Teaching and Learning

Prévia do material em texto

Teaching and Learning
Table of Contents
 Preface
 Introduction
 Why competency based learning and education
 Compentence and performance
 CoBaTriCE competencies for ICM training
 Competency domains for ICM
 How do professionals learn in practice
 Learning in practice
 Learning by immersion
 Learning by doing
 Learning from role models
 Learning by social interaction
 The hidden curriculum, socialisation, and individual differences
 Conclusion
 Stimulating professional learning in practice
 Striving for the best possible medical practice and organizing trainees
participation
 Conscious role modelling
 Assigning tasks relevant for learning
 Planning teaching moments and strategies in the clinical workplace
 Providing feedback
 Utilisation of clinical practice
 Stimulating professional learning outside clinical practice
 Lecturing
 Small group teaching
 Practical skills teaching
Simulation based training
 Assessing clinical competence
 Why do you assess clinical competence?
 When do you assess clinical competence?
 What do you assess?
 Who is assessing?
 What ways of assessment do you use?
 Quality of assessment
 Dealing with difficult situations
 How to design learning on and off the job
 Quality improvement
 Faculty development
 Evaluation of a programme (or component)
https://collaboration.esicm.org/Teaching+and+Learning%3A+Preface?page_ref_id=1173
https://collaboration.esicm.org/Teaching+and+Learning%3A+Introduction?page_ref_id=111
https://collaboration.esicm.org/Teaching+and+Learning%3A+Why+competency+based+learning+and+education?page_ref_id=112
https://collaboration.esicm.org/Teaching+and+Learning%3A+Why+competency+based+learning+and+education+-+Compentence+and+performance?page_ref_id=403
https://collaboration.esicm.org/Teaching+and+Learning%3A+Why+competency+based+learning+and+education+-+CoBaTriCE+competencies+for+ICM+training?page_ref_id=404
https://collaboration.esicm.org/Teaching+and+Learning%3A+Why+competency+based+learning+and+education+-+Competency+domains+for+ICM?page_ref_id=405
https://collaboration.esicm.org/Teaching+and+Learning%3A+How+do+professionals+learn+in+practice?page_ref_id=113
https://collaboration.esicm.org/Teaching+and+Learning%3A+How+do+professionals+learn+in+practice+-+Learning+in+practice?page_ref_id=406
https://collaboration.esicm.org/Teaching+and+Learning%3A+How+do+professionals+learn+in+practice+-+Learning+by+immersion?page_ref_id=407
https://collaboration.esicm.org/Teaching+and+Learning%3A+How+do+professionals+learn+in+practice+-+Learning+by+doing?page_ref_id=408
https://collaboration.esicm.org/Teaching+and+Learning%3A+How+do+professionals+learn+in+practice+-+Learning+from+role+models?page_ref_id=409
https://collaboration.esicm.org/Teaching+and+Learning%3A+How+do+professionals+learn+in+practice+-+Learning+by+social+interaction?page_ref_id=410
https://collaboration.esicm.org/Teaching+and+Learning%3A+How+do+professionals+learn+in+practice+-++The+hidden+curriculum%2C+socialisation%2C+and+individual+differences?page_ref_id=411
https://collaboration.esicm.org/Teaching+and+Learning%3A+How+do+professionals+learn+in+practice+-+Conclusion?page_ref_id=412
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+in+practice?page_ref_id=114
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+in+practice+-+Striving+for+the+best+possible+medical+practice+and+organizing+trainees+participation?page_ref_id=414
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+in+practice+-+Conscious+role+modelling?page_ref_id=415
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+in+practice+-+Assigning+tasks+relevant+for+learning?page_ref_id=416
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+in+practice+-++Planning+teaching+moments+and+strategies+in+the+clinical+workplace?page_ref_id=417
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+in+practice+-++Providing+feedback?page_ref_id=418
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+in+practice+-++Utilisation+of+clinical+practice?page_ref_id=419
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+outside+clinical+practice?page_ref_id=115
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+outside+clinical+practice+-+Lecturing?page_ref_id=420
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+outside+clinical+practice+-+Small+group+teaching?page_ref_id=421
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+outside+clinical+practice+-+Practical+skills+teaching?page_ref_id=422
https://collaboration.esicm.org/Teaching+and+Learning%3A+Stimulating+professional+learning+outside+clinical+practice+-Simulation+based+training?page_ref_id=423
https://collaboration.esicm.org/Teaching+and+Learning%3A+Assessing+clinical+competence?page_ref_id=116
https://collaboration.esicm.org/Teaching+and+Learning%3A+Assessing+clinical+competence+-+Why+do+you+assess+clinical+competence%3F?page_ref_id=424
https://collaboration.esicm.org/Teaching+and+Learning%3A+Assessing+clinical+competence+-+When+do+you+assess+clinical+competence%3F?page_ref_id=425
https://collaboration.esicm.org/Teaching+and+Learning%3A+Assessing+clinical+competence+-+What+do+you+assess%3F?page_ref_id=426
https://collaboration.esicm.org/Teaching+and+Learning%3A+Assessing+clinical+competence+-+Who+is+assessing%3F?page_ref_id=427
https://collaboration.esicm.org/Teaching+and+Learning%3A+Assessing+clinical+competence+-+What+ways+of+assessment+do+you+use%3F?page_ref_id=428
https://collaboration.esicm.org/Teaching+and+Learning%3A+Assessing+clinical+competence+-+Quality+of+assessment?page_ref_id=429
https://collaboration.esicm.org/Teaching+and+Learning%3A+Assessing+clinical+competence+-+Dealing+with+difficult+situations?page_ref_id=430
https://collaboration.esicm.org/Teaching+and+Learning%3A+How+to+design+learning+on+and+off+the+job?page_ref_id=117
https://collaboration.esicm.org/Teaching+and+Learning%3A++Quality+improvement?page_ref_id=118
https://collaboration.esicm.org/Teaching+and+Learning%3A+QUALITY+IMPROVEMENT+-++Faculty+development?page_ref_id=431
https://collaboration.esicm.org/Teaching+and+Learning%3A+QUALITY+IMPROVEMENT+-+Evaluation+of+a+programme+%28or+component%29?page_ref_id=432
 Conclusion
 Self Assessment
 Type A Questions
 Type K Questions
 Patient Challenges
 
https://collaboration.esicm.org/Teaching+and+Learning%3A+QUALITY+IMPROVEMENT+-+Conclusion?page_ref_id=433
https://collaboration.esicm.org/Teaching+and+Learning%3A+Self+Assessment?page_ref_id=1176
https://collaboration.esicm.org/Teaching+and+Learning%3A+Self+Assessment+-+Type+A+Questions?page_ref_id=1177
https://collaboration.esicm.org/Teaching+and+Learning%3A+Self+Assessment+-+Type+K+Questions?page_ref_id=1178
https://collaboration.esicm.org/Teaching+and+Learning%3A+Patient+Challenges?page_ref_id=1174
Teaching and Learning
 
