class.
MICROTEACHING
Having learnt some of the important teaching skills required to be an effective teacher, the
challenge now lies in imbibing these skills in our teaching style. The best way to do so would
be to actually practice these skills in teaching schedules. However, to experiment with these
skills for the first time in a regular class of 60-200 students can be intimidating. Nor can
these skills be learnt by any amount of reading or by emulating other teachers. It would be
easier to experiment in a smaller, more compact setting where nevertheless, critical
feedback from the pupils is forthcoming. Microteaching was designed to create this
compact platform where one could practice newer teaching skills to improvise oneself
98
How does one acquire these skills?
Observation of others –risk of emulating the mistakes of others .
Trial & error in the classroom – difficult- is like learning to swim at the deep end of the pool!
Reading?
What is microteaching?
Microteaching is a training technique where the student teacher involves in a scaled down
teaching encounter for the improvement of specific teaching skills. It is scaled down in
many aspects:
1. to teach a single concept of content
2. using specified teaching skills
3. for a short time (5- 10 minutes)
4. to a very small member of pupils(4-5)
It was first developed by D.W Allen and his group in Stanford University in 1960s.
The Process:
How is microteaching done?
The
Micro-teaching
programme
involves
the
following
steps:

Step I Particular skill to be practiced is explained to the teacher trainees in terms of
the purpose and components of the skill with suitable examples.

Step II The teacher trainer may give the demonstration of the skill in Micro-teaching
in
simulated
conditions
to
the
teacher
trainees.

Step III The teacher trainee plans a short lesson plan on the basis of the
demonstrated
skill
for
his/her
practice.

Step IV The teacher trainee teaches the lesson to a small group of pupils. His lesson
is
supervised
by
the
supervisor
and
peers.

Step V On the basis of the observation of a lesson, the supervisor gives feedback to
the teacher trainee. The supervisor reinforces the instances of effective use of the
skill and draws attention of the teacher trainee to the points where he could not do
well.
99

Step VI In the light of the feed-back given by the supervisor, the teacher trainee
replans the lesson plan in order to use the skill in more effective manner in the
second
trial.

Step VII The revised lesson is taught to another comparable group of pupils.

Step VIII The supervisor observes the re-teach lesson and gives re-feed back to the
teacher
trainee
with
convincing
arguments
and
reasons.

Step IX The ‘teach – re-teach’ cycle may be repeated several times till adequate
mastery level is achieved
100
Time duration for the microteaching is;
o Teaching 6 Minutes.
o Feedback : 6 Minutes.
o Re-Plan :12 Minutes.
o Re-Teach : 6 Minutes.
o Re-Feedback : 6 Minutes
How does it compare to traditional classroom teaching?
Microteaching is not a teaching technique, it is a training technique to acquire teaching
skills. Medical professionals have little training in teaching techniques- we learn by trial
&error in the classroom. Microteaching makes us better prepared for the classroom.
Microteaching
· Teaching is Relatively Simple
· Carried out in controlled situation
· small class of 5-7 students
· takes up one/few skills at a time
Classroom teaching
* Teaching is Complex Activity
* Carried out in uncontrolled Situation
*35 to 40 students
* practices several skills at a time
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· Teaching time is 5 to 10 mts.
· provided immediate feedback
· Provision for reteaching
. Easy to organize – inexpensive
* Teaching time is 40 to 60 mts
* No immediate feedback
* No provision for reteaching
* large nos involved- more difficult
Assignment
Activity:
Microteaching session on day 3
1. Choose appropriate topic
Relevant
Small scale
Interactive
3. Teach -5 minutes

Group- peers , supervisor, students

Feedback

Guidelines/feedback form-
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Key Learning



Teaching skills, both verbal and non-verbal are integral to the making of a better
teacher
Microteaching is an easy, convenient way of inculcating these skills in our
teaching methods.
The cycle of microteaching includes planning, teaching, feedback, re-planning, reteaching and repeat feedback
103
ASSESSMENT OF CLINICAL COMPETENCE
Competency
The Medical College teacher participant should be able to assess the clinical competence
of a medical student, comprehensively ensuring reliability, validity and objectivity
Learning Objectives
The participants at the end of this session should be able to.



Discuss the advantages and limitations of the conventional clinical exams
Define an ‘OSLER’s – Objective structured Long Examination Record’
Modify existing conventional clinical examinations to improve clinical
assessments
Introduction
Acquiring knowledge and skills without application has no value in medical education.
Assessment of this ability to apply acquired knowledge is assessed by the various methods
of assessment of clinical competence. The method of assessment is determined by the
objectives and nature of the teaching programme, the logistics involved, and the
expectations of the teachers and the licensing Board 1. The method that most of us are
familiar with and have experienced personally is the Conventional Clinical Exams which
typically includes a long case, 2-3 short cases and viva voce. However the conventional
clinical exams have many advantages and disadvantages and this chapter addresses these
issues with special emphasis on how best the typical long case examination can be modified
to overcome its drawbacks.
Why do we need to assess clinical competence?
There are many compelling reasons to have a reliable and valid method of assessment of
clinical competence and these include

To ensure that the candidate has attained a minimal level of knowledge and
skill

This in turn will ensure safety of patients who will be entrusted to the
candidate.

