Thamer.K.Yousif/MBChB/FICMS/MsC.
Hani AL Moallim/Ass.Prof.

 

Summary Active participation of learners in any Postgraduate training programs needs to be critically examined, by an internal review process. This should depend on the best evidence based medical education principles. An evidence-based review of morning reports, lectures in postgraduate training programs, outpatient clinics and journal clubs is presented. Morning reports should emphasize active participation of all residents without humiliation. Lectures do not enhance higher order thinking. Residents should spend more time in outpatient clinics. Journal clubs are an essential strategy.

Postgraduate training programs aim to produce professionals competent in their knowledge, skills and attitudes. These programs need to prepare candidates to meet the demands of real life practices in a continually changing and fast growing medical field. The final goal is clearly to improve patient care. There are multiple teaching methods that can be employed in a training program. This would provide different learning styles for different candidates.

The active participation of candidates in the learning process, the presence of clear aims and objectives for each activity, the relevance of what is to be taught to candidates and the presence of a two way feedback mechanism between candidates and their teachers are all important. Some common problems relate to vague objectives and expectations, and lack and or deficiency in promoting problem solving skills and attitudes⁽¹⁾.

The objective of the article is to present an evidence-based review for some of the common learning interventions undertaken in Arab Family Physician postgraduate training programs, we hope to establish and or initiate a critical internal review.

Morning reports are meetings where junior and senior staff meet to discuss the newly admitted cases, and they can function as an instructive teaching conference providing a broad coverage of topics. There is no doubt that there are unique educational opportunities in the morning report. It stands out as the only large, formal conference generally used for the evaluation of case management and the overall performance of medical residents. The cases discussed in a well designed morning report are closely comparable to the curricular contents designed by supervising health authorities.

The objectives of the morning report need to be clear in the minds of program directors, supervising staff and residents. The majority of residents thought that the main purpose of a morning report should be educational.

The practice of listing all admitted cases and reciting a few words about each case and stating where the patients are located should have a very limited time in morning reports. Morning reports should not be just listing of cases without any educational discussions around them. The discussions should be clinically relevant to residents. In addition, the discussions should not be conducted in a threatening environment, where the focus of residents is on the fear of poor performance rather than enjoying the challenge of learning. Patient guidance and respect for residents will yield more positive benefits and the learners will be more effective, more responsible and develop better problem solving skills⁽²⁾.

The most frequent instructional method used during morning report was case-based presentation, followed by discussion.

The most important features of coordinators and physicians attending morning reports are excellent general medical knowledge, an ability to ask effective questions, and good interpersonal skills. The cases for presentation are best selected by residents. It was concluded in one study that residents do an exceptional job of selecting difficult diagnostic cases for discussion at morning report⁽³⁾.
The way of distribution of seats where consultants are in front and residents are in the back row should be discouraged. It is advisable to have all attendees setting in a circle where interactions are stimulated. Presence of food and drinks during morning report tend to enhance interactions as well.

The coordinator should use the board to write pertinent information from presentations. The presentation itself should be concise and it is better to be presented from copied or printed notes to avoid missing information or providing inaccurate information. They should not take more than 5 minutes⁽⁴⁾. The practice of overwhelming the post-call resident(s) with detailed questions exposing their lack of knowledge in an ironic way should be strongly discouraged. This creates a threatening environment and impedes learning. The coordinator may run the morning report in a stepwise approach. After the history is presented, there should be a pause and a question raised as to further relevant information that is needed. A brief discussion is then conducted aimed at improving history-taking skills. Then before proceeding to the physical examination findings, another question is raised by the coordinator about what physical findings based on history presented, should be looked for.

After the presentation of the physical findings, a senior resident is asked to summarize the case and develops a problem list with differential diagnoses and management plan. An open discussion might be conducted now; on whether any modifications should be undertaken in the plan described.

Investigations are presented and another question is raised on the interpretation of these investigations and if the plan will change or not. A senior resident is asked again to discuss the therapeutic interventions that she/he will consider in this case. Finally, the presenter (who should be from the post-call team) is asked to present the rationale of what treatment the patient received. The depth of discussion should be based on the number of residents present from each level.

These types of questions in a stepwise approach are advocated in order to stimulate higher level of mental functions like thinking, analysis and synthesis of data. This is to avoid the exchange of low-level factual information, not optimal for promoting problem-solving skills.

The morning report should include a summary of what was learned, presented by one of the residents. It should also include the formulation of a clinical question with a direct relation to the case presented that needs to be researched in the literature. The result of the research work can be presented briefly the next day. The presence of attending physicians should help residents to create effective and relevant questions. When useful, updates on previous cases discussed in morning reports should be presented. This is to help create an overall understanding of the natural history of certain presentations and build up clinical experience.

Unfortunately lectures remain the most common form of teaching methods used in the medical field.
Lectures can be informative and even inspirational if they are done properly⁽⁵⁾ and used skillfully they permit the dissemination of unpublished or not readily available materials, and allow the instructor to precisely determine the aims, content, organization, pace and direction of presentation. They can be used to arouse interest in subject, complement and clarify text material, can address certain individual learning preferences, and allow for gradual development of complex concepts and theories)⁽⁶⁾.

Lectures were defined by some experts as "a process by which the notes of a teacher become the notes of a student without passing through the minds of either"⁽⁷⁾.
There is documentation in the literature of learners' dissatisfaction with non-challenging lectures. It was shown that student concentration in lectures rose sharply to reach a maximum in 10-15 min, and fell steadily thereafter.

