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Library of Congress Cataloging-in-Publication Data

Names: McKimm, Judy, editor. | Forrest, Kirsty, editor. | Thistlethwaite, Jill, editor.

Title: Medical education at a glance / Judy McKimm, Kirsty Forrest, Jill Thistlethwaite.

Other titles: At a glance series (Oxford, England)

Description: First edition. | Hoboken, NJ : John Wiley & Sons, Inc., 2017. |

Series: At a glance series | Includes bibliographical references and index.

Identifiers: LCCN 2016045903 (print) | LCCN 2016046543 (ebook) | ISBN

   9781118723883 (pbk.) | ISBN 9781118723814 (pdf) | ISBN 9781118723821 (epub)

Subjects: | MESH: Education, Medical

Classification: LCC R735 (print) | LCC R735 (ebook) | NLM W 18 | DDC

   610.71–dc23

LC record available at https://lccn.loc.gov/2016045903

Cover image: © kali9/Gettyimages

Welcome to the first edition of Medical Education at a Glance. This book was conceived as an introduction to key aspects of medical education, which would provide an accessible overview for those new to medical education or a handy summary for those more experienced. We also envisaged that it would provide a taster for medical educators who might then wish to explore the more substantial books produced by Wiley such as Understanding Medical Education (2nd edition) and Researching Medical Education.

Medical Education at a Glance will be relevant to doctors, dentists, nurses and other healthcare professionals at various levels (including students), as well as to support staff. The book is particularly appropriate for guiding medical students and doctors in training and their teachers, supervisors, mentors and trainers. It aims to inform and encourage those engaged in improving education and training. As well as the chapters written by ourselves, we have been fortunate in attracting additional contributors with huge expertise and knowledge about medical education in both the academic and clinical environments.

In the usual at a Glance style, the book is designed to summarise what are often fairly complex or substantial topics, so that readers learn some of the language and key terms while gaining a broad understanding of the topic. Given this approach, we cannot go into depth on any one area and so further reading and resources are identified for each topic for the reader to explore further. What we have aimed to do is provide an introduction to some key educational concepts as they relate to clinical practice and university-based education. We have tried to make the chapters practically focussed with examples of how concepts or approaches might be applied in practice. Each chapter (or group of chapters) is free standing, although reading the whole book will provide a good grounding in medical education theory and practice.

The book begins with an overview and introduction to medical education, its purpose, structure and predominant educational or learning theories. It also considers some of the core aspects of contemporary education including curriculum, selection, leadership and international contexts. We move on to consider approaches to learning and teaching planning and implementation in different contexts and with different groups of learners. The later chapters consider assessment and feedback in both the academic and clinical environments. A comprehensive further reading, resources and reference list concludes the book. We hope that you enjoy the book, and that it stimulates you to reflect on and develop your own educational practice and that of others.

Judy McKimm, Kirsty Forrest and Jill Thistlethwaite

We would like to acknowledge all the contributing authors who have offered different perspectives on various aspects of medical education. The book reflects our experiences over many years working with learners, teachers and patients in a range of international contexts and we would also like to acknowledge their contribution to our understanding of medical education. Finally, as ever, we'd like to thank our partners – Andy, Derek and George – for their unfailing support and patience.