Attainment of minimal level of knowledge and skill is necessary for licensing

Helps to grade the candidates based on their performance, which is a means
of academic competition

Assessment is formative, as feedback is an important learning tool

Finally assessment is an important driving force for acquiring knowledge.
104
What do we measure?
While testing for clinical competence, the stress should be on testing skills and attitude,
rather than on knowledge. Assessment of clinical competence should evaluate the ability to
obtain a detailed history, elicit the appropriate clinical findings, interpret these findings and
plan further investigations and treatment and communication skills.
How do we assess clinical competence?
a) Conventional clinical exams using long and short case examination.
b) Objective Structured Clinical Examination (OSCE) (This will be dealt with in detail
in the next chapter)
c) Modified conventional clinical exams like OSLER’s (Objective Structured Long
Examination Record)
Conventional Clinical Examination using the Long Case
Conventional clinical examination using the long case is the most commonly used
assessment tool for clinical competence in our country and many parts of the world. But it is
slowly getting replaced by the OSCE system, due to its multiple drawbacks.3 The long case
examination has its charm with its holistic approach and bio-psychosocial ethos unlike the
OSCE. Moreover recent studies have shown that the reliability and validity of the long
examination of the long case with a few modifications is comparable to the now favored
OSCE.4-7The long case examination is a valid test of clinical competence as it does measures
clinical competence to a large extent.
What are the requirements of a good assessment tool?
The three most important attributes of a good assessment tool is 1
a) Reliability: a test is said to be reliable if it is reproducible and gives consistent
results
b) Validity: A test is valid when it measures what it was intended to measure.
c) Objectivity: A test is said to be objective if there is a high degree of concordance
between any two examiner’s
Exercise 1
All of us present here, have experience with the conventional clinical exams as examinees
and as examiners. List all possible difficulties you have encountered or heard about or you
can think for the conduct of a fair clinical examination. Use the questions listed below to
help you in this exercise: What are the drawbacks of the long case exams?
105
List out the possible reasons for your answer
Is
the
Conventional
Examination reliable?
Clinical
Is
the
Conventional
Examination valid?
Clinical
Is
the
Conventional
Examination objective?
Clinical
Is the Conventional Clinical Examination reliable and objective?
Variability in the patient’s and examiner’s behavior is a very important cause for poor
reliability of the long case examination. Each examiner will emphasize on a different aspect
of a case and will not be applied uniformly to all candidates. The examiner is only human;
each with their own personal problems and preoccupation which may interfere with their
objectivity. Very often the assessment leads to a global pass or fail with no grading given to
different aspects of clinical competence.
Patients’ behavior towards a candidate may vary.They may help some students and obstruct
others. Moreover there is no definite grading of the level of difficulty for a case. This will
result in a one candidate getting a more difficult case than the next, bringing in an element
of luck. And luck has no place in a situation which calls for objectivity. The candidate is
assessed by their performance in one or two cases. Performance in a case does not predict
performance in another case; performance on a day does not truly reflect on the
candidates’ capability – good or bad.
Is the Conventional Clinical Examination valid?
During the conduct of the traditional long case examination, the candidate elicits history
followed by a detailed physical examination before arriving at an appropriate diagnosis or
differential diagnosis. No attempt is made to observe the students taking a history or
eliciting the physical findings, the examination skills and the important patient-physician
interaction are presumed. Frequently, attention is paid to the detection of abnormal
physical findings and communication skills are not assessed.
The candidate then presents his/her findings to the examiners and the discussion focuses on
the differential diagnosis and planning of management. The clinical exams started with a
premise to assess clinical competence which includes all three domains of learning i.e.
cognitive, psychomotor and affective. However we most often end up assessing a higher
order of cognitive domain, which can be assessed using other methods already dealt with in
106
the previous chapter.
competence.
So the conventional examination is not a valid test of clinical
Can the long case examination be improved?
Many formats of modification of the long case have been devised and are in use today. They
differ from each other in many ways but the essence of these formats is to make the long
case examination as objective, reliable and valid as possible. Some of these include:
a) Objective structured long examination record (OSLER’s)
b) Leicester Assessment Package
c) mini- CEX format
The Objective Structured Long Examination Record (OSLER’s)
The objective structured long examination record (OSLER) was introduced by Gleeson in
1992 in an attempt to remodel and improve the long case examination. 8,9 The modifications
suggested by him to improve the long case examination are highlighted below.
To enable the evaluators to be objective and maintain uniformity the long case is divided
into 10 items on which each candidate is assessed. The 10 items cover all aspect of working
up a long case, presenting the findings and the discussion. The process of history taking and
examination of the patients is observed. In addition to observation during history taking,
communication skills are also evaluated by asking the candidate to advise the patient
regarding an investigation or a need for change in lifestyle for the management of a
particular disease, etc. These 10 items include pace and clarity of presentation, 2)
communication process, 3) systematic approach 4) establishment of case facts 5) systematic
examination 6) examination technique 7) establishment of correct physical findings 8)
formulation of appropriate investigations 9) formulation of appropriate treatment and
10)clinical acumen or the ability to identify and solve a problem. By defining the items to be
examined, the examiner is reminded to be consistent with all candidates.
Each of the 10 items is graded individually as P+ for good/excellent, P for pass and P- for
below pass. Then an overall grade is given for the complete performance. The marking is
“criterion referenced”, which means candidates are evaluated appropriate for a set
standard eg. Graduate Vs Postgraduate level. This is very important as a graduate being
assessed at a postgraduate level may not do as well as expected.
OSLER also makes an attempt to standardize the case to reduce the element of “Luck” by
defining the level of case difficulty. The case difficulty is arbitrarily divided into “standard
case” that has a single problem, “difficult case” with 2-3 problem and “very difficult case”
with greater than 3 problems. For example a case of left hemiplegia with right facial nerve
palsy would constitute a standard undergraduate internal medicine case, while a case of
paraplegia or paresis with optic neuritis would be a “difficult case”.
Gleeson has been using this method for many years and has found serious defects in basic
clinical skills in both undergraduate and postgraduate levels. The feedback knowledge of
these defects improved the performance of candidates when they were reexamined. Thus
107
OSLER has a potential to improve clinical competence. The OSLER is also feasible logistically
even in a setting like ours.
Leicester Assessment Package (LAP)
Leicester assessment package (LAP) is a structured assessment tool used for assessing the
clinical competence of trainee as well as practicing General Practioners in the UK. Here the
assessed, is observed directly or through a video recording while they are involved in the
management of a patient in the clinic. Observation of the long case is an important
modification which helps the examiner evaluate communication skills, attitude to the
patients and examination skills which are very important attributes of a good physician and
often neglected in the present format of long case examination. This simple modification
has been found to improve the value of this format of exams.5-7
All are assessed in seven key areas, identified as history taking, physical examination,
patient management, problem solving, relationship with patient, anticipatory care and
record keeping. Each of the 7 components is graded from A-E with A being the best grade
possible and E being the worst. A global competence score is also given for each candidate.
The strengths and weaknesses of the candidate in each component is elaborated and a feed
back given. This has become very popular in the UK.
Mini-CEX Format
The mini-CEX format is a modification of the traditional CEX (clinical evaluation exercise)
which is the assessment tool used by the American Board of Internal Medicine. 10 The
traditional CEX is similar to the long case exams as practiced by us, with similar limitations.
The mini-CEX was introduced in 1995 to overcome the limitations of the traditional CEX. The
traditional CEX is conducted by an experienced physicianwho observes a resident while that
resident interviews a single unfamiliar patient, does a complete physicalexamination,
presents findings, and plans the patient's management.After the exercise, the evaluator
gives the resident substantivefeedback and documents the experience on a form provided
bythe Board. In mini-CEX the encounters are intended to be short (about 20minutes) and to
occur as a routine part of training so thateach resident can be evaluated on several
occasions by differentfaculty members.
Summary