Current Status 2017
Awaiting major review 
Latest Update
First Edition
ELearning Committee
Chair
Kobus Preller Dr., Consultant, John Farman ICU, Cambridge University Hospitals
NHS Foundation Trust, Cambridge, UK
Deputy
Mo Al-Haddad MD, Consultant in Anaesthesia and Critical Care, Queen Elizabeth
University Hospital; Honorary Clinical Associate Professor University of Glasgow,
Glasgow UK
Project Manager
Estelle Pasquier , European Society of Intensive Care Medicine
First Edition 2005
Module Authors
Lia Fluit , Quality and Development of Medical Education Department University
Medical Centre Nijmegen The Netherlands
Sanneke Bolhuis , Quality and Development of Medical Education Department
University Medical Centre Nijmegen The Netherlands
Medical Illustrator
Kathleen Brown , Triwords Limited, Tayport, UK
Update InfoLearning Objectives
After studying this module on Teaching and learning, you should be able to:
https://collaboration.esicm.org/tracker13
Understand how professionals learn
Use effective methods for teaching in the clinical setting and other venues
Choose appropriate methods to assess clinical competence
Discuss components of a curriculum plan
Describe the evaluation process for learning experiences
 
eModule Information
COBATrICe competencies covered in this module:
Faculty Disclosures: 
The authors of this module have not reported any disclosures.
Duration: 7 hours
Copyright©2017. European Society of Intensive Care Medicine. All rights reserved. 
ISBN 13 978-92-9505-193-5 - Legal deposit D/2005/10.772/40
1. Introduction
In order to deliver high qualitygood healthcare young physicians should be prepared
well for contemporary and future carel. Medical education and training programmes
should motivate practitioners to learn and develop continually during their professional
life. Throughout this process of continous professional development leading to
professional identity formation, medical specialists in their role as teachers play a
pivotal role in curriculum planning and evaluation, by facilitating the learning process,
role modelling, providing feedback to trainees, and assessing trainees.
However, medical teaching is a daily activity that has to compete with other priorities
including clinical commitments, management and research.
Quote: It goes without saying that no man can teach successfully who is not at the
same time a student.' Sir William Osler
 References
Killminster S, Cottrell D, Grant J, Jolly B. AMEE guide No.27. Effective
educational and clinical supervision. Med teach. 2007;29(1):2-19.''
Furthermore, allthough many physicians are involved in training and most regard
teaching as an intrinsic part of their occupation, few have had the opportunity to
formally train and develop their teaching skills. The same may be true for residents,
nurses and other healthcare staff in the ICU. Although many teachers may intuitively
educate their learners well, it is nevertheless relevant to take notice of new insights
into learning and teaching. This will broaden one's teaching and learning
competencies needed in the clinical setting in general, and in intensive care medicine
specifically.
 References
Prideaux D, Alexander H, Bower A et al. Clinical teaching: maintaiing an
educational role for doctors in the new health care environment. Med Educ
2000;34(10):820-6.
Launer J. Supervision, mentoring and coaching. In: Understanding Medical
education. Evidence, theory and practice, chapter 8, p111-122. Swanick T
(ed). 2nd edition, 2014.
http://www.cobatrice.org/
Finally, it has become impossible to remain an adequately performing professional in
medicine without lifelong professional learning. Medical specialists are teaching,
supervising, guiding and assessing trainees, but they also need to be learners
themselves. Trainees are not only learners, but also teach and guide others in
learning. Thus, teaching and learning has become an integral part of all medical
professions, regardless of level and phase of training.
http://www.cobatrice.org/
2. Why competency based learning and education?
 
2. 1. Compentence and performance
With the launch of Tomorrow's Doctors in the United Kingdom in 1993 (General
Medical Council 1993, 2009), the framework guiding medical education began to shift
from a time-based framework to a competency-based model.
 References
Iobst et al. Competency-based medical education in postgraduate medical
education. Med Teach. 2010;32(8):651-6
Frank JR, Danoff D. The CanMEDs initiative: implementing an outcomes-
based framework of physician competencies. Med teach. 2007;29(7):642-7
Much education and training used to focus on the acquisition of knowledge and skills,
assuming that these would then be more or less automatically ‘applied’ in practice.
However, competent performance in (any) practice does not naturally follow from
having the necessary knowledge and skills. Competent performance requires another
learning process in which the specific context, with all the variability of practice, is
important. In this context one needs to decide what to do, how and when, depending
on the specifics of the moment. In competent performance in clinical practice
knowledge, skills, and attititudes are used in an integrated way.
Professional postgraduate education and training, such as a training program for ICM
specialists, needs to focus on what the trainee does in practice, on performance. The
outcome of the program should be that trainees have become competent specialists
who are able to perform their tasks adequately and independendly. Thus the separate
assessment of knowledge and skills only is not enough. Progress in a competency-
based training programme is defined by the competencies achieved, as evidenced by
the assessment of performance. Competencies as such are not directly visible or
measurable, but are demonstrated when performing tasks.
 Note
Competencies can be defined as the ability to adequately carry out a
professional activity in a specific authentic context.
 References
Rethans JJ et al. The relationship between competence and performance:
implications for assessing practice performance. Med Educ 2002;36:901-
909
Leung W. Competency based medical training: review. BMJ 2002;325:693-6
 
