Doctors as teachers
September 2006
Teacher education in the medical profession
The requirement to undertake formal teacher education in the state sector was introduced in the 1970s; yet it is not a concept that has been formally adopted by the medical profession and there are no national data on the number of doctors who attend teacher education courses or who have attained teaching qualifications. A survey of undergraduate and postgraduate medical deans in 1993 found that teacher education courses were available at most institutions in the UK; however, only a limited number were specifically aimed at medical teachers.
[Go to note 5] A subsequent report from the Standing Committee on Postgraduate Medical and Dental Education (SCOPME) identified a deficiency in the teacher education of hospital teachers,
[Go to note 2] and this deficiency was further recognised in a study of the teaching and learning needs of hospital consultants.
[Go to note 6] A follow-up study from SCOPME in 1999, however, demonstrated that many hospital doctors were developing their educational roles – which included acquiring the skills needed for appraisal and assessment, educational supervision and formal and in-service teaching – and that there was a diversity of courses available throughout the UK for teacher education in the medical profession.
[Go to note 25]
Requirements for medical teacher education
Despite the educational obligation of all doctors,
[Go to notes 13 and 14] there is no mandatory requirement in the medical profession to undertake teacher education or to attain formal teaching qualifications, and therefore there is no defined or pre-specified route to competence. Even with the principles set out by the GMC and the PMETB with regard to the training of teachers in medical education,
[Go to note 15] the provision of teacher education does not form a substantive part of the undergraduate or postgraduate medical curricula. Training in teaching skills at the undergraduate level is restricted to non-compulsory student-selected modules. For those doctors who are required to provide supervision and informal teaching as part of their daily routine there is no requirement to undertake in-service teacher education.
‘I am very keen to teach and I think I will be quite good at it. A formal teaching course would be extremely beneficial prior to becoming a house officer. I know some of my colleagues are petrified of having to teach! Building confidence in our knowledge, and our ability to communicate it, is the key.’
BMA member
According to the recommendations set out by the JCPTGP, GP trainers should prepare carefully for the teaching responsibilities of a trainer and should attend trainers’ courses and workshops.
[Go to note 17] Although each postgraduate deanery has its own specific criteria for trainer selection, in general, GP trainer applicants are expected to have a minimum of three years’ experience following completion of the GP vocational training scheme. Following selection, applicants are required to undertake a specific training programme. Each UK deanery operates its own training programme that is usually organised by experienced GP educators and often validated by a local university.
There is insufficient recognition of the increasing requirement for formal training in teaching for newly appointed medical academics. The majority of higher education institutions, however, now require newly appointed academics to undertake a teaching qualification before they can complete probation (minimally a postgraduate certificate), and many encourage individuals to obtain a diploma or masters. Selection criteria for specific posts vary between institutions. The 1997 Dearing report recommended to higher education institutions that ‘over the medium term, it should become the normal requirement that all new full-time academic staff with teaching responsibilities are required to achieve at least associate membership of the Institute for Learning and Teaching in Higher Education (ILTHE), for the successful completion of probation’.
[Go to note 26] The work of the ILTHE was taken over by the Higher Education Academy (HEA) in 2003. Academic teachers can undertake a Certificate in Learning and Teaching in Higher Education (CLTHE) which is accredited by the HEA, and depending on the specific course, may provide training in classroom-based teaching only.
Despite the opportunity afforded by MMC, there is insufficient recognition of the teaching skills required by doctors in hospitals and general practice, focusing instead on the education and training of the limited number of doctors who are likely to make major contributions to medical education.
[Go to note 27] This lack of formal teacher education in medicine is little different from other disciplines and university courses in tertiary education in the UK. As with medicine, teacher education is not normally provided or required prior to appointment as a dental academic nor is it common for in-service teacher education to be provided in the dental profession. This situation contrasts with teacher education in the nursing profession (see box 1).
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Box 1 – teacher education in the nursing profession
Student nurses are predominantly taught by nurse educators who have undertaken an approved teaching course and are themselves qualified nurses. The resultant teaching qualification (eg Postgraduate Certificate in the Education of Adults (PGCEA)) is recorded on the Nursing and Midwifery Council (NMC) register. Teaching is also undertaken by nurse teachers, known as practice educators, who are based in service delivery and who support mentors and students in clinical areas. The nursing regulatory body, the NMC, has published standards for the preparation of teachers of nurses, midwives and specialist community public health nurses.[Go to note 28] These standards were originally agreed and published by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting (UKCC). The standards set out what the programmes leading to a recordable teaching qualification should offer, including:
- flexible modes of delivery
- a modular structure that will enable practitioners to access modules that are most appropriate to the environment in which they will be teaching
- linkage to a higher education accreditation system
- credit for appropriate prior learning and prior experiential learning
- opportunities to observe, participate and be assessed, in a range of teaching activities and settings.[Go to note 28]
To undertake one of the programmes leading to a recognised teaching qualification, a registered practitioner is required to have:
- an entry on an appropriate part(s) of the current NMC register
- completed a minimum of three years’ full-time experience (or equivalent part-time experience) in relevant professional practice during the last 10 years
- acquired additional professional knowledge that must be relevant to the intended area of teaching/practice, and at no less than first degree level.[Go to note 28]
The programmes should be at postgraduate level and the teaching practice element of the programme must be equivalent to 12 full-time weeks (360 hours). A review of these standards has been carried out and a proposed new standard to support learning and assessing is due to be published shortly.