The modifications common to the 3 methods described above include:

Observation of history taking and clinical examination to elicit physical findings.

Division of the whole assessment process into specific number of tasks to be
evaluated individually.

All candidates to be assessed over the same time frame

Increasing the number of cases to be examined by candidate

Reducing the element of luck by defining the level of case difficulty or by having
tutored patients.
108
Exercise 2 - Role Play
Role play will highlight the modifications which can be incorporated into the present
conventional clinical examination
Conclusion
In conclusion the long case examination is a reasonably good assessment tool of clinical
competence, provided attempts are made to make it objective, reliable and valid. Some of
the modifications of the long case examination in use in other parts of the world which have
been highlighted in this chapter are only suggestions for us to act upon. Institutions and
universities should consider these modifications and adapt what is feasible in a country like
ours with its own set of social and economic mores. Each teacher could contribute to this by
individually being attentive and objective with every candidate they examine thus making
conventional clinical exams relevant in today’s world.
References
1. Wass V, Bowden, Jackson N. The principles of assessment design. In editors Jackson
N, Jamieson A, Khan A. Assessment in Medical education and Training. A practical
guide. Radcliff Publishing Oxford, pages 11-26
2. Sood A. Long case examination- can it be improved? J, IndAcad Clinical Med
20021;2:252-255
3. Benning J, Broadhurst M. The long case is dead – long live the long case. Psychiatric
Bulletin 2007;31:441-442
4. Van der Vleutem C. Making the best of the “long case” Lancet 1996;347:704-705
5. Wass V, Jolly B. Does observation add to the validity of the long case? Med Education
2001;36:729-734
6. Pavlakis N, Laurent R. Role of the observed long case in potgraduate medical
training. Internal Med J 2002;31:523-528
7. Norman G. The long case versus objective structured clinical examinations. BMJ
2002;324:748-749
8. Gleeson F. Defects in postgraduate clinical skills as revealed by objective structured
long examination record (OSLER) Irish Med J 1992;85:11-14
9. Gleeson F. Assessment of clinical competence using the objective structured long
examination record (OSLER) Med Teacher 1997; 19:7-14
10. Norcini JJ, Blank LL, Arnold GK, Kimball HR. The MINI-CEX (Clinical Evaluation
Exercise) – A preliminary report. Ann Int Med 1995;123: 795-799
109
OBJECTIVE STRUCTURED CLINICAL EXAMINATION
OBJECTIVE STRUCTURED PRACTICAL EXAMINATION
Competency
The participants should be able to effectively design and conduct clinical /practical
assessment of medical students using OSCE/OSPE
Learning Objectives
At the end of this session students should be able to