2. 2. CoBaTriCE competencies for ICM training
CoBaTrICE is an international collaboration managed by the European Society of
Intensive Care Medicine’s division of Professional Development, and endorsed by the
European Board of Intensive Care Medicine and the national training organisations of
28 European countries. CoBaTrICE uses survey and consensus techniques, combined
with expert opinion and external consultation, to develop the component parts of an
internationally acceptable competency-based training programme for intensive care
medicine for Europe and collaborates on this subject with representatives from other
world regions.
In 2006 the CoBaTrICE programme published competencies for an international
training programme in ICM. This programme has now been adopted by 15 European
Union (EU) member states, with another 12 countries planning to adopt them.
 References
www.cobatrice.org
Barret H & Bion J. An international survey of training in adult intensive care
medicine. Intesice Care Med 2005;31:553-561
Barret H & Bion J. Developmetn of core competencies for an international
training programme in intensive care medicine. Intesive care med
2006;32:1371-1383
Bion J. Models for Intensive Care Training. American Journal of Respiratory
and Critical care Medicine. 2014;3:256-262
2. 3. Competency domains for ICM
The CoBaTrICE competencies define the minimum standard of knowledge, skills and
attitudes required for a doctor to be recognized as a specialist in intensive care
medicine (ICM). They have been developed with the intention of being internationally
applicable but at the same time able to accommodate national practices and local
constraints. They comprise 102 competence statements grouped into 12 domains.
These domains are:
https://collaboration.esicm.org/www.cobatrice.org
1. Resuscitation and initial management of the acutely ill patient
2. Diagnosis: assessment, investigation, monitoring, and data interpretation
3. Disease management
4. Therapeutic interventions/organ system support in single or multiple organ
failure
5. Practical procedures
6. Peri-operative care
7. Comfort and recovery
8. End-of-life care
9. Paediatric care
10. Transport
11. Patient safety and systems management
12. Professionalism
Level of expertise and supervision 
CoBaTrICE identifies three levels of expertise on which competencies may be
acquired. Unless otherwise indicated, in the last phase of specialist training,
competencies should be performed at a level of independent practice (this may include
the capacity to supervise others and/or leading a team) with indirectsupervision
provided by a trainer. Where competencies refer to being performed 'under
supervision' this implies direct supervision. The CoBaTrICE competencies thus
indicate the minimum standard, and in many instances a higher level of expertise (i.e.
a lower level of supervision) is both possible and appropriate. Trainees thus gradually
become independent of their supervisor.
Level of expertice
Further development of the programme will be a dynamic and evolutionary process
taking into account the evolving roles of the intensivist and advances in medical
education. Recent evidence for example underscored the value of more generic, not
specifically medical competencies. Examples are communication and teamwork,
keeping a professional distance and setting boundaries, respect, leadership,
organisation and management skills.
Reference:
Reader TW, Flin R, Mearns K, Cuthbertson BH (2009) Developing a team
performance framework for the intensive care unit. Crit Care Med 37:1787–1793
https://collaboration.esicm.org/dl101?display
A competency based curriculum places new demands in clinical teachers and
residents, where learning is acollaborative process in which responsibility is
increasingly shared between teacher and learner. Clinical teachers should understand
the principles of competnecy based learning, know how learning in the clinical pracitce
takes place, and how they can help to enhance learning.
3. How do professionals learn in practice?
From the perspective of education and training, we tend to think of learning primarily
as an outcome of education and training. However, people learn all the time, and they
also do so while working. This spontaneous learning is an inevitable side-effect of
working. Spontaneous learning 'on the job' is implicit, unplanned, happening more or
less unconsciously, and is a result of day to day activities (Fluit, 2013).
Spontaneous learning (also called experiential learning) may or may not result in
better performance and a higher level of expertise. Therefore professionals need to
monitor their spontaneous learning by conscious reflection and planned action,
including 'off the job' learning in workshops, courses, and other types of continuing
professional development. This type of life long learning is what society expects from
professionals. Thus, trainees should also acquire the habit of life long professional
learning.
Most of a trainee's learning takes place in the clinical setting ('on the job'), with only a
small part of learning ‘off the job'. Obviously learning on the job needs attention in
attempts to transform spontaneous workbased learning into professional learning
which is workbased but adds intentional and reflective learning.
3. 1. Learning in practice
Spontaneous learning in practice has the following characteristics:
Spontaneous learning is not organised, but happens all the time – also when no
one is paying attention.
Spontaneous learning occurs as a result of participation in any social context,
such as a professional practice. Participation provides opportunities to learn by
immersion, by one’s own activities, by role models, and by other social interaction.
Much spontaneous learning goes on implicitly, without conscious attention, and on
a very regular basis.
The learning effects become deeply ingrained. Behaviour and performance
become habit and part of routine practice. Learning effects are often very
valuable, but as they pass unvalued and unaddressed, they may also be
suboptimal or even wrong.
Spontaneous learning may result from intentional activity, but in that case
intentions are usually not focused on learning, but on activities (to getting a job
done, to help a patient, to prove oneself, to survival).
Spontaneous learning includes learning by immersion, learning by doing, model (or
observational) learning and learning through social interaction, as discussed below. Of
course these learning processes are often intermingled.
3. 2. Learning by immersion
Trainees who start working in the intensive care unit(ICU) will not only learn how to
solve clinical problems, but will also learn whatkind of organisation it is. What are the
implicit rules, what is and is notdone, how do the staff behave, what kind of behaviour
is expected fromtrainees, and how do staff interact with one another, newcomers, and
withpatients? This is not discussed butexperienced by the newcomer, who is learning
the implicit rules by being immersed uin the social context.Trainees learn by observing
and adapting to the habits of the 'model' practice.Trainees acquire the habits of the
department without explanation and oftenwithout much explicit thought. <o:p>
Think: What do you remember of your 'first time' as an intern, resident, or new start in
a hospital department? What happened to you? What were your positive and negative
impressions?
3. 3. Learning by doing
Trainees learn from their own direct experience in performing tasks, and it is very
important that they have many and varied opportunities to learn by doing. Learning by
doing is the only way to build adequate routines and developing expertise. 
Although trainees may learn much from their own problem solving, some of this
learning may be rather by trial and error, hopefully without adverse consequences. The
tasks are not just the concern of trainees, but part of the activities in the ICU.
Supervising trainees and providing feedback based on observation are important both
for patients and for trainees learning.
3. 4. Learning from role models
Trainees will have many opportunities to observe how more experienced colleagues
behave and how they perform their tasks. They learn from these role models. This is
called model learning or observational learning. Who serves as a model depends on
who a trainee considers competent, attractive, powerful, and trustworthy. Models can
be positive or negative. Trainees may copy less desirable behaviour from a negative
model. It is very difficult to learn alternative, better behaviour in the absence of a good
model. When suboptimal behaviour is accepted as the norm, newcomers will adapt to
the norm most of the time. Participating in different clinical contexts provides more
opportunities for reflection because of the differences in models that may be observed.
All participants in the ICU need to realize that they are a role model all the time, not
only when they think of showing something and giving an explanation.
Quote: 'Junior doctors do not simply learn from consultants, but learn to be like the
consultants they admire and respect' Alan Bleakley (2002)''
 Think
Do you still remember the physician(s) you admired and in who’s steps you
planned to follow? Do you remember physician(s) you disapproved of? How did
you learn from these positive and negative role models?''
3. 5. Learning by social interaction
What it means to be a physician and how to become one, becomes clearer to trainee
physicians while participating in medical practice. Trainees learn from experienced
physicians but also from social interaction with and between patients, nurses,
administrative and paramedical professional staff, ambulance personnel etc. The daily
interaction teaches the trainee what it is to be a physician in that location, and the
respective positions of patients and other participants. Social interaction comprises the
way we go about our daily activities and each other, and includes our habitual way of
talking, called discours. Discours refers to questions like: how do we talk about each
other and our job, what do we (not) talk about, who is talking with whom and about
whom or about what (not)?
 Note
Every participant in professional practice is learning spontaneously; it happens
all the time, whether desired or not, and whether or not you are conscious of it.
The results from spontaneous learning in practice are quite marked, and have a
direct and pervasive effect on behaviour and performance in practice.
3. 6. The hidden curriculum, socialisation, and
individual differencesThe concept of spontaneous learning is related to the concepts 'hidden curriculum' and
'socialisation'. In the educational literature 'hidden curriculum' refers to the effects of
spontaneous learning, that are due to characteristics of the curriculum, but consist of
not overtly intended effects. An example: history lessons may 'teach' that the common
people are of no importance. A hidden curriculum is what the learning environment
'teaches' while nobody pays explicit attention. The hidden curriculum in education and
training in the clinical setting is in the implicit rules of clinical practice, in daily
conversations, in implicit role modellig and the way clinical tasks are handled.
The word socialisation is often used to refer to the spontaneous learning by which
newcomers learn to adapt to a new environment. Spontaneous learning is obviously
influenced by the social context, and the older literature took socialisation as a one-
way process. However, socialisation is also influenced by the individual's
characteristics.
What trainees learn spontaneously from experience in your department also depends
on what they bring to the situation: their prior knowledge of medical practice, self-
awareness, preferred ways of learning, expectations, hopes and fears. Trainees learn
from their own perspective, or frame of reference. Thus, socialisation is mediated by
the individual frame of reference.
 References
Bleakley A. Broadening conceptions of learning in medical education: the
message from teamworking. Med Educ 2006; 40(2): 150-157. PMID
16451243
Question: Trainees may differ in several ways. What differences do you think are
important in their learning? What is the importance?
3. 7. Conclusion
Spontaneous learning tends to be overlooked but is very powerful. We need to start
recognizing spontaneous learning and its effects in order to improve learning in
practice and practice itself. The advantages and disadvantages of spontaneous
learning are listed in the table below. In the next section we will discuss how to profit
from the advantages while countering the disadvantages.
 
https://collaboration.esicm.org/dl102?display
4. Stimulating professional learning in practice
The recognition of the power and nature of spontaneous learning is a starting point for
stimulating learning in practice in a more conscious and intentional way. The implicit
effects of spontaneous learning need to become subject to explicit questioning,
discussion and reflection in order to improve one's clinical competence and
performance. Are we matching words with deeds? Are we doing the right things? Can
we improve? What are we overlooking?
You may stimulate trainees' professional learning in practice by:
Clearly striving for the best medical practice for patients, since participating in
such practice provides good opportunities for professional spontaneous learning
Organizing trainees’ participation as a new colleague
Providing good role models, who are not only visible but also explain the rationale
behind what can be observed, and who help novices to notice what there is to
observe.
In case of negative role modelling, turn this learning experience into a positive one
by correcting explicitly.
Assigning tasks that are challenging enough to learn from (but safe enough), so
that the novice may progress from relatively simple and partial tasks to full
responsibility
Planning teaching moments and strategies in practice
Interaction: asking questions to understand trainees’ thinking (and problems) and
to assess trainees' present levels of competence in all relevant domains.
Giving feedback based on observation, tailored to the individual trainee
Being clear about assessment criteria, and about when you use these criteria to
stimulate learning (formative use) or for final judgments (summative use).
Assessment will be discussed in task 5.
 
