BMA - The way forward

Doctors as teachers

September 2006

The way forward
There is a pressing need to redress the imbalance between teaching and the competing activities of clinical work, research and administration. This necessitates the development of a structured pathway to teaching competence, an increase in the support systems that permit its implementation and continued use, a profession-wide change in attitudes towards teaching, and practical opportunities that provide more time for teaching.

Funding and support for teaching
Teaching needs to be a top priority for all academic institutions and organisations involved in the training, employment and development of doctors. The financial support for education in the medical profession is of critical importance, both in terms of the funding available to support formal and informal teaching, and the financial implications of providing ongoing teacher education. The funding and support for teaching needs to adequately reflect the contribution of doctors to formal teaching, but must also recognise and facilitate the informal teaching provided by all doctors. With the competing demands of clinical activity, research and administration, doctors need to be given the support and flexibility to teach. Effective teaching requires a significant commitment in terms of a doctor’s professional time. By setting aside protected time for teaching and educational responsibilities, doctors will be able to adequately prepare and deliver effective teaching. This includes lessening service pressures – by reducing the number of patients a doctor is required to care for – and ensuring that research, managerial and administration responsibilities do not adversely impact on the time allocated to teaching. It is important that all medical staff and management recognise that while junior doctors in training posts have a service commitment, protected time for education is essential.

Through the development of job plans, doctors and employers have a framework with which they can set out and formally recognise a doctor’s teaching responsibilities and the support that is required to fulfil these duties. A job plan is a record of a doctor’s commitment to the NHS that is formally agreed with his/her employing authority. It ensures that the post delivers its aims and the requirements of the contract of employment are met, including provision for CPD. The BMA’s Consultant handbook 2005 sets out guidance for consultant job plans and recommends that they should include a work schedule that covers all professional work, including teaching and research.[Go to note 32] It also recommends that the consultant job plan should set out how the employer will support the consultant in delivering agreed commitments, for example, through providing facilities, training, development and other forms of support.[Go to note 32] In the case of consultants who are also clinical academics, or undertaking teaching activities, job plans should take full account of both university and NHS commitments with equal importance attached to each work commitment. The BMA’s General Practitioner Committee’s (GPC) job planning guidance for salaried GPs lays out principles for a good job plan.[Go to note 33] These principles include personal CPD, which may incorporate private study or attending educational events, and specific specialist roles in the practice which could be medical student or registrar teaching or training.[Go to note 33] The framework provided by job plans could be applied to all grades of doctors to support their teaching and learning experience.

Adequate facilities and resources (eg IT equipment, libraries and teaching rooms) are required in all healthcare and academic settings to facilitate and support the provision of teaching and learning, and a suitable environment is essential to promote effective teaching and learning. Flexibility and adequate funding is also required to allow doctors in all stages of the medical profession to attend teacher education courses on a regular basis.

There is a requirement for education funding streams to be more transparent. Universities and colleges receive public funds from the four UK higher education funding bodies to provide core facilities for medical education and research.[Go to footnote d] This funding allocation occurs annually and is dependent on the number and type of students, the subjects taught, and the amount and quality of research undertaken. Individual institutions spend the allocated resources according to their own priorities and within broad guidelines set out by the respective funding bodies. The selective distribution of public funds by the four UK higher education funding bodies is determined by the Research Assessment Exercise (RAE) that assesses the quality of UK research. The quality of teaching and learning at each university is assessed by the QAA, and this occurs at the level of the medical school as a whole. The GMC also plays a fundamental role in quality assuring medical undergraduate courses. Aside from these funding allocations, universities also receive money from research councils and charities, industry, fee paying students, and other sources such as sponsorship and leasing of conference facilities.

The increased medical student tuition fees are likely to have a significant impact on teaching in the medical profession as the added expense of attending medical school will mean students become increasingly interested in the quality of teaching they receive. This increased income as a result of tuition fees should be reflected in the commitment of institutions to undergraduate and postgraduate teaching. In England and Wales, institutions that undertake training of undergraduate students on behalf of the NHS receive funding from the Department of Health (DH) and the Health and Social Care Department respectively in the form of Service Increment for Teaching/Multi Professional Education and Training (SIFT/MPET). SIFT/MPET has the explicit aims of ‘ensuring that the NHS supports undergraduate medical and dental education’ and ‘ensuring that service providers do not have higher treatment costs simply because they support medical and dental education’.[Go to note 34] This funding, however, is not a direct payment for teaching.[Go to note 35] There are similar arrangements to SIFT in Scotland in the form of additional cost of teaching (ACT) payments and in Northern Ireland with the supplement for teaching and research (STAR). A similar levy is provided for postgraduate training in the form of the medical and dental education levy (MADEL), which takes care of part of the salary and all the training costs of junior doctors. SIFT/MPET monies are allocated by NHS Executive Regional Offices, and the money is used to fund medical practice placements and facilities (fixed and semi-fixed infrastructure costs).