Define an OSCE/OSPE

List the steps in the process of designing and implementing an OSCE/OSPE

Compare the advantages and disadvantages of an OSCE/OSPE.
1. What isan OSCE / OSPE?
OSCE is the acronym for Objective Structured Clinical Examination, which is a method of
assessment of skills of medical students in the Clinical setting while OSPE is the acronym for
Objective Structured Practical Examination, which is a method of assessment of skills of
medical students in the pre- and para-clinical setting.
Since these assessment methods are aimed at assessing mainly the level of skill and attitude
of a student and to a lesser extent knowledge, the OSCE and OSPE are generally a part of
the practical examination. The assessment of knowledge is done at length by other
methods, in the theory part of the examination.
Over the years, it has been found that traditional methods of practical assessment including
bedside presentations and viva voce suffer from many problems which have been
elaborated in the previous chapter.1 Since traditional methods of practical assessment are
not necessarily objective, valid or reliable all of the time, an alternative method was
required. Harden et al in 1975 were among the first to outline the principles of Objective
Structured Examinations (OSEs) as a means to a better assessment of students’ skills. 2
3. What are the steps involved in the planning and organization of an OSCE?
The design and implementation of an OSCE requires a lot of planning and organization on
the part of the examiners. The following is a series of steps which may be used in planning
and implementing an OSCE:
110
STEP ONE
Clarity on OBJECTIVES
Since an evaluation is a measure of the extent to which an objective has been attained, it
follows that we must have clear objectives in order to have clear evaluation
STEP TWO
Identify the PRACTICAL aspects of the objective
Exercise 1

Each of you will individually write down broad objective (examples are given
below)
◦
The student should be able to diagnose and treat essential hypertension
◦
Diagnose hypothyroidism

Select any one broad objective and identify all the practical aspects of the
chosen objective which the student should know and write it down in the
space provided. For example if you take “Hypothyroidism” as the broad
objective, the practical aspects would include
◦
◦
◦
◦
Take an appropriate history in a patient suspected to have hypothyroidism
Elicit ankle jerk
Investigate appropriately to confirm the diagnosis of hypothyroidism
Counsel the patient regarding the need for long term treatment and follow-up
Broad Objective
Practical aspects of the broad objective
111
STEP THREE
Select which of the tasks will be assessed in the PRACTICAL/ CLINICAL examination.
It may not be necessary or feasible to assess the students level of skill in performing ALL
tasks related to a given objective. So select one of the practical aspects of the broad
objective and break it down to its constituent units or subtasks. In the example, out of the
four practical tasks, the task “Recording response to the ankle jerk” may be considered
suitable for assessment
STEP FOUR
Taking each selected task, break the task down into its constituent units
Each task which is capable of being tested ,actually comprises of several sub tasks, each of
which has to be performed if the entire task is to be performed.
In the example of “Recording response to the ankle jerk”, examiners may agree upon the
following:
“If the student is able to record ankle jerk response correctly, then he/she must be able to do
the following:
This list below constitutes the sub components, or CHECKLIST for assessment of that
particular task. Every broad task, like Recording temperature or performing a peripheral
smear of blood from a patient suspected to be having malaria, can be broken down into a
series of steps which make up the task, when correctly performed
112
Task – Record Ankle jerk
Time - 3 minutes
Specific sub tasks
Introduce yourself, explain the procedure to
Marks – 5
Total marks Marks obtained
0.5
the patient, take his consent
Ask the person to lie down, making sure
2
that the knee is flexed , foot is everted and with one
hand slightly dorsi-flex the foot
Expose the achilles tendon
0.5
Strike the achilles tendon with the rubber
1
hammer appropriately
Record the response appropriately in the
0.5
scoring form provided
Take leave of the patient, thanking him
0.5
for his co-operation
TOTAL (5)
STEP FIVE
Assign scores (weights) for each of the sub components of the task.
Each sub task is given a score, and when this is added up, it gives the total score attainable
for that task, which is the basis for marking each student. When all the sub-tasks are listed,
and scores assigned to each of them, this constitutes the “checklist” for assessment of that
task. The checklist will be used by the examiner for marking when the student is being
113
assessed.
Certain sub tasks may be considered more important than others, and are given a greater
score (weight).For example making sure that the “Position of the lower limb, flexed at the
knee, everted and slightly dorsi-flexed at the foot” may be considered more important than
“Expose the achilles tendon”, as shown in the checklist above. That is, if the student
positions the lower limb correctly, he is given 5. If he exposes the tendon correctly before
striking it, he is given a score of 2
STEP SIX
Set up “Stations” for assessment of tasks
A “station” is the site at which the student is actually assessed on a particular ability
Stations are of different types, depending on the nature of the task to be assessed