4. 1. Striving for the best possible medical practice and organizing
trainees participation
First of all, you need to think about whether your department and hospital offers the
optimal medical practice, for patients as well as for trainees and other participants.
What kind of medical practice is offered as a learning environment? What is the
learning potential of this practice? Are trainees immersed in the best practice
possible? What do newcomers experience? Do trainees have the best opportunities
for observational learning? What do trainees observe? What behavior and
performance do role models show? Do trainees have many opportunities to learn by
doing and to build sound routines? What kind of social interaction is taking place? In
what kind of everyday conversations are your trainees expected to participate?
 Note
The best clinical practice is also the best environment in which to learn clinical
practice.
Analysing your department may be difficult because of blind spots we all have for the
things we are used to. Even here we tend visualize and conceptualize matters from
our own perspective, each of us having our own individual glasses, providing a most
often unconscious, but limited ‘ situational awareness’.
 Note
Why not invite trainees to help you? As they enter with a novice perspective,
you may ask them to observe the way things go, stimulate them to ask
questions, and if possible for them to offer alternative ways. This would also
convey the message to trainees that they are not only welcome but also taken
very seriously as professional colleagues.
Trainees learn from participating in the clinical setting. Traineeship involves moving
from peripheral to full participation in practice. When trainees start they are relative
outsiders who are not yet fully part of what is going on. They need to learn what it is to
be a responsible physician in this particular setting. The task of the trainer is therefore
to assist this process, by introducing trainees as incoming colleagues, by consious role
modelling, by assigning meaningful tasks with increasing responsibility, and by
providing constructive feedback.
 Note
Imagine how your clinical practice looks to newcomers, and think of what and
who trainees need to know, and how do they get acquainted as soon as
possible? Who and what can be of help? You may want to write an introductory
manual for new trainees.
 References
Irby D, Bowen J. Time-efficient strategies for learning and performance. The
Clinical Teacher 2004; 1(1): 23-28
Bandiera G, Lee S, Tiberius R. Creating effective learning in today’s
emergenc departments: how accomplished teachers get it done. Annals od
Energency Medicine. 2005;45(3):253-61
Question: When trainees go to different hospitals during their training, they may learn
more consciously and reflectively from their experiences in these different hospitals.
Explain why training in different places could counter possible disadvantages of only
spontaneous learning, and stimulate more reflective learning?
4. 2. Conscious role modelling
Whether you want it or not, trainees learn much from you as a role model. Do not think
your role modelling only starts when you think of demonstrating and explaining
something to your trainee. You are role modelling all the time in every thing you do, but
also in what you do not. Conscious role modelling is an important method for helping
trainees acquire the knowledge and skills, as well as the values, attitudes and
behaviour associated with professionalism, humanitarianism and ethical practice.
Conscious role modelling requires that:
trainees can observe your professional behaviour and clinical performance
you explain what your trainee can not observe: why you do what you do and the
way you do it
you help novices to see what there is to see. Newcomers may overlook what is
obvious to you. What we see is usually related to what we know!
 Note
You are a role model all the time, and not only when you think about it!
Characteristics of positive role models include personal qualities (such as compassion,
a sense of humour, integrity), clinical skills (such as proficiencyas a diagnostician and
effective interaction with patients and their relatives), and teaching skills (such as
ability to explain difficult subjects and a non-threatening style). Experienced physicians
who have been identified as positive role models by trainees are those who spend
more time on teaching, participate more often in faculty development programmes,
emphasise interactions between patients and physicians and the psychosocial aspects
of medicine, give more in-depth specific feedback to learners and last but not least,
they enjoy teaching.
 References
Thurgur L, Bandiera G, Lee S, Tiberius R. What do emergency medicine
learners want from their teachers? A multicenter focus group analysis. Acad
Emerg Med 2005; 12(9): 856-861. PMID 16141020
Bleakley A. Pre-registration house officers and ward-based learning: a 'new
apprenticeship' model. Med Educ 2002; 36(1): 9-15. PMID 11849519
Cruess et al. Role modelling- making the most of a powerful teaching
strategy. BMJ 2008;336:718-21
Question: Give examples on how to make role modelling explicit to your trainees. 
Question: Nobody is perfect all the time! When you notice you behaved not as you
would consider optimal, what would be the best thing to do with the trainee who
observed you?
4. 3. Assigning tasks relevant for learning
Learning by doing is very important. Therefore it is crucial to decide what trainees are
assigned to do. Before assigning tasks to trainees you need to know their level of
competency. Even if known, it is advisable to discuss with your trainees what you want
them to do and why, so that they may give their views about what they need to learn.
When you assign tasks which are too difficult, you are threatening the safety – not only
of your patients, but also the necessary safety for trainees' learning. When tasks are
too difficult, trainees may learn to take risks which are too great, or they may get
discouraged and start thinking about another career choice. When tasks are too easy,
trainees stop learning. The golden rule is 'balance between safety and challenge'. Of
course, tasks still need to be performed, but as a clinical teacher you need to make
sure that trainees have sufficient tasks to learn from. This also implies that in the
course of time you go from assigning easier (and/or partial) assignments to more
complex (and complete) assignments for your trainees.
A note on the concept 'experiential learning' 
Learning by doing is also referred to as experiential learning. However, the concept of
experiential learning is often used with the suggestion of a learning cycle moving from
experience to concept formation, evaluation, and testing hypotheses in intentional
experimentation. However, sponteneous experiential learning does not necessarily, let
alone automatically, include conscious concept formation, or testing of these concepts
in subsequent actions. Experiential learning does not automatically happen that way!
Explicit efforts are needed to progress from experiential learning to reflective learning.
4. 4. Planning teaching moments and strategies in the
clinical workplace
The first and most important point in planning is that you recognise opportunities for
teaching in practice. Ask yourself which moments and events are most valuable for
your trainees to learn from, and plan to use them. To give you some ideas, please see
the following reference.
 References
Demonstrating enthusiasm for teaching
Knowing trainees / participants by name
Asking for personal goals
Encouraging interaction and discussion
Showing respect to trainees and others.
Planning helps to sharpen expectations, clarify roles and responsibilities, allocate time
for instruction and feedback, and focus learners on important priorities and tasks.
Excellent teachers have a repertoire of teaching strategies to involve trainees actively
and meet learners' needs. They select the most appropriate method for the learner.
Some examples are given below, from the more general advice to 'create a positive
learning climate' to the more specific 'diagnostic questioning'. (The next section
discusses how to use clinical practice for teaching.)
A safe learning environment is extremely important. In a hostile, overly competitive
environment it is impossible to stimulate professional learning in practice. Learners are
more likely to ask questions, pursue learning issues and contribute to the group's
learning if a safe and respectful learning environment is created. This can be achieved
by:
When novice learners are left to their own devices, they often spend too much time
with the patient and don't elicit the important information required for patient care.
Prepare learners for an upcoming patient, for instance by asking in advance what the
most important complications are or what information they need to differentiate
competing diagnoses. More advanced learners can be invited to discuss cases with
the senior staff.
Question: Why would it be important to explain in advance to novice learners what
they can expect to see, for instance during rounds or on the ward?
Novice learners should be assigned to evaluate patients with more straightforward,
typical problems. Advanced learners should be challenged with more complicated
cases. Stimulate trainees to learn more about the diagnosed disease(s), such as
pathophysiology and aetiology. A good way to achieve deeper understanding is to ask
them to prepare a short presentation for the following day or week. In this way you can
also check their understanding.
Use 'diagnostic questions' to stimulate active learning 
Questioning is a key strategy for both effective patient care and teaching. As a
physician you use questioning every day with your patients in history taking. With your
patients you want to learn what is bothering them, what is going well, what they want
to know about their condition, and you want to check their understanding of the
information you gave them. You can also use these skills when teaching trainees.
As an expert you may tend to ask long, complex questions. Try to realise what the
underlying questions are. For example, you want to ask your trainees which of several
patients they would treat first. This implies underlying questions about each patient
(What do you see? What does it indicate? What else do you need to know and why?
How do you find out? Is it life threatening?) and necessitates a comparison of the
answers to decide which patient needs treatment first.
With appropriate questioning you find out what your trainees do (not) know sufficiently
well, what hinders their professional development, and what they think of your
teaching. By asking questions you can trigger reasoning, problem solving, and other
higher cognitive skills. Moreover asking questions helps trainees to realize what they
already know and what they still need to learn. An open way of questioning stimulates
learning.
Question: When asking questions, it can be helpful to have different purposes and
levels of questions in mind. What purposes and levels of questions can you
distinguish? Give examples.
Read more about questioning and listening skills in the following reference and in the
ESICM module on Communication skills
 References
!Reference List Missing
4. 5. Providing feedback
To guide the learning process it is essential that trainees receive feedback. The
purpose of feedback is to inform them about what is good in their professional
behaviour and what needs improvement, why and how. In order to be able to provide
feedback it is necessary for the teacher to know about a trainee's performance. This
may sometimes be based on what you hear from others. However, as a responsible
teacher you also need to create opportunities to observe trainees yourself. Direct
observation provides you with the opportunity of giving immediate feedback in
conjunction with concrete suggestions on how to improve. Next, trainees need to get
tasks that imply opportunities for improvement. Finally, the outcomes should be re-
assessed.As a clinical teacher you should be aware of your role modelling, since
feedback is only useful if considered credible by the trainee. 
Also helpful is to take individual differences into account. Some trainees will easily
accept and actively seek feedback. Others should be encouraged in to actively sollicit
feedback, and need more attention in order to really learn from your feedback.
 References
Watling et al. Rules of Engagement: Resindets’ Perceptions of the In-
Training Evaluation Process. Academic Medicine 2008;83(10):s97-s100
Hewson M & Little M. Giving Feedback in Medical Education. J Gen Intern
Med 1998;13:111-116
 Note
 
