scheele_Opmaak 1 11/12/12 15:10 Pagina 266 FVV inObGyn, 2012, 4 (4): 266-269 Viewpoint The art of medical education F. Scheele Professor Medical Education, VU University Medical Centre, Amsterdam, the Netherlands. correspondence at: [email protected] Abstract Is the art of medical education just making sure to provide sufficient up to date medical knowledge and a lot of clinical experience? It is much more. The art of medical education is about a teaching program that is designed to serve the community of the near future. The program is the result of a thorough evaluation of societal needs and is capable of influencing the properties of future care. New care professionals who are trained in the program will become instrumental in solving complex problems in health systems. The art of medical education is about the change of traditional ideas of how to cope with these health systems. This change will raise anger and resistance. Effective change management is essential to survive attacks from laggards and to maintain enthusiasm to invest in the health care of the future. Educationalist science provides several important insights that help us find the optimal shape of the program. Good role models and a learning environment that is an example of the intended professional and organisational behaviour, learning by doing, simulation programs, educational tools like e-learning systems, a good assessment and feedback system, and a portfolio to prove and discuss professional progress are all pivotal components of the ideal program. To achieve mastery within the art of medical education, a quality improvement program will be the crown of the process. Medical education is a multifaceted process and so the quality improve- ment should be. The art of medical education is a great challenge. The health care of your future deserves it. Key words: Medical education, strategic planning, change management, learning, role model, hidden curriculum, quality care. Introduction does society expect from medical personnel? Which pitfalls are recognized in daily medical care and in several countries medical education, especially in which solutions for the future can be proposed? the clinical context, has become part of a process of What is the right balance in several scales? For ex- redesign and change (Scheele et al., 2008). The re- ample, do we need generalists or specialized doc- design is based on current insights. however, prob- tors? Do we need a focus on a certain group of ably a lot of insights still have to become apparent patients like the elderly? Do we need a focus on cer- in the future. The process of redesign and change is tain technologies like information technology? Do an excellent opportunity to gain more knowledge we need very creative professionals that thrive in a and understanding of medical education in the clin- world of ambiguity and relative chaos or do we need ical context. concerning the art of medical educa- humble, adaptive and disciplined team members in tion, in this article, an impressionistic picture is a world where protocols and checklists bring us to created lacking detail and lacking classical prime ed- optimal performance? The point made is that med- ucational facts. An attempt is made to have a glance ical education should be recognized as an important at future developments in clinical medical education. tool in the governance of health systems (van der lee et al., 2011). The goals for governance of health Strategic planning systems should be the main driving force for a med- ical school or a clinical learning environment. These Medical education is done for a purpose: To serve goals may differ between high and low resource health systems for the near future. What are the countries, between various cultures and even accord- prospects of health systems for the future? What ing to persons within one country (Wallenburg et al 266 scheele_Opmaak 1 11/12/12 15:10 Pagina 267 2010). Moreover, these goals will change in time. planned change management programs. Fortunately, The discussion about the goals for governance in during the process of change management selling of health systems should be a continuously discussed high quality is often easier, than selling mistakes. matter. When working with clinicians, one of the most important items to take care of during change man- Complex problems agement processes is the possibility of free enterprise within carefully chosen borders (Maravelias, 2003). The discussion about problems in health systems and Professionals seem to thrive with professional free- the description of goals is a complex matter. The pro- dom and their initiatives often show of paramount vision of health care can be addressed from several importance for the success of projects. Too much different scientific paradigms. health care systems regulation will strangle professional free enterprise are an economic burden in several countries. On the and takes out the soul of medical education. instead other hand prevention or quick handling of health of creating dense regulations, change managers care problems of labourers is of economic advan- should focus on shared visions and stories that tell the tage. Medical personnel in health care systems tend ideas of good medical practice. These visions and to create professional societies that protect autonomy stories are the skeleton of the change management