Judy McKimm

Judy's current role is Director of Strategic Educational Development and Professor of Medical Education in the College of Medicine, Swansea University. From 2011 to 2014, she was Dean of Medical Education at Swansea and before that worked in New Zealand from 2007 to 2011, at the University of Auckland and as Pro-Dean, Health and Social Care, Unitec Institute of Technology. Judy initially trained as a nurse and has an academic background in social and health sciences, education and management. She was Director of Undergraduate Medicine at Imperial College London until 2004 and led the curriculum development and implementation of a new undergraduate medical programme. In 2004–2005, as Higher Education Academy Senior Adviser, she was responsible for developing and implementing the accreditation of professional development programmes and the standards for teachers in HE. She has worked on over 60 international health workforce and education reform projects for DfID, AusAID, the World Bank and WHO in Central Asia, Portugal, Greece, Bosnia and Herzegovina, Macedonia, Australia and the Pacific. She has been a reviewer and accreditor for the GMC, QAA, the Higher Education Academy and the Academy of Medical Educators for many years and is a member of ASME Executive and Council. She is programme director for the Leadership Masters at Swansea and Director of ASME's international Educational Leadership programme. She writes and publishes widely on medical education and leadership and runs health professions' leadership and education courses and workshops internationally. Her most recent books are Global Health (with Brian Nicholson and Ann Allen), Health Care Professionalism at a Glance (with Jill Thistlethwaite), Clinical Leadership Made Easy (with Helen O'Sullivan) and the ABC of Clinical Leadership, 2nd edition (with Tim Swanwick).

Kirsty Forrest

Kirsty is Deputy Head of Medicine in the Faculty of Health Sciences and Medicine at Bond University, Australia. Prior to this she was Associate Dean, Learning and Teaching and Director of Medical Education in the Faculty of Medicine and Health Sciences Macquarie University (2013–2016). She moved from the UK where she was an Honorary Senior Lecturer at the University of Leeds (2005–2013) and Clinical Education Advisor for the Yorkshire and Humber Deanery (2009–2013). She received her medical degree from the University of Edinburgh and has specialty fellowships in anaesthesia from the UK and the Australian and New Zealand Anaesthetic Colleges, and continues to work clinically. She has a Masters in Medical Education from the University of Sheffield and has coauthored and edited a number of medical textbooks. These include: How to Teach Continuing Medical Education, Essential Guide to Acute Care, Professional Practice for Foundation Doctors – Becoming Tomorrow's Doctors, Essential Guide to Educational Supervision in Postgraduate Medical Education and Simulation in Clinical Education.

Jill Thistlethwaite

Jill Thistlethwaite is a health professional education consultant, medical adviser at NPS MedicineWise and adjunct professor at University of Technology Sydney. She received her medical degree from University College London and has since practised as a general practitioner (family doctor) in both the UK and Australia. She received her PhD on the topic of shared decision making and medical education from the University of Maastricht. For over 20 years she has worked across the continuum of health professional education at undergraduate, postgraduate and continuing professional development (CPD) levels. Her main interests are interprofessional education (IPE) and collaborative practice, professionalism and communication skills. Jill has written/coedited several books and book chapters, and has published over 90 papers in peer-reviewed journals. Her most recently published books are: Values-based Interprofessional Collaborative Practice; Health Care Professionalism at a Glance with Judy McKimm and Leading Research and Evaluation in Interprofessional Education coedited with Dawn Forman and Marion Jones. She is coeditor-in-chief of The Clinical Teacher and an associate editor of the Journal of Interprofessional Care. In 2014, she was a Fulbright Senior Scholar at the National Center for Interprofessional Practice and Education in the USA.

Michelle McLean, Chapter 12

Professor of Medical Education and Academic lead for PBL, Bond University, Australia

Andrew Grant, Chapter 26

Practising GP and Professor and Dean of Medical Education, Swansea University Medical School, UK

Nicola Cooper, Chapter 27

Consultant Physician & Hon Clinical Associate Professor, Derby Teaching Hospitals NHS Foundation Trust, and Division of Medical Sciences & Graduate Entry Medicine, University of Nottingham, UK

Claire Vogan, Chapter 32

Associate Professor and Director of Student Support and Guidance, Swansea University Medical School, UK

Sean Smith, Chapter 35

Systems Developer, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Trust, UK

Sam May, Chapter 36

Lecturer in Medical Education, Swansea University Medical School, UK

Heidi Phillips, Chapter 37

Practising GP and Admissions Director for Graduate Entry Medical Programme, Swansea University Medical School, UK