Anybody may provide feedback (subconsciously), just by their reactions to
trainees. For instance, nurses, physiotherapists, paramedics and patients give
informal feedback, verbal and non-verbal (e.g. body language). In giving your
trainees educational feedback you may want to think about the informal
feedback that they have already received in practice.
The feedback given should meet generally accepted feedback criteria. When providing
feedback, keep the following in mind:
It is about specific, observed performance (and does not include statements about
the person, unchecked assumptions, or vague statements)
It informs about which performance is good (reinforcement, so that this behaviour
will be maintained)
It informs which specific performance shows weaknesses, mistakes, omissions,
including why, and what is the desirable behaviour
It is individual – adapted to the competency level and to the personal
characteristics of your trainees. For example, you may want to encourage trainees
who are doing fine but feeling insecure, and you may want to be more strict with
trainees who overestimate their competency
Invite trainees to self-assess (an important professional competency). Feedback
should be provided immediately after the observation.
Feedback should be accompanied by concrete learning goals and plans for follow-
up.
It is not really easy to provide useful feedback for learning! It may be useful to follow
workshops on giving feedback.
Tip: Tell your trainees what they need to know
 References
Step 1: Ask the trainees what was good in their professional behaviour.
Step 2: Provide your feedback.
Step 3: Ask the trainees what could be improved concerning their
professional behaviour.
Step 4: Provide your feedback.
Step 5: Let the trainees think of alternative behaviours, ask for a summary
and what they will do in a subsequent situation. In that way you can check if
your trainees did understand the message.
When delivering feedback to your trainees or students, the following structure can be
helpful in making the feedback meaningful, recognisable and by creating a safe
environment.
 Important
Positive feedback is easily confused with only saying good things about a
trainee such as 'you did well and you were nice to that patient'. But feedback
should focus on the trainee's specific actions and what you observed.
Examples: 'when the patient said he was afraid he was going to die you stopped
your examination and asked him where that fear came from. That made me
conclude you really listened to the patient'. Or 'when the family was very upset
and agitated, you stayed very calm, you spoke very calmly and clearly and told
them you respected their feelings. At that point the family relaxed a little'.
 References
Brown N & Cooke L. Giving Feedback to psychiatric trainees. Advances in
psychiatric treatment 2009; 15:123-128.
Swanwick T. Informal learning in postgraduate medical education: from
cognitivism to 'culturism'. Med Educ 2005; 39(8): 859-865. PMID 16048629
Eraut M. Deconstructing apprenticeship learning: what factors may affect its
quality? Oxford Studies in Comparative Education 2004; 13(1): 45-57.
Chapter 2.
 Note
 
Use the five steps described above to deliver feedback to your trainees or
colleagues. Analyse how the method works: can you say what has to be said?
Do trainees accept the feedback? Do they improve after the feedback session?
What do trainees think about this way of delivering feedback? (A good way to
analyse a feedback session is by videotaping it and then watching it, alone or
with colleagues or peers).
 Note
When you know the trainees you are aware what kind of learners they are, you
can adapt feedback accordingly. Are they good scientists, but forget to
communicate what they are doing? Provide feedback on both aspects and
explain why it is important to share. Are they very friendly and communicative,
but sometimes neglectful? Provide feedback on both aspects, and stress the
danger of being neglectful. Are they lacking self-confidence? Focus on positive
feedback (things they do well) and provide reassurance.
State expectations clearly 
At the beginning of each rotation or clinic, it is important to communicate clearly the
expectations. Introduce people to each other, formulate learning goals, ask trainees to
formulate personal goals and clarify responsibilities and expectations of both the
learner and the teacher. You might plan which patients you want your trainees to
discuss and ask them to prepare accordingly. And/or you think in advance which
questions you will ask them and what special points to explain.
4. 6. Utilisation of clinical practice

Good clinical practice is at the heart of good clinical teaching! 
--Prideaux et al (2000)
 