of doctors and other care providers. The professional process and provide global borders for free enterprise. culture of medicine is one of scientific development and making progress in individual treatment. could Learning by doing we make professional autonomy supportive for some of the governance goals? Representatives of patients Depending on the goals set during your strategic and other potentially important discussants should planning, by retrograde planning end terms (knowl- be included in solving complex problems and de- edge, skills and attitude) essential for your new scribing goals for the future of health systems doctor may be defined. These end terms must find (caron-Flinterman et al., 2005).important discus- their place in the curriculum of medical education. sants may come from various scientific fields like Medical education is a mixture of theoretical educa- ethics, social sciences, economics, information tech- tion and practical education. The challenge is to nology and so on. Mono disciplinary solutions are balance a program in such a way that learning by usually much less effective and durable than trans doing is optimally supported by simulation training disciplinary solutions (Rosenfield, 1992). Strategic and theoretical education. learning by doing is the planning for health systems and defining a tactical most powerful learning tool (Teunissen et al., 2007). approach for complex problems is laborious and ex- blended learning combining e-learning with simu- pensive, but indispensable for mastery of the art of lation training and learning by doing should be medical education. pursued. Various ways of e-learning like webinars or serious gaming may become very important to Change management enhance learning at the work place (cook et al., 2010). Simulation training for rare or difficult skills When the goals for governance of health systems and for team skills is very helpful to support learning have become explicit, a strategy for the use of on the workplace. years of merely theoretical train- medical education is the next step. having brilliant ing are less effective (but often cheaper) and learning ideas is possible, but making them come true is by doing should be regarded of paramount impor- almost impossible (Grol & Grimshaw, 2003). The tance. The mastery of the art of medical education is science of making ideas come true is the one of found in medical education management. Good change management. This science will help you to management means looking for the right clinical prioritize goals, make visible which players are activities for the needs of the trainee, for the optimal important to deal with, which societal movements or use of simulation trainings and for the optimal sup- hypes you could use to smoothen the way and which port form e-learning in a context of restraints of time factors may enhance success or may bring failure of and money. the process. change management is about tactical timing of steps, the use of planning and control on Appropriate clinical exposure in different phases of the process and to keep an eye on budgetary risks training (Gale & Grant, 1997). The main mistake in educa- tional reform seems to be the use of inappropriate One of the challenges of optimal management of change management. content oriented persons often medical education is to provide appropriate clinical believe that quality will sell itself. Unfortunately, that exposure to students and trainees in different phases is not the case. Quality has to be sold by thoroughly of their career. clerks should at least be confronted The ART OF MeDicAl eDUcATiOn – Scheele 267 scheele_Opmaak 1 11/12/12 15:10 Pagina 268 with patients with clear cases of common diseases. structure of our learning environment could be the Trainees in obstetrics should start to master the nor- most important educator during learning by doing. mal delivery before entering more complicated ob- Ask the questions concerning your goals continu- stetrics. Final year trainees should not spent much ously and redesign the structure until all questions time on coaching normal deliveries, but should have are met. The educational impact will be enormous abundant exposure of complex operative deliveries and the quality of care should improve (if the goals and of generic problems like triage during peak ex- are well-chosen). posure of acute patients. Several clinical wards are hard to manage in such a way that teaching will be- Educational tools come optimal for the trainee. The art is in exposing the trainee to clinical problems that are ranging from educational science has brought helpful insights to fairly difficult to almost too difficult most of the improve medical training, both by curriculum design time. At least every 3 month the trainee and the su- based on adult learning principles and on the contin- pervisor should discuss the steepness of the learning uous use of effective education. educational science curves of the trainee. has evidence for the prominent place for learning by doing and the combination with simulation and (ict Role modelling supported) theoretical training. For adequate man- agement of education transparency of the learning Role models have a strong influence on professional process is essential. end terms coming from strategic development. Role models should continuously get planning, a curriculum on paper and a