Luci Etheridge, Chapters 38–41, 44

Consultant Paediatrician, St George's University Healthcare NHS Foundation Trust, and Honorary Senior Lecturer, St George's, University of London, UK

Rebecca Hodgkinson, Paediatric Registrar at Evelina London Children's Hospital, Former Chair London School of Paediatrics Trainee Committee and Former Trainee representative RCPCH Assessment Committee

Kathy Boursicot, Director, Professional Assessment Consultancy, Singapore

Chapters

1. 1 What is medical education?
2. 2 Stages of medical education
3. 3 Evidence-guided education
4. 4 Learning theories: paradigms and orientations
5. 5 Learning theories and clinical practice
6. 6 The curriculum
7. 7 Planning and design
8. 8 Equality, diversity and inclusivity
9. 9 Principles of selection
10. 10 Evaluation
11. 11 Educational leadership
12. 12 International perspectives

Medical education is ‘the process of teaching, learning and training of students with an ongoing integration of knowledge, experience, skills, qualities, responsibility and values which qualify an individual to practice medicine. It is divided into undergraduate, postgraduate and continuing medical education, but increasingly there is a focus on the “lifelong” nature of medical education.' (IIME, 2016).

Medical education has evolved over the last century to become a discrete educational field of study, which has shaped not only the way doctors are educated and trained but has also influenced wider education. Prior to the Flexner Report (Flexner, 1910), medical education was undertaken on an apprenticeship model, and it was usually the most privileged and wealthy who had access to such training. The Flexner Report recommended that the American and Canadian medical school system be transformed to one which provided university education in the basic medical sciences and also trained students in the workplace to be practising clinicians. Since then, around the world, basic (undergraduate or prequalifying) medical education has moved into universities, and medical education at all stages has become ever more tightly controlled and regulated.

Professionals who are involved in the education of students, doctors in training and qualified practitioners are termed medical educators. Medical educators come from a range of backgrounds: education, other health professions and the social and behavioural sciences, as well as from the biomedical sciences and medical specialties (i.e. practising clinicians). Doctors' world views and paradigms have traditionally reflected positivism, the scientific method and the pragmatism of the real world. This is both a strength and a weakness: a strength in that it can bring scientific rigour to research, and engagement in everyday clinical practice brings authenticity to teaching, learning and practice-based research; a weakness in that ‘medical education is about people and the way we think, act and interact in the world. Medical education research is not a poor relation of medical research; it belongs to a different family altogether' (Monrouxe and Rees, 2009, p. 198).

Currently, a range of approaches in medical education practice and research exists – from social, behavioural and management sciences, and the humanities as well as from more traditional disciplines. This has led to a richness and diversity of activities and outcomes, which utilise different approaches from other subject disciplines (particularly school and adult education) to explore what works, why and how? in the real world. For example, situational, experiential and outcomes-based education are derived from general education; and patient safety and simulation education was extended and adapted from work done in the airline and nuclear industry. And the ‘taken for granted' role of reflection in developing medical professionals drew heavily on Schön's (a philosopher) work on learning organisations and the reflective practitioner (e.g. Schön, 1987). See later chapters.

Medical education also gives back to the wider education and health community through specific educational strategies and social accountability initiatives: the social good of Tan et al. (2011). For example, problem-based learning (PBL), developed at McMaster University, Canada in the 1960s, is now used in many educational sectors and the objective structured clinical examination or OSCE (Harden and Gleeson, 1979) is now widely used in veterinary and health professions' education.

Professional education and training

The first professions established were medicine, divinity and law, and medical doctors continue to have a very privileged position in society. It is partly because of the high status of medicine that medical education is somewhat set apart from the education and training of other health professionals. Medical schools often operate semiautonomously, have relatively high power, utilise different funding streams and offer higher rates of remuneration for their clinical teachers than other disciplines (Swanwick, 2014). At postgraduate level, doctors have one of the longest training periods of any professional before they are deemed fit for independent practice, typically overseen by specially established postgraduate colleges.