4. 6. 1. Teaching at the bedside
Bedside teaching includes any teaching done in the presence of the patient,
regardless of the setting. Certain situations require bedside teaching such as
demonstrating and practising physical diagnosis, communication and procedural skills.
Besides educational advantages, such as the possibility to directly observe clinical
skills, there is evidence that patients favour bedside teaching and report better
understanding of their illness due to its application. Of course this excludes using
patients for extensive skills teaching which should be done in simulated or virtual
situations. It also excludes the type of clinical teaching where the patient's role is to
demonstrate the teacher's superiority and importance! 
An effective strategy for bedside teaching includes: attending to patient comfort, using
focused teaching methods, and managing group dynamics. The latter refers to making
sure every trainee profits, stimulating interaction between patient and trainee and
between you and the trainees.
 References
Janicik RW, Fletcher KE. Teaching at the bedside: a new model. Med Teach
2003; 25(2): 127-130. PMID 12745518
4. 6. 2. Clinical rounds
Clinical rounds are well known for their importance in postgraduate professional
development. If well prepared, they provide very valuable learning experiences for
both trainer and trainee. Preparing includes such strategies as discussed before
(sharpening expectations, briefing participants, selecting cases, preparing questions).
A distinction can be made between teaching rounds and business rounds.
4. 6. 3. Teaching rounds
These can be clinical rounds where time is reserved explicitly for teaching. It could
also be a more formal session where a single case or several cases are selected for
examination and discussion. The latter fits well in undergraduate and early
postgraduate training. The disease process is a central theme, with clinical
assessment (history taking and physical examination) as the starting point from which
discussion can develop.
Consider the following points:
Treat the patient with respect, even when the patient is unconscious. When
possible involve the patient. Ask permission in advance; explain the purpose;
during the teaching don't only talk about, but firstly with the patient
Choose clear goals that are appropriate to the trainee, the setting, and patients'
problems
Adapt the teaching strategies to the existing needs, capabilities and experience of
the learners
Actively involve learners, e.g. by asking them to perform (parts of) the
investigation, asking them to explain what they are doing,and what their opinion is
Give feedback on their performance afterwards (not in the presence of the
patients)
Summarise at the end or ask your trainee to summarise.
4. 6. 4. Business rounds
These are more part of everyday working in the hospital. In this type of round, the
patient, their treatment and progress are the central focus. You are role modelling in
this work situation. Junior staff can take the opportunity to safely display their
diagnostic competency, proposed treatment and follow-up capabilities. The outcome of
clinical interventions on a disease process in severely ill patients provides instant
feedback on the problem-solving and decision-making skills of those involved. This
provides excellent motivation to learn further, not only on the round, but also in other
associated formal teaching activities. 
More information can be found in
 References
Ramani S. Twelve tipe to improve bedside teaching. Med teach
2003;25:112-115.
Prideaux D, Alexander H, Bower A, Dacre A, Haist S, Jolly B, et al. Clinical
teaching: maintaining an educational role for doctors in the new health care
environment. Med Educ 2000; 32, 820-826
 
4. 6. 5. Morning report
During the morning report one party accounts for patient care (diagnostic and
therapeutic actions) during the previous night, and the other party is taking over. If
these sessions are conducted in an interesting and active way, they can be a valuable
learning experience and offer a good opportunity to assess the progress of trainees.
The following areas can be practised and assessed during the morning report:
prioritising a patient's problems; making clear distinctions between sick and less sick;
recognising the need for actions; requests for additional investigations are well thought
out and based on a good differential diagnosis; and formulating a clear conclusion.
Tips:
Use a simple format for the presentation of the patient
Actively involve the trainees in choosing which patients are discussed
Ask questions to clarify, motivate etc
Choose a chairperson who is responsible for structure and time
After trainees have seen senior staff model the morning report, ask trainees to
chair sessions (taking turns)
Start and end on time
Remember how tired the person who is presenting is compared to those starting
work!
 Note
 
Analyse the morning report in your department. How is it organised? Can it be
improved in terms of a learning event for participants? What does it take to
make these improvements? Who do you need to make these changes?
 References
Ten Have E, Nap R, Tulleken J. Quality improvement of interdisciplinary
rounds by leadership training based on essential quality indicators of the
interdisciplinary Rounds Assessment Scale. Intensive Care Medicne
2013;39(10):1800-1807.
 
5. Stimulating professional learning outside
clinical practice
Although learning ‘on the job’ is considered pivotal in a recent study among Dutch
intensive care fellows, teaching and learning off the job, in the formal, non clinical
teaching curriculum should not be neglected, according to the trainees. Teaching 'off
the job' comprises quite different formats such as lecturing, small group teaching, and
skills training. However, any planned teaching session can be broken down into three
key elements: the set, dialogue and the Closure.
 References
What they will learn (objectives)
Why it is important (motivation)
How the content is related to other parts (e.g. of a course) or practice
What is expected of the trainees and the trainer (e.g. should trainees listen,
or should they be practising, can they ask questions).
During the Set it must be clear for trainees
Dialogue is the crucial part of a planned session which involves the interaction of the
trainees and the trainer. It includes elaboration on the main messages of the session
(in lectures), or working on an assignment to reach the learning objectives (in small
group teaching, workshops, and skills training).
 Note
When preparing a teaching session always try to focus on the key message:
what should your learner never forget after this teaching session.
The Closure has three elements:
Review (ask for questions; check if objectives have been reached)
Summarising (by trainer or participant)
Terminate the session.
Question: What is the benefit of asking for questions before the summary and
termination of a teaching session?
5. 1. Lecturing
Lecturing happens in educational settings, but also in conferences. Large group
lecturing has long been seen as the most important method of teaching in medical
education. But over the past decades the role has been questioned. Adults learn more
effectively through active participation and lectures are criticised for being too passive
a learning experience. However, a good lecturer activates the audience in a variety of
ways.
A lecture is appropriate when the aim is to:
Deliver information that is not available in another way
Stimulate interest, raise curiosity, motivate
Adapt information to the level of the audience
Underline specific information
And/or
Provide the learners with the overall picture
Ensure shared knowledge (e.g. within a team).
Think about the lectures you enjoyed immensely in your medical career and lectures
that you thought were really bad. What made these lectures so good or so bad? What
did the lecturer do?
When you expect your audience to listen only, you should realize that they will have al
hard time remembering much of what you said. The famous pyramid (below) makes
clear that it is important to include textual and visual information, a live or video
demonstration, and involving your audience.
How much do people remember from several
activities?
 