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Although not directly comparable, teacher education is a significant component of mainstream education in the UK. Teachers in state or local authority schools in England and Wales are required to complete a Postgraduate Certificate in Education (PGCE) or have obtained a Bachelor of Education. A PGCE incorporates a one-year initial teacher education and training course for existing bachelor degree holders leading to Qualified Teacher Status (QTS). The course is normally taught at a university or other higher education institution, though most of the course time is spent on placements in local schools. After gaining QTS, the candidate becomes a Newly-Qualified Teacher (NQT). Student teachers can also become a teacher by completing a Graduate Teacher Programme (GTP), where they are employed by a school and train on the job. A four-year Bachelor of Education provides graduates with a degree level teaching qualification and leads to QTS. In Scotland, completion of a PGCE leads to Teaching Qualification (TQ).
Teaching qualifications and teacher education courses
Despite the lack of a formal system of teacher education in the medical profession, recent years have seen a number of encouraging developments including a commitment to teaching and training in the NHS,
[Go to notes 11 and 12] a significant increase in the level of research in the field of medical education and the streamlining of the medical career pathway through MMC. While the belief may persist that professional qualifications and a doctor’s own experience of education are sufficient preparation for teaching,7 recent initiatives have meant there are a variety of teaching qualifications and specialised teaching courses available to healthcare professionals. These range from masters programmes to two or three-day teaching improvement courses. Many of these courses are accredited or certified and the vast majority of the smaller courses are free. The range of courses include:
- masters degrees
- postgraduate diploma
- postgraduate certificate
- short courses (eg Teaching the Teachers (TTT) courses, Teaching Improvement Programme (TIPS))
- distance learning courses
- GP trainer courses and workshops.
‘I’ve been called upon to teach and lecture medical students, but until this year I have never received any formal teaching on how to teach. The benefits of the teaching course were multiple. It highlighted deficiencies in the way you teach and gave ways to improve your teaching style, and it was useful to learn other different teaching styles and pointers on what works well in different situations.’
BMA member
The following case studies are designed to give an indication of the range of teacher education courses currently available in the UK through universities, deaneries and the medical royal colleges (case studies 1- 7). Contact details for deaneries can be found on the Conference of Postgraduate Medical Deans website at
www.copmed.org.uk and the Committee of General Practice Education Directors website at
www.cogped.org.uk. Contact details for the medical royal colleges can be found on the Academy of Medical Royal Colleges website at
www.aomrc.org.uk.
Case study 1 – medical education courses at the University of Dundee
The Centre for Medical Education within the School of Medicine in the University of Dundee offers a series of courses in medical education leading to postgraduate certificate, diploma, masters and PhD qualifications. The programme of courses is designed to allow a progression from an introduction to medical education, through the award of a certificate and diploma to the award of a master’s degree. Applicants are able to exit at any of these four points with the relevant award or qualification. The courses offer:
- an introduction to education for the healthcare professional
- an overview of specific subject areas including curriculum development, teaching and learning, assessment, and instructional materials development
- a study of one aspect in greater depth (eg for a teacher who may have been given responsibility for assessment within his/her institution)
- recognition, in the form of a certificate or some other qualification, for experience and training gained in the field of education
- an introduction to research in medical education.
The Centre also offers postgraduate certificates in medical education with specific relevance to GPs and anaesthetists.
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Case study 2 – Teaching Improvement Programme (TIPS) at the University of Nottingham
The University of Nottingham Medical School runs an intensive TIPS course that provides basic teaching skills to medical academics and NHS staff. The course involves a two-day workshop, usually for 12 participants, with two teachers or facilitators. It provides teaching in generic skills aimed towards health professionals and uses bio-medical and clinical examples. The course includes a number of sessions including:
- theories of learning
- using learning objectives
- using questioning techniques
- structuring learning episodes
- microteaching
- teaching methods
- evaluating teaching
- assessing learning.
The course involves formal teaching, small group discussions, active group work, analysis and discussion of teaching videos, individual presentations, self and group evaluation of teaching skills, and feedback sessions. The course does not provide formal qualifications, but gives healthcare professionals the opportunity to improve their teaching skills via a short programme of interactive sessions.