History Taking stations are sites where the history taking ability of a student is assessed.
e.g. “This patient complains of abdominal pain. Take a history pertaining to abdominal
pain”
Examination stations are sites where the student’s ability to perform a clinical
examination is assessed, e.g. “Record ankle jerk response”
Skill stations are sites where stuents are tested on their ability to perform a skill eg.
Provide CPR, start IV line ( simulated models required )
Communication stations are sites where the communication ability of a student is
assessed e.g. “This is a mother of a three year old child with diarrhea. Advise her
regarding use of ORT for her child”
Response stations are sites where the interpretative ability of a student is assessed e.g.
“ Interpret this Chest X ray of a 40 year old patient with acute dyspnea and state 3
reasons for your answer.”
Rest stations are inserted in between two task-oriented stations to give students a
chance to organize their thoughts, and to have a cup of coffee (if provided)!
Requirements of Stations:



Instruction to the candidate, for example “Record the ankle jerk response for this
patient”
Materials - Table/chair/couch and other materials as required for the task e.g. knee
hammer
A patient.
If the task is “Measure the head circumference of this 3year old child”, where the
emphasis is more on performance and less on interpretation, then there is no need to
have an actual patient. In this scenario, “SIMULATED” patients can be used. Tasks
related to communication and history taking ability is also suited for the use of
simulated patients.
114
However, tasks like “examine this person’s respiratory system” done in order to see if
the student can recognize an abnormal clinical finding – e.g. rhonchi , or crepitations,
will necessitate the use of REAL patients with clinical problems. Simulated patients and
real patients must be trained / informed of the nature of the procedure prior to the
examination


An Assessor. If the station is a history, examination, procedure or communication
station then the EXAMINER must be the assessor, since direct observation must be
done. But in RESPONSE stations, there is generally no need for an observer. If required,
an assistant can be present to ensure that the instruction is understood, and to ensure
that the exercise proceeds smoothly.
The TIME allotted for each task is generally uniform.
Some tasks may require shorter periods of time, but in general, the time allotted for
each task is fixed, as the time required for the task requiring most time.
STEP SEVEN
Conduct the OSCE
When the entire team is prepared and all the stations are checked and ready, the students
may be led into the hall, for the OSCE. The students will need to be oriented to the pattern
of examination, at least in the beginning. The orientation could include:





Briefly introducing them to the concept
Ensuring that they are ready with all material they need for the OSCE – clinical
examination material, pen ( preferable to provide the material )
Emphasizing the TIME to be spent at each station
Introducing them to the fact that they must visit a station, read the instruction and
proceed accordingly.
Introduce them to the person who they should ask in case of doubt or clarification
Once the students and examiners are oriented and the stations are ready the examination
may commence. During the OSCE, it is important to identify a person who is entrusted with
the task of checking on the process, including




Checking each station periodically,
Ensuring the patients and simulated patients are okay,
Checking that the examiners and students are okay.
Time keeping
115
Exercise 2




Observe an OSCE/OSPE exam being conducted
Checklist for each station is given at the end of this chapter
Assess the candidates using the checklist, as an examiner would do
Observe the OSCE being conducted keenly and make a note of all that was good and
bad in your opinion
STEP EIGHT
Use the results of an OSCE for improving educational content
Following an OSCE, the results can be studied to assess performance of students, which is
the immediate objective. But an analysis of the scores obtained by students in performing
specific tasks can also yield useful information regarding the general level of performance of
students for each specific task. Tasks in which the general level of performance is low
indicate that the educational process should aim at improving skills of students in that
particular task.
For example, if 4 students S1, S2, S3 and S4 were assessed on four tasks – History taking, a
procedure, an interpretation (response station) and a communication task, the following
table gives the possible scores.
TASK
Student
S1
S2
S3
S4
Total – TASK
Max
History
14
15
18
18
55
80
Response
15
18
19
18
70
80
Procedure
18
17
16
19
70
80
Communication
13
12
10
11
44
80
TOTAL - Student
60
62
58
51
Maximum marks
80
80
80
80
From this table it is seen that student S2 got the highest marks (62 out of 80). Also, it is seen
that the general level of performance in the “Communication” task was poor (44 out of 80).
This could point to a need to improve educational efforts in this area.
4. What are the disadvantages of OSCEs?
116