Large group formats tend to encourage passive learning, however what is required to be developed in postgraduate education is active participation in the learning process with residents taking full responsibility for their own education. Lectures should not be regarded as an effective way of teaching skills, changing attitudes, or encouraging higher order thinking. All these are considered essential skills for training doctors⁽⁸⁾.

It was shown that lecture-based and problem-based learning formats in postgraduate education are both effective. However, problem-based programs appeared to be more effective than the lecture-based programs in improving performance⁽⁹⁾.

It is clearly described in depth in the literature that the good teacher can use many different techniques for the sake of effectiveness. The good teacher is more than a lecturer⁽⁷⁾. There are multiple efforts developed by experts in medical education directed to educators to help them maximize learning outcomes from lectures⁽⁶⁾. These guidelines are encouraging the principles of integrating and actively involving learners in the delivery process of lectures.

Program directors and participants in residents' education in our local training programs need to consider newer teaching methodologies and move beyond didactic lectures.

Interacting with learners during the learning interventions is essential for success.. A meta-analysis on continuous medical education (CME) activities concluded that didactic sessions do not appear to be effective in changing physician performance⁽¹⁰⁾. only interactive CME sessions effect professional practice and, on occasion, health care outcomes⁽¹⁰⁾.

The learner will get more benefit from being in direct contact with patient problems and complaints and if an adequate number of patients is available and proper time is given, positive achievements are expected⁽¹¹⁾.

On the other hand outpatient training can be criticized for the minimal time given to instruction and most importantly inadequate feedback from consultant or teacher⁽¹²⁾.

There is a move towards community-based and community-oriented medical education. The in hospital inpatients (both mean the same) represent a tiny proportion of actual numbers of sick people in the community and their problems and management issues are different. The training of future doctors should emphasize what the doctor will face in his/her real practice. Therefore, there has to be greater emphasis on outpatient training for our residents. Unfortunately, the focus of some of our local training programs is to provide medical coverage for their wards without paying attention to the needs of our residents. This is happening at the expense of providing quality training to residents by specifying adequate time in outpatient settings. There are suggested tips published in the literature for programs willing to incorporate more training in outpatient settings, including issues like: making training in the ambulatory setting a priority, and how to teach and evaluate in the examination room⁽¹³⁾.

On the other hand, teaching in outpatient clinics is still less well structured and in its infancy compared to teaching in the hospital settings.

In this regard it is essential to enhance quality of teaching in outpatient settings^{(11, 13)}.

Considering learning as an active process, we suggest that the teacher should act as a facilitator. Many alternative approaches can be used to improve the instructiveness of apprenticeships or clinical clerkships.

One minute preceptor (teacher):-

A one minute preceptor follows a series of ordered steps, that is teaching general principles; help the learner to be aware of the omissions and errors, confirm the case by available diagnostic tools , stimulate reasoning thinking, knowledge and taking into consideration the history, clinical examination etc. toward improving or correcting the way the learner deals with the case described, by Ferenchick et al (1997)

Enhancing independent learning can save time, and benefit both the teacher and the learner as DaRosa etal (1997) mentioned.

This will include the case of the week, which has the benefit of adding more clinical attachment, also the opportunity it provides for the learner to discuss and exchange information and ideas and to provide best feedback.

By this method, critical thinking will be encouraged as described by Spencer (2003). Also the implementation of a mentor and conference system will enhance the educational process by providing feedback for students.

Clinical problem solving on the other hand will help the learner be better and more efficient in diagnosing cases in the proper way (illness script development). Many programs have tried to rely on a PBL curriculum and approach, but have not fully achieved the criteria outlined in Barrows taxonomy of PBL, despite the fact that these programs wer innovative in many aspects. (Foley et al 1997).

In medical education, problem based learning may help the student in producing tentative explanations for the phenomena under study and the task also will be to discuss these problems and explain them as suggested by Geoffrey et al (1992).

Journal clubs are now considered an essential component of any training programs. They are included in almost all training programs in all specialties. There is no ideal format for journal clubs to be conducted, but the most common format as outlined in the literature was for a club that is conducted once per month, where 2-3 original research articles are discussed, in the presence of knowledgeable leaders. It may be helpful for a biostatician to be present as well⁽¹⁴⁾.

Articles should be selected by residents and they should be related to cases and problems originating from their own practice. They should be distributed in advance to all participants in the club, so everybody will have a chance to go over the studies. It is less useful practice for journal clubs to be conducted where most of the participants receive the papers to be studied only at the time the club meets. Presentations should be short and concise. Residents critically appraising the studies may use checklists for evaluating different studies on diagnosis or on therapy. The publication of the Users' Guides to the Medical Literature series (now published in a book⁽¹⁵⁾ has fueled the implementation of journal clubs devoted to evidence-based medicine in many postgraduate training programs.

The goal is to avoid boredom from listening and following a lengthy presentation. It also leaves time for discussions on how to apply the evidence in the practice. Here is where the presence of experts is really needed.

There are certain characteristic for journal clubs with high attendance and longevity, these are: mandatory attendance, availability of food, and perceived importance by the program director.(14)

There is good evidence in the literature that addresses the learning achieved in journal clubs. The two most important objectives achieved in one study among community medicine residents with strict criteria for conducting a weekly journal club were acquisition of critical appraisal skills and keeping up with current literature⁽¹⁵⁾. In a systematic review of all studies on journal clubs to evaluate their effectiveness, there was a statistically significant improvement in epidemiology and biostatistics knowledge, change in reading habits, and increase in the use of medical literature in practice.

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