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 93 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 101 · 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- 102 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