The assessment of skills tends to get somewhat compartmentalized in an OSCE, and
the ability of a student to consider a patient “on the whole” is not assessed. 1 The
traditional method of long case presentation at the bedside allows the examiner to
assess a student’s skill in a variety of aspects – history taking, examination,
interpretation and decision making, at one opportunity. It has been observed that
clinical competence includes a number of attributes, and the OSCE alone cannot
assess all the attributes, unless it is combined with other methods.
 It has also been observed that while OSCEs are appropriate for assessment of
Undergraduate student skills, Postgraduate examinations may require a method
which assesses skills to a greater depth.2
 The reliability of OSCEs has been found to be low if there are a small number of
stations, noisy environments, untrained patients and lack of structured checklists for
scoring. Hence attention to detail is an important part of OSCEs.
 OSCEs involve lots of planning
o Listing skills/knowledge to be tested
o Preparing checklists of sub skills
o Obtaining suitable material, patients, simulated patients, personnel
o Preparation of stations
o Organizing manpower to conduct the OSCE
 Requires time, effort on the part of the examiners, during the examination. OSCEs
have also been found to be expensive, since the preparation and implementation is
costly.
However, despite the limitations, the Objective Structured Examination is here to stay, and
presents an option worth consideration in the assessment of practical skills of medical
students in the clinical or laboratory setting.
SUMMARY
In Summary, the steps in designing and implementing an OSCE/OSPE are:
1. Have a set of CLEAR OBJECTIVES, and select those which are to be assessed
2. Identify the PRACTICAL aspects of the objective, in terms of the tasks which the student
must be able to do if the objective is to be attained
3. Of the tasks, select the TASK for assessment in the current examination
4. Break the task down into SUB-TASKS
5. Assign SCORES (WEIGHTS) for each sub task, the total marks, and the TIME required for
the task, and create checklists
6. Set up STATIONS for the OSCE / OSPE, ensuring that each station is complete in all
aspects, including Instruction to students, Materials, Patient/ Simulated patient, Assessor
117
7. CONDUCT the OSCE after orienting the students and examiners
8. Make NOTES of the process and review for improvement in the future
9. ANALYZE the results and use the same for student assessment and for educational
process improvement
References:
1. R M Harden, M Stevenson, W WDownie and G M Wilson; Assessment of clinical
competence usingobjective structured examination; Br Med J 1975;1;447-451.
2. Critiques on the Objective Structured Clinical Examination; Barman A; Ann Acad Med
Singapore, 2005;34 478-82.
3. Patil JJ; Objective Structured Clinical Examinations; CMAJ 1993;149; 1376-8
Exercise 3
As a group select one specific learning objective and make a checklist using the template
below. Make a list of the material that will be required to setup the station and conduct an
OSCE exam
________________________________________________________________________
Task –
Time -
Marks –
________________________________________________________________________
Specific sub tasks
Total marks Marks obtained
118
Procedure Station -1
Instruction to candidate: Check the Blood pressure of this patient accurately within 5 mmHg
of the actual recorded BP as a part of the clinical examination
Materials required
Bed or couch, stool for candidate, BP apparatus, stethoscope, patient, assessor, instructions
to candidate and checklist for the examiner
Checklist with marks assigned
Subtasks
Marks
allotted
Inform the patient of the intention
0.5
Position patient sitting with arm exposed
1
Marks
obtained
Arm at heart level
Apparatus at level of observer’s eyes (0.25 each)
Check BP by palpatory method –
1
Palpates using thumb over Brachial or Radial artery
Check BP by auscultatory method –
1
Positions stethoscope over Brachial artery
Deflates by 3 mmHg every second
Records Systolic
Records Diastolic BP (0.25 each)
Records SBP/DBP accurately within 5 mmHg of patients known BP (0.5 1
each)
Deflates, removes cuff & replaces equipment carefully
0.5
Thanks patient (0.25 each)
119
Procedure Station -2
Instruction to candidate: Perform a “Hanging drop” test on the provided specimen and
report on the test
Materials required: Table and stool, gloves, glass slides with circular wax ring, cover slips,
test tube containing the specimen, wire loop to pick up the specimen, candle with match to
light, cotton to clean up the area, microscope, assessor, instructions to candidate and
checklist for the examiner
Checklist
Subtasks
Marks
Marks
allotted
obtained
Wears gloves, lights candle
0.5
Heat the loop red hot and cool it
0.5
Use loop to pick up a drop of specimen and places on a 0.5
coverslip
Gently heat the wax on the slide and place the slide over the 0.5
coverslip
Inverts the slide, places under the microscope, focuses under 1.0
LP & HP
Record the findings
Cleans
surface,
0.5
disposes
of
the
infected
material 1.0
appropriately
Removes gloves and washes hand
0.5
120
Communication Skills station
Instructions to the candidate: Counsel this patient with type 2 diabetes of 10yrs duration
regarding care of his feet to prevent diabetic foot and its complications
Requirements: Patient, table , 2 chairs, assessor, instructions to candidate and checklist for
the examiner
Checklist
Subtasks
Introduces self to the patient and informs of intention
Marks
Marks
allotted
obtained
0.5
Explains the effect of Diabetes on the peripheral blood 1
vessels/nerves and consequences of poor control
Reinforces the primary need for good sugar control
0.5
Reinforces the need for regular self foot care including 1
inspection
Explains the need for appropriate preventive footwear
0.5
Asks for and clarifies any doubts patient may have
1
Ends the conversation politely and takes leave