carefully de- feedback about the messages send by their behaviour signed hidden curriculum are the fundaments to (lombarts et al., 2010). Role models could be excel- build on. A work place with a good learning climate lent preachers of the goals set for the governance of (boor et al., 2011) has to be created. Asking help health systems. When role models do share visions from educationalists in creating a proper curriculum and live the stories that describe the goals, medical and a good learning climate seems obvious. More- education is delivering doctors fit for the future. over these professionals should advice on the use of Sometimes goals do not correlate with the profes- simulation training and theoretical (e-) learning. sional culture and role models do not send the de- Faculty development is needed to assure the sired messages. This is a matter of putting these proper attitude of the clinical staff and to distribute items on the agenda over and over again and having knowledge about clinical assessment and feedback a long breath. Part of faculty development should be (Schofield, 2010). Active learner courses for trainees raising the awareness of the responsibility of being are helpful. Trainees are instructed to get the most a good role model and knowing the desirable out of their training time and to use the educational messages to show during clinical practice. structure in a creative and effective way. An appropriate assessment and feedback system Designing the hidden curriculum will ensure knowledge about the progress and learn- ing needs of the trainee (van der Vleuten et al., The structure of the learning environment must be 2010). Statements of awarded responsibility will an example for the planned education in which the help to define the level of competence of trainees goals for the future are embodied. This warrants a and enhance patient safety during the development continuous observation of the hidden messages that as a trainee. Step by step the trainee will be awarded are sent by this structure (hodges & Kuper, 2012). more clinical responsibility (ten cate & Scheele, Does the structure enhance effective inter-profes- 2007). The transition to the work as a licensed sional practice? Does the structure facilitate ethical medical specialist will be optimally prepared by a considerations? Does the structure provide feedback virtually full responsibility already before the on personal performance and team performance? moment of licensing. Does the structure bring in patients for shared deci- The use of a portfolio is helpful (Driessen et al., sion making? Does the structure enhance patient 2007a). it should contain summaries of assessment safety? Does the structure make sure that residents procedures, proof of simulations and theoretical do work they are fit for? Does the structure demand education , output from scientific work, the attained adherence to protocol? Do we have a system for levels of competence in a time frame and reflections quality assurance? We could discuss hundreds of on the learning process. On a regularly basis (e.g. questions here that could concern chosen goals for every three months) the program director discusses governance of health systems. Asking these ques- the portfolio with the trainee. The first result of this tions about your educational work floor is of the discussion is proof of sufficient progress of compe- highest importance for optimal medical training. The tence within the time frame described in the curricu- 268 FVV inObGyn scheele_Opmaak 1 11/12/12 15:10 Pagina 269 lum. The second result is a logical choice of next mally brought in to the learning places. Quality care training goals. The goals are described SMART. The should bring in the ongoing drive for innovation and third result is an agreement about how these goals continuous improvement of the system. are going to be reached in the next clinical rotation. An electronic portfolio is advisable to make the col- References lection and integration of assessment data easier (Driessen et al., 2007b). An electronic portfolio may barnett R. improving higher education: Total Quality care. 1992 Open University Press, bristol, UK. enhance the transparency of the training results. boor K, Van Der Vleuten c, Teunissen P et al. Development and These results mirror off the combination of proper- analysis of D-RecT, an instrument measuring residents’ ties of both the trainee and the educational quality of learning climate. Med Teach. 2011;33:820-7. caron-Flinterman J, broerse J, bunders J. 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The assessment of professional competence: building blocks for theory de- program for improvement are the crown on the velopment. best Pract Res clin Obstet Gynaecol. achievement of mastery in the art of medical educa- 2010;24:703-19. tion. Wallenburg i, van exel J, Stolk e et al. between trust and ac- countability: different perspectives on the modernization of postgraduate medical training in the netherlands. Acad Med. Conclusion 2010;85:1082-90. The art of medical education will become apparent in an environment where teams of clinicians and educationalists try to bring in a multi-perspective on teaching. They should give lots of attention to setting the goals for future health care, to the process of change and to the way educational science is opti- The ART OF MeDicAl eDUcATiOn – Scheele 269