5. 1. 1. Preparation
Structure your lecture according to the three main components identified above. You
may want to divide the second part (dialogue) into several steps, depending on your
goals and available time. Important points are:
Think of a good start. Try to imagine what would grab the attention of your
audience – and focus their attention on what you want to say. A story? A strange-
looking slide? Part of a movie? A statement? Tip: observe how advertisements try
to capture your attention and think of possibilities to do the same.
https://collaboration.esicm.org/dl103?display
Limit your messages. Don't cram your lecture with too many goals. It is better to
get across one main point than to drown your audience in your expertise. Keep it
simple.
Use examples for each of your messages. Start with an example (from practice)
and use it during the more general explanation to illustrate what you want to
convey (theory). Don't restrict your message to abstract theory.
Preparation includes being aware of the setting and preparing the use of material such
as slides. When preparing the set you should think about the environment. What does
the room look like, how does the lighting work, is there a laptop available etc. Be as
familiar with the environment as possible.
Be clear about the role of the audience. Can they interrupt you? If so, prepare to tell
them and to invite them to do so. Also think of how you may want to stop the audience
participating if you anticipate time problems. You may have to choose between
audience participation and completing your lecture.
Use of slides or other audiovisual materials 
Take care that the slides are helping you to deliver your message, not htat the slides
are taking over control of your presentation. On the internet you can find a lot of
websites on how to ddesign your presentation. Some helpful tips can be found on the
following link:
 References
www.garrreynolds.com/preso-tips/design/
During your presentation 
When conducting a teaching session, you always deliver your message in more than
one way. As well as content, learning is also dependent on how you deliver your
message and what your body language is saying.
 Note
A confident start forms the basis of a successful presentation
Helpful tips to make your presentation even moreeffective:
Be prepared and focus on your role as lecturer.
Maintain eye contact; in a large room this requires looking around (from left to
right, front to back, and vice versa).
Don't stand like a statue – but don't move around too much either.
Avoid distracting the audience e.g. by playing with keys or coins, fiddling (e.g.
fingers through your hair, rubbing your nose).
Speak clearly and loudly – exaggerate as if you were an actor.
Use a microphone if necessary (check if the audience can hear you clearly).
https://collaboration.esicm.org/www.garrreynolds.com/preso-tips/design/
Speak slower than you normally do, for your audience needs time to think (at least
when you tell them something that they do not know already).
Avoid turning your back (don't speak to your slides).
Slides and visual material: Their value should not be underestimated. It helps
people to remember your message, it can help them to make sense of complex
ideas and it can help to keep their attention. You may also use slides as your
notes, your backbone of the presentation.
Beware of:
Too many words. Think 'bullet points' and avoid textual sentences.
Too many slides e.g. use one slide per minute (rule of thumb).
Unnecessary information on the slides (e.g. logos, names, numbers). No need to
give full references for example, just enough to allow the listener to look up the
reference on pubmed afterwards.
Misspelling and too many typefaces.
The use of green, red or other difficult to read colours for text.
Insufficient contrast between background and text.
Too many visual effects. These make the file large and hard to carry on a 'memory
stick' and the lecture venue may not have the software to 'play' videos etc.
Useful information about how to deliver a lecture can also be found in
 References
Long A and Lock B. Lectures and large groups. In: Swanwick T.
Understanding Medical education.(2014). Chapter 10:p137-148
Cantillon P. Teaching large groups. BMJ 2003;326:437-440
Laidlaw JM, Hesketh EA; NHS Education for Scotland. Developing the
teaching instinct. 8: Presentations. Med Teach 2003; 25(4): 368-371. No
abstract available. PMID 12893546
Think about how you learn from teaching your trainees. If teaching is such an
excellent way to learn, what does it mean for teaching? Can you think of ways to turn
your trainees into teachers?
Tip: The secret to giving an effective presentation is in its preparation
5. 2. Small group teaching
Small group teaching may take different forms, for instance workshops and discussion
groups. One important advantage over lecturing in that it is easier to actively involve
learners. Well organised small group teaching
allows learners to develop generic skills like problem-solving, interpersonal,
presentational and communication skills
allows learners to question and challenge assumptions and to develop deeper
understanding of a topic through discussion. A deeper understanding will facilitate
the application of what is learned in the future and in new situations
allows learners to develop skills and attitudes for team work
requires active involvement which tends to stimulate motivation and a positive
attitude towards what is learned
SNIPPET The key to successful learning in a small group lies with the teacher.
During small group teaching learners could learn by discussing their mistakes, either
mistakes of their own or mistakes made by their peers. ln a recent study among
intensive care medicine trainees learning from own and others' mistakes was
considered especially useful. Self-reflection as a starting point for learning
professionalism was stressed
 References
Mook et al. Fellows' in intensive care medicine views on professionalism
and how they learn it. Intensive Care Med 2010; 36(2): 296-303.
Mook W et al. Intensive care medicine trainees' perception of
professionalism: a qualitative study. Anaesth Intensive Care 2011; 39(1):
107-115
Question: Describe two major roles of a teacher in small group teaching.
You can read more about small group teaching techniques and the role of the teacher
in
 References
McCrorie P. Teaching and leading small groups. In: Swanwick T.
Understanding Medical education.(2014)
5. 3. Practical skills teaching
The traditional approach of learning psychomotor skills by practising on patients has
obvious drawbacks, especially with novice learners. Today, patient safety requires
skills training off the job as much as possible, e.g. in so-called skills centres. Here
students, residents and specialists can be trained in new skills using (dead) animals,
manikins, simulators, virtual technology and standardised patients.
Most skills training is based on several stages including demonstration, explanation,
and practise with feedback:
Expert demonstration of the skill can be done live by a trainer or virtually, and is
necessary to provide the novice with a picture of the different elements as well as
the whole event
To understand the skill, trainees need an explanation of what they see: why is it
done this way? Should it always be done this way or may (part of) the skill be
done in another way? In what cases? What are risks of changing (part of) the
activities?
Next, trainees need to practise the specific psychomotor skills. Sometimes a skill
needs to be subdivided if it is complex
When practising, trainees need feedback to inform them about their progress
In the end an integrated, fluent application is required: automation is reached by
sufficient practice.
 References
Hamdorf JM, Hall JC. Acquiring surgical skills. Br J Surg 2000; 87(1): 28-
37. Review. PMID 10606907
A teaching model, very well appreciated by surgical skills training, is the so-called four-
stage model
Stage 1 Demonstration: instructors demonstrate the skill
Stage 2 Verbalisation: instructors demonstrate the skill and explain what they are
doing
Stage 3 Formulation: instructors perform the skill while learners tell them what to
do
Stage 4 Practice: learners perform the skills and say what they are doing.
The four-stage model mainly focuses on acquiring a specific skill and therefore on the
first phase of skill learning. It does not include repeated practice and feedback. The
explanation is focused on the activity and not so much on understanding the
background and context.
Other teaching models may vary in specifying stages, in providing extra steps, or
repeating earlier stages. In practice, you may vary the model because of your trainees'
level of competence, their speed of learning and what skills you want your trainees to
acquire. When you think of learning to perform an operation, a whole range of skills
may be involved that can be learned separately, but need to become a whole in the
end.
 Important
Although skills training usually starts in isolation from clinical practice, it should
be followed by guided practice in real life. In real life, inform your trainees
beforehand which part they are expected to do, so that you don't need to
interrupt unexpectedly, leaving your trainees wondering what they did wrong.
 References
Wayne DB, Butter J, Siddall VJ, Fudala MJ, Wade LD, Feinglass J, et al.
Mastery learning of advanced cardiac life support skills by internal medicine
residents using simulation technology and deliberate practice. J Gen Intern
Med 2006; 21(3): 251-256. PMID 16637824
McGaghie W & Issenberg B. Does Simulation-based Medical education with
Deliberate Practice Yield Better Results than Traditional Clinical Education?
A Meta-Analytic Comparative Review of the Evidence. Acad Medicine
2011;86(6):706-711
Krautter M, Dittrich R, Safi A, Krautter J, Maatouk I et al. Peyton’s four-step
approach: differential effects of single instructional steps on procedural and
memory performance – a clarification study. Advances in Medical education
and Practice 2015;6:399-406
 