Cost shifting and cross-subsidisation of higher education funding occurs within teaching, research and clinical practice, and with the increasing pressure to minimise costs and justify all budgetary allocations, the funding available for teaching can be adversely affected.[Go to notes 36 and 37] Individual institutions are able to determine how higher education grant allocations are directed, and there is anecdotal evidence suggesting that this funding is being used inappropriately to fund research and non-medical courses and activities.[Go to note 23] The distribution of SIFT/MPET monies is equally blurred. The facilities element supports the provision of NHS service in medical undergraduate teaching hospitals, but it is not clearly linked to the additional service costs of student teaching and is used for non-teaching purposes.[Go to note 38]

In general practice, the move away from short placements towards longer attachments demands considerable educational input from GP teaching practices. While short placements are designed to provide medical students with exposure to general practice, GP teaching practices are now being contracted by universities to provide longer attachments that cover increasingly significant sections of the undergraduate curriculum. These longer attachments require GP teaching practices to meet a large number of specific educational targets in order to ensure that students complete a range of educational experiences. GP teaching practices, however, are not allocated a set amount of funding for teaching but are required to make precise costings of the resources necessary to fulfil their teaching obligations and apply to the university for the appropriate funding. Frequently, this funding providing for the longer placements only compensates for lost clinical time; and there is, for example, no payment for GP cover, for the time spent in preparation for teaching, or for the costs that a practice may incur in order to provide a suitable teaching environment and resources. A recent survey of UK GP trainers found that the grant received from the Doctors and Dentists Review Body (DDRB) – which determines GP pay annually – was an inadequate reflection of the workload and teaching commitment involved in being a trainer, and this results in professionals and practices subsidising the training process.[Go to note 39]

It is essential that there is a clear framework setting out how funds are allocated, how they should be accounted for and how they are distributed. There needs to be an appropriate balance in the funding allocated to educational institutions for the purpose of carrying out their dual responsibilities of providing medical education and performing research. It is vital that the boundaries between these two different activities are clearly defined and remain separate so that research is not subsidised at the expense of education. In light of the RAE programme and the competition between universities and medical schools for the variable levels of government funding, there is insufficient recognition of teaching. Institutions are currently able to obtain significant funding based on the quality and level of research they conduct, rather than their contribution to teaching. The current recommendations for the MMC academic career pathway mean that, because they are able to attract research grant funding and contribute to RAE, senior lecturer career posts specialising in research are much more assured than those specialising in medical education.[Go to note 27] In providing funding for higher education institutions, there needs to be equal recognition of the importance of medical education and research.

The status of teaching in the medical profession
Doctors contribute a significant amount of their time to teaching despite the pressures associated with other professional activities such as research and clinical care. Until the status of teaching is comparable to that of research, clinical service and management, it is unrealistic to expect those involved to devote the necessary time and effort to teaching. To improve the status of teaching it should be recognised by the whole medical profession as a core professional activity and not just an obligation. Recognising both formal and informal teaching as a core professional activity will encourage a change in attitudes to teaching and improve the commitment of doctors, employers and regulatory bodies to their educational responsibilities. Teaching may have a traditionally low status because it is a part of medical practice that is poorly rewarded and that everybody is required to undertake. It is important, therefore, to develop a culture in the medical profession that demands certain standards from all doctors with respect to teaching and accords high status to those who continue to develop their teaching skills. Despite the expectation for doctors to deliver teaching, there is a perception among teachers that neither the healthcare service nor educational establishments afford teaching the level of recognition and reward associated with research and clinical work.[Go to note 21]