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Case study 3 – Cardiff University distance learning medical education course
Cardiff University offers a Postgraduate Certificate in Medical Education (PCME) distance learning course for teachers, trainers, course coordinators and education managers in medicine. The PCME aims to provide participants with a sound knowledge and understanding of principles and practice of adult learning, the ability to relate knowledge and understanding to practical educational needs in the health professions, and develop professional skills in applying educational knowledge to practice. Course applicants must have professional qualifications in medicine and can take from 15 months to two years to complete it. The PCME course offers learners flexibility within a structure where:
- attendance is only required on an induction day and mid course review day
- learning is undertaken independently at one's own speed
- support is provided from a tutor and fellow learners
- accreditation of prior learning is available for suitable candidates
- flexibility is provided for the completion period.
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Case study 4 – London Deanery web-based learning for clinical teachers
As part of an initiative to develop web-based educational packages to support the generic training of doctors and other healthcare professionals, the London Deanery has designed a new web-based learning programme for clinical teachers. The programme has been designed primarily for doctors who have responsibilities as teachers, including teaching of undergraduate students or postgraduate trainees or peers. It consists of a number of modules that can be studied in any order and there is no set timescale that has to be adhered to. The modules include:
Understanding Teaching and Learning (UTL) modules – these cover core aspects of teaching and learning including generic knowledge, skills and attitudes about different aspects of the learning process relevant to clinical teachers
Practical Applications in Clinical Settings (PACS) modules – these consider the process of learning either in particular clinical contexts or by highlighting a specific practical feature of clinical teaching and learning.
All the UTL and PACS modules are underpinned by current educational theory and good practice, and they aim to provide a stimulus and introduction to the key concepts of teaching and learning in a clinical context. The modules are designed in sections that include short pieces of stimuli, or scene-setting material, with related reading, activities and reflective writing. The online activities are supported by downloadable articles, documents and handouts. The programme also provides links to sources of further information and reading on teaching. Completion of the course provides a solid foundation to proceed to a more formal programme in teaching and learning (eg a Diploma in Medical Education course).
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Case study 5 – Oxford Deanery GP trainer teaching
The Oxford Deanery operates an interprofessional New Teachers Course aimed at future GP trainers, undergraduate tutors and community nurse practice teachers. The course consists of three residential modules that each last three days and involve work-based learning, small group work and plenary sessions. It is designed to prepare teachers for one-to-one teaching roles in primary care and much of the work-based learning reflects the day-to-day activities of modern general practice and includes preparation for the practice of teaching. All course delegates are required to undertake pre-course work for each module and successful completion of the course leads to a Postgraduate Certificate in Medical Teaching, accredited by Oxford Brookes University.
Specifically, the course is designed to develop an understanding of the concept and theories of adult learning, and an appreciation of their application in one-to-one teaching in primary care. It also provides training in the knowledge and skills required for curriculum planning, assessment and feedback. Each of the three modules is designed to explore different aspects of teaching and learning including the culture for learning (module 1), the theory of learning (module 2) and educational skills and practice (module 3). Course delegates are assessed on their competency as a teacher in medical education through a combination of five assessments, a reflective diary, a personal development plan and a structured tutor’s report. The Oxford Deanery covers the tuition/certificate costs of future GP trainers from within the Oxford Deanery.
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Case study 6 – the ‘Physicians as Educators’ programme
The Royal College of Physicians (RCP) introduced the ‘Physicians as Educators’ programme in 1999 to provide the opportunity for physicians who have teaching, appraisal and assessment roles to improve their skills. The programme is conducted by physicians and educationalists, and consists of a series of one or two day workshops held throughout the UK. All workshops have CPD approval from the RCP and the programme offers the following workshops:
- effective teaching skills
- on-the-job teaching
- how to assess a trainee
- how to be an effective educational supervisor
- how to conduct a trainee appraisal
- trainees in difficulty
- understanding consultant appraisal
- effective educational supervision for the foundation programme
- training for mentors.
It is possible to obtain accreditation from the RCP by completing the objectives set out below within two years:
1. Attend three compulsory workshops (On-the-job teaching, How to conduct a trainee appraisal and How to assess a trainee), and attend any other two full-day workshops (Trainees in difficulty, How to be an effective educational supervisor or Understanding consultant appraisal) or the two-day workshop, Effective teaching skills.
2. Attend three consecutive Peer Support Network workshops in the same year. These workshops offer participants an opportunity for critical reflection on knowledge and skills acquired through the other workshops.
3. Show evidence of learning through a ‘reflective diary’ based on thoughts and observations about each workshop attended.