0.5
121
Response station
Instructions to the candidate
This is a report of a routine and microscopic examination of a mid-stream sample of
centrifuged urine of an elderly male patient with fever and dysuria.
Urine
Colour:
Light yellow
ph:
6.0
Specific gravity
1.020
Protein
Negative
Sugar
Negative
Microscopy
WBC/hpf
30-40 /hpf
RBC/hpf
20 /hpf
Casts
Not present
1. What are the abnormal features on the Urine report?(0.5 each, total 1)
2. What is the most probable diagnosis?
(1)
3. What would be the next two relevant investigations while initiating specific
treatment?
(0.5 each, total 1)
4. What specific choice of treatment needs to be initiated on an OPD basis? (1)
5. What underlying condition would need to be considered in this elderly man?
(1)
Response station
Instructions to the candidate
This is a report of a routine and microscopic examination of a mid stream sample of
centrifuged urine of an elderly male patient with fever and dysuria.
Urine
Colour:
Light yellow
ph:
6.0
122
Specific gravity
1.020
Protein
Negative
Sugar
Negative
Microscopy
WBC/hpf
30-40 /hpf
RBC/hpf
20 /hpf
Casts
Not present
KEY : Questions with the answers
1. What are the abnormal features on the Urine report?
WBC/hpf>5 /hpf; RBC/hpf>2 /hpf
0.5 each (total 1)
2. What is the most probable diagnosis?
Uncomplicated Urinary Tract Infection
1
3. What would be the next two relevant investigations while initiating specific
treatment?
0.5 each (total 1)
Urine Culture and Sensitivity
Renal Ultrasound including the bladder/prostate
4. What specific choice of treatment needs to be initiated on an OPD basis? 1
Oral Antibiotics (Amoxycillin; Co-trimoxazole; 1st Gen Cephalosporin,
fluoroquinolones)
5. What underlying condition would need to be considered in this elderly man? 1
Benign Prostatic Enlargement/Bladder neck obstruction/Malignancy Prostate
Procedure Station -1
Instruction to candidate: Check the Blood pressure of this patient accurately within 5 mmHg
of the actual recorded BP as a part of the clinical examination
Procedure Station -2
Instruction to candidate: Perform a “Hanging drop” test on the provided specimen and
report on the test
123
Communication Skills station
Instructions to the candidate: Counsel this patient with type 2 diabetes of 10yrs duration
regarding care of his feet to prevent diabetic foot and its complications
124
MEDICAL EDUCATION RESOURCES ON THE INTERNET
BOOKS
Annotated bibliography of books on medical education in the Library of Rush University Medical
Center(prepared by David Barnett, Ph.D., Office of Medical Student Programs, Rush Medical College)
(a PDF file)
ARTICLES
BMJ Collection of Articles about Learning and Teaching in Medicine (Over sixty articles which focus
on
a
variety
of
aspects
of
teaching
and
evaluation)
http://bmj.com/cgi/collection/teaching
BMJ Collection of Articles about Postgraduate Learning and Teaching (Only ten articles appear in
this
collection
so
far.)
http://bmj.com/cgi/collection/postgraduate
BMJ Collection of Articles about Undergraduate Learning and Teaching (Over 160 articles.)
http://bmj.com/cgi/collection/undergrad
Office-based teaching (Family Medicine)(These columns appear regularly in the journal Family
Medicine. This site has gathered columns 1996 to the present. The columns cover a variety of
aspects
of
teaching
medical
students
in
community-based
settings.)
http://www.stfm.org/teacher/hub.html
TIME (Topics in Medical Education)
TIME covers the subject of medical education. The database currently contains almost 50,000
items collected over the past two decades by the Director of the Centre for Medical Education
at Dundee, RM Harden. The references cover a range of topics in: healthcare professional
education, in health education and in patient education. Journals include: medical education,
general education, specialized areas of education, medicine and medical specialties. There is a
range of magazines and newsletters—and even some material from newspapers.
http://www.dundee.ac.uk/meded/refs/
Stanford Faculty Development Center Literature Databases
Each of Stanford's faculty development programs has a literature database saved as a bibliographic
database file, managed by EndNote (which include citations for articles, books, and other
publications). The databases are not intended to serve as comprehensive reviews of the literature,
but rather as sources of relevant supplemental readings. The available databases include: clinical
teaching, professionalism in contemporary practice, end-of-life care, and geriatrics in primary care.
http://www.stanford.edu/group/SFDP/sfdc_lit_data.html
125
JOURNALS
Academic Medicine
Description: International forum for the exchange of ideas, information, and strategies that address
the major challenges facing the academic medicine community.
Topic Areas: Theoretical and/or practical facets of education and training issues; health and science
policy; institutional policy, management, and values; research practice; clinical practice in academic
settings; other topics relevant to medical schools and teaching hospitals.
Types of Articles: Articles, perspectives, commentaries, research reports, special features (e.g.,
letters to the editor).
Acceptance Rate/Time: Acceptance rate: Up to 20%. Goal for notification: 60-90 days.
http://www.academicmedicine.org/
Advances in Health Sciences Education
Description: Forum for scholarly and state-of-the art research into all aspects of health sciences
education. For those committed to improvement of health professions education: researchers &
educators in medicine, nursing, occupational therapy, physiotherapy, nutrition and related
disciplines.
Topic Areas: Admissions, problem-based and self-directed learning, faculty development,
achievement testing, motivation, curriculum development, curricular comparisons, program
evaluation, expertise development, clinical reasoning, continuing education, community-based
education, and communication skills. Quantitative & qualitative research accepted.
Types
of
Articles:
Not
listed.