The assessment of teaching quality through the QAA rarely translates into rewards for teachers in promotion and performance-related pay.[Go to note 9] To improve the status of teaching in the medical profession, there should be clear benefits to developing as a medical teacher. To enable doctors to provide high quality teaching, there needs to be support, opportunities and incentives to acquire teaching skills and keep up to date with curricular developments. Developing systems that reward doctors on the basis of their teaching contributions will serve to increase the involvement of doctors in teaching and encourage them to meet, and surpass, their teaching obligations. Rewards can be in the form of financial compensation, promotion on the basis of teaching involvement and ability where applicable, and the opportunity to formally develop professional skills. Where a doctor’s teaching is found to be below the expected standard the removal of incentives and rewards will serve to encourage a greater commitment to teaching. In many institutions, the predominant route into medical academic posts is via a research-intensive portfolio rather than an educational portfolio, yet, teaching remains a key component of these roles. It is vital that institutions provide appropriate salaries to recruit and retain medical educators where necessary, and that the recruitment to posts that involve significant levels of teaching is based primarily, if not wholly, on proven teaching ability and experience. This will ensure that individuals occupying such posts are adequately experienced and committed to providing effective teaching. It is essential that the reward of teaching contributions and recruitment on the basis of teaching competence occurs via a system that identifies suitable standards and assesses teaching abilities against them. This must also be recognised in relation to new contracts for clinical academic staff.

Who is best placed to do the teaching?
Through formal and informal teaching, doctors provide the specialist training required to ensure that future generations of healthcare professionals are adequately skilled and qualified. There is, however, a conflict in this training between the desire to provide a broad educational experience and the need to ensure a technical training in how to be a doctor. In light of the specialised nature of medical training, it is necessary that the majority of the clinical curriculum components are taught by doctors who actually do the job, provided they have acquired appropriate teaching skills. Some components of the medical curriculum, however, can be taught by non-medically qualified teachers (eg basic medical sciences, communication skills, teaching skills, equality training). Ensuring both a broad educational experience and adequate technical training could be achieved by providing teaching in a variety of contexts from a combination of individuals including medically-qualified professional educators (ie medical academics specialising in medical education), non-medically-qualified professional educators and doctors who have acquired appropriate teaching skills. In encouraging doctors to undertake educational responsibilities, it is important to recognise the differences in the desire to be involved in teaching between individuals. Those doctors who have a particular interest or aptitude for teaching should be encouraged to take up specialist teaching roles and assume a greater responsibility for coordinating and delivering teaching. Those who wish to restrict their teaching duties to a minimum should be trained accordingly and encouraged to take up posts that have limited teaching responsibilities.

Role models – attributes of a good medical teacher
Role models are people we can identify with, who have qualities we would like to have and are in positions we would like to reach.[Go to note 40] Role modelling is an integral component of medical education as it is an important factor in shaping the values, attitudes and behaviour of medical trainees. Role models have a strong influence on the career choices of medical students,[Go to note 41] and are important in medical teacher development.[Go to note 7] Doctors who hold senior posts such as consultants, lecturers, professors, tutors and researchers are often seen as role models and it is these individuals that provide teaching to medical students and junior doctors. Effective role models will inspire, teach by example, and stimulate admiration and emulation. As future teaching styles are influenced predominantly by learning experiences,[Go to note 7] it is vital that role models have acquired the appropriate attributes of a good medical teacher which can be passed on to medical trainees, junior doctors and colleagues. The attributes of medical role models might include a positive attitude towards junior colleagues, integrity and compassion for patients. The characteristics of excellent role models identified by medical students include personal qualities (eg interpersonal skills), clinical skills and teaching skills (eg the ability to explain complex subjects).[Go to note 42]

An American study examining the factors that distinguish physicians – who were considered to be excellent role models – from their colleagues, found there to be a graded association between the extent of assigned teaching responsibilities and the likelihood of being identified as an excellent role model.[Go to note 41] The study also identified an inverse relationship between research activities and the probability of being identified as an excellent role model.[Go to note 41] In examining physician behaviour, the study identified five attributes that were independently associated with being named as an excellent role model including:

spending more than 25 per cent of their time teaching
spending 25 or more hours per week teaching and conducting rounds when serving as an attending physician[Go to footnote e]
stressing the importance of the doctor–patient relationship in their teaching
teaching the psychosocial aspects of medicine
having served as a chief resident.[Go to footnote f]

As most of the attributes associated with being an excellent role model are related to skills that can be acquired and to modifiable behaviour, it is vital that the right advice, training and environment is provided to allow more doctors to become role models. It is also important that role models are encouraged at all levels of the medical profession to promote effective teaching throughout the medical career pathway. Further research is required into the impact role models have on the effectiveness of teaching and the acquisition of teaching skills.

Specific teacher education programmes
If doctors are to fulfil their professional obligation to teach and provide a broad educational experience to their students, they should be trained accordingly. In light of the current availability and diversity of teacher education courses, a greater emphasis is required from regulatory and educational bodies on the formal requirement for medical students and doctors to undertake a suitable level of training. This requires development of a structured teacher education programme that provides access to suitable and accredited teacher education courses, and that is appropriately regulated and resourced. Doctors should also recognise the need to be competent teachers. With teaching occurring at all stages in the medical career pathway, it is essential that teacher education is provided at every level of the medical profession, from undergraduate training continuing through to senior posts.