4. Submit two educational initiatives at the end of the programme.
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Case study 7 – Kent, Surrey and Sussex (KSS) Deanery Certificate in Teaching
The KSS Deanery Certificate is based on a ‘reflective practitioner’ model involving a cycle of observations of each teacher’s teaching practice undertaken by a professional educationist. A written record of each observation is then used as the basis for a discussion between the teacher and the observer with a view to supporting further development in the understanding and practice of teaching within real life contexts. The key feature of the certificate is its delivery in the teacher’s own work-place rather than at a remote location, so that learning about teaching is rooted in the specific everyday experiences of the individual teacher. It is designed as a repeated cycle of observation, recording and reflection in which the process of assessment is itself part of the ongoing learning process.
The programme aims to support, develop and accredit good teaching as part of CPD, and because it takes place in the normal work-place setting, it provides a convenient and cost-effective method of teacher education. The programme follows a specific format where:
the individual teacher is observed during a minimum of three teaching sessions that may take place within a variety of contexts including small group seminars, formal lectures, ward rounds, individual tutorials and out-patient clinics.
the process is observed and recorded by the tutor as a ‘time-line’. This forms an account of what has happened and constitutes the evidence from which both the teacher and tutor will draw during upon when reflective on the teaching process.
following each teaching session, the tutor and the teacher discuss the observational evidence within the context of a ‘professional conversation’.
Following satisfactory completion of the course, the teacher gains certification from the KSS Deanery.
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The diversity of courses currently available provides doctors with the opportunity to voluntarily develop their teaching skills, and/or attain appropriate qualifications, that reflect their level of involvement in medical teaching. It is also possible to undertake generic courses not specific to medical education but that provide training and qualifications in educational and teaching methods (eg Postgraduate Certificate in Higher Education (PGCHE) and Postgraduate Certificate in Academic Practice).
The development of medical teachers
The majority of research on the development of medical teachers has focused on the acquisition and improvement of teaching skills following attendance at formal training courses. It is vital, however, to understand how medical teachers develop, yet there has been very little research into how individual trainers acquire the skills they have and no clear framework exists that outlines the development process. A survey of 10 experienced medical teachers examining the different ways in which doctors have learned to teach and train found there to be no coherent theory of medical teacher development, and that it is the teachers’ experience of learning rather than learner styles that influence future teaching styles.
[Go to note 7] An American survey examining the quality of supervision provided by attending doctors in the clinical setting found that most of their teaching skills have been acquired through observation, trial and error, and reflection on personal experience.
[Go to note 8] Doctors are able to improve and develop their teaching skills through a combination of attending formal teaching courses, by receiving feedback and by operating a system of co-teaching.
[Go to notes 7 and 29] Further research is required into the methods of medical teacher development and the implications this has for healthcare institutions.
Attitudes towards teaching and teacher education in the medical profession
The beliefs and attitudes of teachers towards teaching are significant factors in the quality of medical education. Teaching is an extremely rewarding experience, offering the opportunity to interact with bright students, junior doctors and colleagues, and there is considerable kudos attached to senior lecturer, teacher and examiner posts. For the vast majority of doctors, however, clinical activity is their priority and they do not enter the medical profession because of the educational opportunities it provides. There are those who actively wish to become involved in medical education, but there are also those who have little interest in formal teaching. It is important to recognise the different levels of involvement and to ensure that the teacher education received by doctors is commensurate with their level of participation in teaching, training and supervision.
In assessing their own abilities, teachers may be complacent about their own teaching competence and/or sceptical about the requirement for teacher education.
[Go to note 30] A study of the attitudes of teachers to teaching in one British medical school found that only 5 per cent of teachers believed their own teaching ability to be below average.
[Go to footnote b],
[Go to note 30] This survey also documented considerable support for teacher education courses with few believing teaching skills can be acquired adequately through general medical training.
[Go to note 30] In a subject review of the quality of medical education provided by universities and colleges in England and Northern Ireland by the Quality Assurance Agency for Higher Education (QAA),
[Go to footnote c] the greater part of the teaching observed by reviewers was found to be good and much was excellent.
[Go to note 31] A number of studies have found a high degree of enthusiasm for teaching in the medical profession and many clinicians derive satisfaction from, and maintain a strong commitment to, teaching.
[Go to notes 18, 20, 21 and 30] There is, however, a perception that teaching does not receive sufficient recognition or prioritisation by medical schools, and that teaching quality is compromised by increasing service pressures and the growing student population.
[Go to notes 20, 21 and 30] Further research is required into doctors’ attitudes to teaching and the implications these have for teacher education.
‘I have a feeling my own teaching style at the moment is a combination of exasperation and frustration that the learner doesn’t see what I’m trying to show them! I would like the opportunity to be shown how to modify that behaviour to bring the best out of my teaching.’
BMA member
Footnotes
(b) Respondents to the survey were asked to rate their own teaching ability as either ‘below average’, ‘average’ or ‘above average’. No information was provided as to the specific definition of these terms.
(c) This review was conducted between 1998 and 2000, and involved observation of approximately 740 classes within the medical schools and in clinical attachments.