Acceptance Rate/Time: Not listed.
http://kapis.www.wkap.nl/kapis/CGI-BIN/WORLD/journalhome.htm?1382-4996
BMC Medical Education
Description: BMC Medical Education is an open access journal publishing original peer-reviewed
research.
Topic Areas: Articles on undergraduate, postgraduate, and continuing medical education.
Types of Articles: Research articles, database, debate, software, study protocol, technical advance.
Acceptance Rate/Time: On-line publication upon acceptance (“fast”).
http://bmj.bmjjournals.com
Journal
of
Continuing
Education
in
the
Health
Professions
Description: Addresses continuing education and continuing professional development in the health
sciences.
Topic Areas: Topics of special interest include: continuous quality improvement, health policy and
performance, competency assessment, knowledge translation, team learning, and disease
management.
Types
of
Articles:
Not
listed.
Acceptance Rate/Time: Not listed.
http://www.jcehp.com/
Journal
of
the
International
Association
of
Medical
Science
Educators
Description: A peer-reviewed publication of the International Association of Medical Science
Educators.
126
Topic Areas: The purpose of this electronic publication is to present scholarly activities, opinions,
and resources in medical science education. Submissions that address a wide array of topics are
invited.
Types of Articles: Original research manuscripts, reviews, editorials, opinion papers, and
announcements
of
interest
to
IAMSE
members.
Acceptance Rate/Time: Not listed.
Medical Education
Description: Pre-eminent journal in the field of education for health care professionals and aims to
publish material of the highest quality reflecting world-wide or provocative issues and perspectives.
Topic Areas: The predominant emphasis in Medical Education is on work related to the education of
doctors and medical students, and papers on interprofessional education are welcomed.
Types of Articles: Original research papers, review articles, discussion papers, special feature pieces,
short reports of research in progress or of educational innovation, commentaries, letters to the
editor.
Acceptance Rate/Time: Initial decision within 12 weeks. Decisions on most papers within 8 weeks.
http://www.blacksci.co.uk/~cgilib/jnlpage.asp?Journal=meded&File=meded&Page=aims
Medical Teacher
Description: Addresses the needs of teachers and administrators throughout the world involved in
training for the health professions. This includes courses at basic and post-basic levels as well as the
increasingly important area of continuing education.
Topic Areas: New teaching methods, guidance on structuring courses and assessing achievement. A
forum for communication between medical teachers and those involved in general education. The
journal recognizes the problems teachers have in keeping up-to-date with the developments in
educational
methods
that
lead
to
more
effective
teaching
and
learning.
Types
of
Articles:
Articles,
short
communications,
letters.
Acceptance Rate/Time: Not listed.
http://www.tandf.co.uk/journals/titles/0142159X.html
Teaching and Learning in Medicine
Description:An international forum for scholarly state-of-the art research on the purposes and
processes of teaching and learning the education of medical professionals.
Topic Areas: Practical issues in the conduct of medical education, as well as issues more basic to
medical education, and provide analysis and empirical research needed to facilitate educational
decision making by administrators, teachers, and learners. Includes all levels of medical education,
from
premedical
to
postgraduate
and
continuing
medical
education
Types of Articles: Perspectives/editorials, analyses/reviews of literature, applied research, research
basic to medical education, research methodology, developments, book reviews.
Acceptance Rate/Time: Not listed.
http://edaff.siumed.edu/tlm/
OTHERS
Canadian Medical Association Journal (CMAJ)
http://www.cmaj.ca/
The Clinical Teacher
http://www.blackwell-synergy.com/servlet/useragent?func=showIssues&code=tct
127
Education for Health
http://www.tandf.co.uk/journals/frameloader.html?http://www.tandf.co.uk/journals/carfax/13576
283.html
Education for Primary Care
Evaluation and the Health Professions
Journal of Medical Ethics
Medical Education Online
PédagogieMédicale
Postgraduate Medical Journal Online
Teaching and Learning in Medicine
OTHER SOURCES
FreeMedicalJournals.Com is dedicated to the promotion of free access to medical journals
over the Internet. It currently has 1380 Journals in several languages available through this
portal.
HighWire Press is the largest archive of free full-text science on Earth! As of 10/15/04, they
are assisting in the online publication of 770,015 free full-text articles and 1,972,541 total
articles.
Public Library of Science is one of several initiatives that promote open access to scientific and
medical literature. They have launched a nonprofit scientific publishing venture that will
provide scientists with high-quality, high-profile journals in which to publish their most
important work, while making the full contents freely available for anyone to read, distribute
or use for their own research.
PubMed Central is a digital archive of life sciences journal literature developed and managed
by the National Center for Biotechnology Information at the U.S. National Library of Medicine
(NLM). NLM is taking the lead in preserving and maintaining unrestricted access to the
electronic literature. PubMed Central aims to fill the role of a world class library in the digital
age. It is not a journal publisher. NLM believes that giving all users free and unrestricted access
to the material in PubMed Central is the best way to ensure the durability and utility of the
archive as technology changes over time. Their full list of journals in the database is located at
http://www.pubmedcentral.nih.gov/front-page/fp.fcgi , including BMC Medical Education
(http://www.pubmedcentral.nih.gov/tocrender.fcgi?journal=38&action=archive)
128