Despite these differences, medical schools have to abide by the rules and regulations of the universities in which they reside in order to be able to award medical degrees. Programme approval and quality assurance mechanisms operate in exactly the same way for medical programmes as they do for any other programme. Medical education and training (and the activities of individual doctors) is subject to regulation from regulatory and professional bodies (e.g. medical councils), just as other health and social care professions are. Basic medical education and training (just as in undergraduate nursing, social work or physiotherapy programmes) is delivered both in the workplace and the university, with the involvement of practitioners and others not directly employed by the university.

Current concerns and issues

Many of the concerns in medical education are those experienced by all higher education and health organisations (Table 1.1). Medical education needs to take account not only of educational concerns and issues, but also those affecting the health services in which the training and education are carried out. At the heart of medical education is the need to produce and maintain safe, competent, caring doctors, so patient safety and fitness to practice issues are high on the agenda. Simulation and the use of computer-based and mobile learning technologies are helping to prepare learners for clinical practice, although they can never compensate for learning from real patients, their families and communities. Changes in health structures and systems, the impact of technologies resulting in shorter inpatients' stays and consequent limitations on clinical placements have huge impact on the type and quality of clinical education that can be provided.

Both health care and education are now global industries and, in many countries the numbers of student places in programmes are capped. Due to these factors, as well as universities becoming more entrepreneurial, many medical schools are seeking other ways (including developing collaborations with overseas partners) to expand student numbers. The expanding knowledge base in medicine and consequent curriculum pressures are leading educators to explore different curricular models as they prepare students and doctors for 21st century practice (Lueddeke, 2012) (see ­Chapter 6). The internationalisation of medical educators is reflected in the way individuals, groups and organisations collaborate and share practice and ideas around the world. Whilst this rich diversity of perspectives may lead to debate and disagreement about the right way to do things, all medical educators share a common purpose: to provide medical education that leads to those who engage in it striving to provide the best health care to the patients and communities they serve.

The stages of medical education comprise basic (undergraduate) medical education, postgraduate medical education (including vocational training, specialist training, and research doctoral education), continuing medical education (CME) and the continuing professional development (CPD) of medical doctors (WFME, 2016).

Basic medical education

Basic or undergraduate medical education refers to the period that begins when a student enters medical school and ends with the final examination for basic medical qualification. In some countries, however, undergraduate education refers to pre-medical college education, which results in a Bachelor's degree and is the training students receive before entering medical school.

Basic medical education is usually provided by universities, whose programmes are accredited by a regulatory body (such as a medical council). Accreditation is a quality assurance process that aims to evaluate educational and training institutions, programmes and practices to determine whether applicable (i.e. national and/or international) standards are met. Increasingly, undergraduate programme accreditation is tied to the regulation and licensing of health professionals, most commonly to initial licensing and ­registration.

Successful completion of medical programmes leads graduates to professional registration and entry into postgraduate training. Many programmes also include opportunities for additional full-time study leading to an intercalated degree, such as a BSc, Masters or PhD in a related science or social science.

Worldwide, two main curriculum models for basic medical education exist, although within these a variety of educational offerings are provided:

1. traditional undergraduate programme, lasting 5–7 years, primarily for school leavers;
2. graduate entry programmes, lasting 4–5 years for graduates with a prior university degree or qualified health professionals. Students on these programmes are also referred to as medical students and can leave with further Bachelors', or more frequently Masters' qualifications. The Masters' degrees often include a strong element of research training.

The latter, most notably in Australia, North America and Europe, are new professional degrees based on the broad-based undergraduate degrees. The rationale behind such shifts was in response to international changes, such as the Bologna Agreement (European Commission, 2015), which aims to streamline and align all higher education programmes and levels in the EU. See Chapter 6 for further description of curriculum models.