Teachers and trainers have become progressively more involved in complex training situations that demand increased levels of responsibility, educational expertise and a more diverse range of training skills. To reflect the continuing developments in healthcare practices, curricula and training, it is essential that teacher education courses are ongoing and allow medical teachers to acquire and update their teaching skills. This training should not occur via a blanket approach, but requires the development of different training programmes that occur in specific phases over a defined time period, and that recognise the varying levels of involvement in teaching. Ensuring that the training provided reflects the level of involvement in teaching is vital to ensure that the finite resources are distributed appropriately.

- Medical academic teachers
Medical academics are commonly required to combine a number of activities including research, teaching, clinical care of patients, and in some cases, managerial and administrative duties. The requirement for medical academics to adequately fulfil their multiple responsibilities is unsustainable.[Go to note 9] The introduction of formal systems to assess research and teaching quality, the growing volume and complexity of clinical care, and the expansion of managerial and planning activities requires medical academics to reduce their focus to a limited number of areas of responsibility. It is important, therefore, to distinguish between those medical academics who are primarily responsible for teaching, and those who focus on research. There needs to be a greater recognition of the specialised needs of medical academic teachers. Their involvement in teaching goes beyond the provision of lectures, seminars and clinical sessions as they also have responsibility for curriculum design and planning, planning of assessments, quality assurance, admissions, and student support. In this light, medical academics who hold official teaching appointments and who have significant teaching responsibilities should be encouraged and allowed the opportunity to attain higher educational qualifications (eg a Masters Degree in Medical Education). Medical academics who are primarily responsible for research, and who are involved in teaching through the provision of lectures, seminars and clinical sessions only, do not need to attain these higher educational qualifications, but should be encouraged to attain a postgraduate qualification in teaching (eg Postgraduate Certificate in Medical Education).

- NHS medical teachers
Doctors who do not hold official teaching posts are still required to provide teaching and supervision to junior colleagues and medical students. The extent of involvement of these doctors in teaching is different from that of medical academic teachers, and this should be reflected in the level of teacher education they receive. All medical teachers require basic level teacher education through attendance on short formal accredited training courses and they should be encouraged to work towards certificates, diplomas and masters in medical education. Such activity will have to be fully funded and rewarded, especially where prospective teachers are not of an employment status that allows secondment. Those who express an interest should be encouraged to take up leadership positions in medical education such as college tutor or director of education.

- Undergraduate and postgraduate teacher education
The undergraduate and postgraduate medical curricula are focused predominantly on the development of competence, knowledge and skills in medical sciences and clinical practice. The inclusion of teacher education is essential in the medical curriculum, beginning at the undergraduate level and continuing through postgraduate training. In light of the new integrated medical curricula and the increasing emphasis on competency-based learning, the development of teaching skills should be introduced as a formal competency. In a review commissioned by the DH, the future role and responsibilities of postgraduate deans and their deaneries was considered with regard to the development of a specialty of medical education.[Go to note 43] This proposal would require the agreement of a framework of skills and competencies and the development of a system to establish standards and test eligibility to be designated a specialist in this field. Successful completion of this specialist training would allow employment as a consultant or GP in medical education, potentially as a dual specialty with primary care or a secondary care specialty. The report recommended the establishment of a group to examine the implications of such a proposal or other alternative routes, to further develop the professional framework which supports medical education at all levels.[Go to note 43]

It is important that strategies are developed to promote and encourage teaching as an inherent part of professional development with clear career pathways for those who aspire to take a leadership role in medical education. Undergraduate and postgraduate training represent the best opportunity for this because it would provide all medical students with a basic level of competence in learning and teaching. Teaching skills could then be developed, updated and improved during the later stages of medical training in accordance with the respective level of teaching involvement of individual doctors. The introduction of teacher education in the initial stages of the medical career pathway would also demonstrate the importance of teacher education and allow it to permeate throughout the whole of the medical profession. Medical students have a responsibility to ensure they take all of the opportunities provided to develop their professional knowledge and skills, including teaching skills, as set out in the Medical School Charter.[Go to note 44]

- Continuing professional development and revalidation
According to Good Medical Practice, doctors are required to ensure their knowledge and skills are up to date throughout their working life and, in particular, should take part regularly in educational activities which maintain and further develop competence and performance.[Go to note 14] Following the introduction of revalidation, doctors will have to demonstrate regularly that they are up-to-date and fit to practise medicine. CPD is a continuing learning process that requires doctors to maintain and improve their standards across all areas of their practice. As such, CPD will be an important process for informing revalidation and should cover all seven headings set out in Good Medical Practice including good professional practice, maintaining good medical practice, relationships with patients, working with colleagues, teaching and training, probity, and health.[Go to note 45] Under teaching and training, it is recommended that doctors keep up-to-date with suitable teaching skills and be willing to teach colleagues and to develop their own teaching skills.[Go to note 45] Doctors should be encouraged to attain and regularly update their teaching skills as part of their requirement for CPD.

Assessing teaching quality and the impact of teacher education
Assessing the quality of teaching in the medical profession is essential to determine where training is required, measure the impact of teacher education programmes and ensure that teaching receives equal weighting with research and clinical work. A range of informal strategies and assessment methods already exist that evaluate different aspects of teaching, including feedback questionnaires, whether training course objectives are met, whether assessment methods reflect course ideals, or whether resources are adequate to deliver specified educational outcomes.[Go to note 18] In assessing the quality of teaching it is important that feedback is sought from the individuals being taught (eg lecturer feedback questionnaires) and from the teachers (see box 2). Those doctors who are involved in assessment should also be able to demonstrate that they have been trained in the assessment methodology and that their judgments are in accord with their peer assessors.

Formal strategies that simultaneously assess multiple dimensions of teaching competence remain elusive, and in particular, there are no approaches that reliably measure knowledge and technical teaching skills in conjunction with interpersonal and humanistic qualities. Although informal assessment techniques provide a valuable insight into teaching quality and methods, they are limited in the extent to which they permit meaningful assessment. Evaluating teaching quality identifies weaknesses in teaching skills, but also provides a subjective measure by which teaching involvement can be rewarded. Informal assessment methods should be complemented by a formal assessment system that monitors both teaching quality of doctors and the frequency and quality of training courses they attend. This assessment should be included in the criteria for the approval of academic and non-academic posts. Standards for assessment should be developed, and these could include assessment of:

the clarity of teaching objectives
the choice of learning methodology to meet the objectives
the quality of teaching materials (notes, handouts and visual aids)
qualitative assessments of their performance in lecturing, workshops and clinical training
the volume and range of teaching undertaken
the range of assessment techniques used.

These standards for assessment, may best be applied to classroom-based teaching, but could be adapted to assess workplace teaching. With a significant component of teaching occurring formally or informally in the clinical setting, a set of assessment standards need to be developed that can evaluate the teaching that occurs outside the classroom setting. Previous research on assessment methods has focused on evaluation of medical knowledge and clinical skills, with very little attention paid to assessing teaching skills and interpersonal aspects of performance.[Go to note 46] Further research is required into the impact of formal and informal assessment methods on the acquisition of teaching skills and any consequent improvement in teaching quality.

Box 2 – the Cleveland Clinical Teaching Effectiveness Inventory (CCTEI)

The CCTEI was developed at the Cleveland Clinic Foundation (Cleveland, Ohio) as a theory-based generic test to measure the effectiveness of clinical teaching across the institution.[Go to note 47] The test consists of an anonymous 15-item questionnaire where each question relates to a different aspect of clinical teaching (eg establishment of a good learning environment and the level of constructive feedback). Each item is rated on a five-point scale by medical students, residents and fellows, and all respondents are required to specify the length of time spent with each clinician and their levels of training. Although the test does not cover every aspect of teaching, it is used to provide consistent regular feedback to all programme directors who make decisions about teaching assignments, as well as permitting analysis of variables that may impact teaching effectiveness. The CCTEI has been found to be reliable, usable and valid, and analysis of the preliminary data found it to be useful in measuring improvement within the institution.[Go to note 47]

Footnotes
(d) In the UK, the four UK higher education funding bodies are the Higher Education Funding Council for England (HEFCE), the Higher Education Funding Council for Wales (HEFCW), the Department for Employment and Learning of the Northern Ireland Executive, and the Scottish Funding Council (SFC).
(e) An attending physician is a doctor who has completed postgraduate training and practises medicine in a clinic or hospital, often focusing on the specialty learned during training. They are responsible for the supervision of junior doctors and medical students, and have ultimate responsibility for patient care.
(f) A chief resident is a doctor who is undertaking postgraduate medical training within a specific branch of medicine, and who is partly responsible for the training, and the organisation of training, of doctors junior to them.

� British Medical Association 2008

Change to another homepage

Doctors as teachers

Doctors as teachers

Log in to your BMA here