Postgraduate training

Internationally, effective postgraduate education is highly structured with clear definition of standards, outcomes and competencies delivered by trained supervisors and measured by a wide range of assessments, as described in Chapters 38–44.

In many low and middle income countries (LMICs), however, whilst basic medical education may be offered, it is at postgraduate level, and in particular in speciality training, that more development is needed. In some areas this has been addressed at regional level through defining standards and sharing resources. Reciprocal agreements exist between councils of some countries to facilitate the movement of individual doctors, whereas between others additional examinations or evidence has to be provided. Most countries have provision for employing doctors who are non-specialists

Academic training

Many countries offer specific programmes for doctors who wish to combine their medical training with research, education or leadership/management development. The most common programmes focus on clinical or laboratory-based research, typically giving opportunities for doctors in training to step out of clinical training for a period of time or to extend their training whilst studying for a doctorate or master's degree alongside clinical practice.

Internship

While differences exist between countries as to the structure and length of medical education, most require new medical graduates to undertake a period of supervised practice (typically 1 or 2 years) often with a limited scope of registration. This period of internship is typically structured around clinical placements in a small range of core clinical specialties: medicine, surgery and primary care. Because doctors also need skills in assessing and managing patients with acute, undifferentiated presentation, many internship programmes also include an emergency medicine rotation. Other rotations are highly variable between programmes and jurisdictions, and may include paediatrics, reproductive health, mental health and community placements. Progression from internship normally requires satisfactory completion of formal assessments, often with a strong emphasis on workplace-based assessment, but some include written assessment.

In the US however, the majority of graduates from medical school progress into residency speciality training programmes. This initially reflected that American students were graduate entrants in medical school and therefore already more mature, and traditionally the students had a higher level of patient contact and management exposure prior to graduation.

Speciality training

Specialty training is where doctors become a specific ‘type' of doctor, such as surgeon, psychiatrist or ‘general practitioner' (GP, family doctor). The length of speciality training ranges from 3 to 10 years depending on the specialty and country/region. In high income countries (e.g. Canada, UK, US) around 60 specialities and subspecialties exist. In LMICs, the number of subspecialties tends to be much lower because health services are less specialised, there are fewer qualified specialists and subsequently a lack of training posts. In order to address this, agreements with other countries have been established to train doctors in required specialties (e.g. surgery, family medicine), who then return to their home country to practise. As in undergraduate education, specialty training may also have a focus on acquiring knowledge and skills that will enable the practitioner to function at an advanced level in rural, remote or relatively under-resourced settings.

Each specialty generally has its own set of national educational standards and assessments, administered by a professional body that is distinct from the overall medical regulator (and may also be distinct from providers of undergraduate education, e.g. professional boards or medical colleges). Specialty training posts are often strictly controlled at national level, tied to workforce planning and the future needs of the healthcare system. Once a doctor has undergone the relevant clinical experience and passed examinations, they become eligible for the specialist register and can gain a post as a consultant or specialist. Hodges and others have critiqued the ‘time-served' apprenticeship model of training, ­suggesting that moving towards competency-based and more tailored personalised training may be more appropriate to address individuals' different rates of learning and experience (Hodges and Lingard, 2012).

Continuing professional development

Once qualified and registered in their field, most countries require doctors to engage in (and be able to evidence) a commitment to education throughout their career in the form of continuing professional development (CPD) or medical education (CME). The main purpose of CPD is for doctors to keep up to date with evolving knowledge and procedures, and to ensure safe practice. Engagement in CPD is typically through participation in small, accredited training/educational courses that are assigned ‘points' or ‘credits'. The number of credits is broadly correlated with the time taken to complete the activity. Increasingly, evidence of CPD participation is a requirement for relicensing (or revalidation). Relicensing is typically undertaken on a 3 to 5-year cycle. It sometimes involves examinations but generally is carried out using a portfolio of evidence.