5. 4. Simulation based training
Simulation and virtual reality are becoming widely established and have the advantage
of offering learner-centred education, away from clinical responsibilities at anyconvenient time. High-fidelity simulation can accurately recreate the conditions of an
ICU and generate a high degree of realism. Crisis management, team working and
communication can be taught alongside skills and procedures.
The weight of the best available evidence suggests that high-fidelity medical
simulations facilitate learning under the right conditions. These include the following’
(in order of importance):  
1. Feedback is provided during the learning experience  
2. Learners engage in repetitive practice  
3. The simulator is integrated into an overall curriculum  
4. Learners practise with increasing levels of difficulty  
5. The simulator is adaptable to multiple learning strategies  
6. The simulator captures clinical variation  
7. The simulator is embedded in a controlled environment  
8. The simulator permits individualised learning  
9. Learning outcomes are clearly defined and measured
10. The simulator is a valid (high-fidelity) approximation of clinical practice
 References
McGaghie W & Issenberg B. Does Simulation-based Medical education with
Deliberate Practice Yield Better Results than Traditional Clinical Education?
A Meta-Analytic Comparative Review of the Evidence. Acad Medicine
2011;86(6):706-711
Kneebone RL, Scott W, Darzi A, Horrocks M. Simulation and clinical
practice: strengthening the relationship. Med Educ 2004; 38(10): 1095-
1102. PMID 15461655
 
6. Assessing clinical competence
Anecdote: trainee in ICU medicine was very skilled in performing his own tasks, but
when observing him it was noticed that he often forgot to communicate with other staff
in acute care. Also, it was said that this trainee made several near-mistakes. The
supervisor decides to have a talk with him and tells him she heard about the near-
mistakes and wants him to go to a training course to practice the relevant skills. But
the trainee objects and denies what the supervisor has been told.
This anecdote illustrates one important goal in assessing trainees; that is identifying
the ‘trainee in difficulty’. For most trainees however, assessment will or should be an
opportunity for personal development and be relatively non-threatening and positive.
Assessment serves three purposes:
To provide feedback on progress and encourage learning (assessment for
learning, called formative assessment)
To provide evidence of the achievement of competence (assessment of learning
to take ‘pass or fail’ decisions, called summative assessment)
To identify the trainee in difficulty
Assessment is an educational and diagnostic activity, concerned with the identification
of strengths and weaknesses. The assessment methodology is not designed to rank
the performance of doctors. Rather, it is about demonstrating achievement (across a
range of assessments) and identifying where more practice or support is needed.
The majority of assessments will be work-placed based, focused on what trainees do
in their normal course of work. Continuing assessment will be formative in nature,
providing feedback on progress, and identifying problems at an early stage to allow
corrective action. Education and training 'portfolios' allow evidence to be collated
which can then inform judgements about progression and contribute towards a
summative decision about whether the trainee is safe for independent practice.
While the majority of trainees will make satisfactory progress, a few will have difficulty.
It is essential for patient safety and for the trainee's career that problems are identified
and managed as early as possible. Trainees shown to be in difficulty will require closer
supervision and further assessment. The detail of the remedial action plan will need to
be determined locally. (www.cobatrice.org) 
The five w-questions about assessing clinical competence are discussed below: why,
when, what, who, what ways?
https://collaboration.esicm.org/www.cobatrice.org
6. 1. Why do you assess clinical competence?
6. 1. 1. Formative assessment
You may want to do a formative assessment of your resident’s clinical competence,
directed at giving feedback. In that case your goal is to stimulate your trainee’s
learning. You want to be as precise and concrete as possible about good and weak
parts in his performance. Make sure that the trainee understands clearly what parts
need improvement, why and how. But don’t forget to be explicit about her/his good
performance as well. Recognition of good performance is important to ensure s/he
continues this good performance (reinforcement)! Formative assessment provides an
important educational tool: ‘Assessment drives learning’.
6. 1. 2. Formative versus summative assessment
You may want to do a summative assessment of clinical competence, directed at
taking decisions about your trainee’s position in the training programme. Is the trainee
ready to proceed to the next stage? Has s/he acquired all necessary competencies to
be your colleague? A decision to pass or fail has serious consequences and must
therefore be based on adequate (valid and reliable) assessments. 
You may think of summative assessment in terms of the question: do I trust my trainee
to do this? Entrustable professional activities (epa’s) are a novel method of
operationalizing competencies and milestones in the development of a trainee. Epa’s
naturally focus on holistic performance of actual physician’s tasks.
 References
Ten Cate, O (2006). Trust, competence, and the supervisor’s role in
postgraduate training. BMJ 333:748-751
Caverzagie K, Cooney T, Hemmer P, Berkowitz L. The development of
entrustable professional Activities for internal Medicine Residency Training:
A report from the education redesign committee of the Alliance for
Academic Internal *Medicine. Acad Med 2015;90(4):479-484
Formative and summative assessments go hand in hand and should be applied in any
medical educational program. 
The quality of summative assessment may improve when you pay more attention to
formative assessment, resulting in you being better informed about your trainee’s
progress. Identifying poor performance is an important goal of both formative and
summative assessment. In formative assessment you still have the opportunity to give
extra attention to your trainee in difficulty. 
When you document your formative and summative assessments in the trainee’s
portfolio, you stand on firm ground in case you have to take negative decisions about
your trainee’s progress. (See also portfolio).
 References
Veloski, J., J. R. Boex, et al. (2006). Systematic review of the literature on
assessment, feedback and physicians’ clinical performance. BEME Guide
No. 7. Medical Teacher 28(2): 117-128.
6. 1. 3. What to do with a trainee in difficulty
Characteristics of a trainee in difficulty may include reluctance to ask for help, poor
communication skills, lack of responsibility, frustration and anger, a disregard for
punctuality, or a failure to see that there is a problem. The underlying causes of
difficulty may be related to personal, environmental or adaptive factors.
 References
Mook W, The threat of the dyscompetent resident: A plea to make the
implicit more explicit! Adv in Health Sci Educ 2014; 20(2):559-74
 Important
During routine practice, incidents that give cause for concern about a trainee
can be considered as early warning signs.
To identify trainees in difficulty and remediable causes, key questions to ask include:
Is this an isolated incident or is a trend/repetition evident?
Does the trainee have the insight to recognise the problem?
Can the incident be turned into a learning opportunity?
What questions does the case raise about the learning environment?
What can you do?
Focus on patients’ as well as trainee’s safety
Ensure the trainee knows how and when and who to call for help
Discuss the event with the trainee and reflect on how to handle such an event in
the future
Make this incident a learning opportunity
Communicate clearly with the trainee and document this carefully
Increase formal and informal monitoring,supervision and review of the trainee and
the learning environment
Link: http://www.cobatrice.org
6. 2. When do you assess clinical competence?
http://www.cobatrice.org/
Formative, informal assessment should be done quite often in various situations.
Possibilities include immediately after patient discussions, debriefings, clinical rounds,
presentations. Keep the assessment short, don’t try to be complete, address only one
or two points at a time. 
Think of possibilities in your situation to give feedback, and turn this into a good
clinical teaching habit.
Organise appointments with your trainee, e.g. twice a year, to discuss her/his progress
in a more comprehensive and formalised way, but still with the formative goal of
providing feedback. 
Summative assessments take place whenever a formal decision needs to be taken
about a trainee’s progress in the training programme: entering the next stage,
completing the programme, or stopping because of inadequate results. In a well-
structured training programme it should be clear when, about what, and with what
consequences summative assessments will be made (e.g. once a year).
 Note
Analyse your training programme and identify when formative and summative
assessments take place. Are these sufficient? Is the trainee well informed about
the assessments? Is the trainer sufficiently well informed to make decisions
concerning the trainee?
6. 3. What do you assess?
The attributes required of a doctor are numerous and no single test can distinguish
between a ‘bad’ or a ‘good’ doctor. Attributes include generic skills and attitudes, such
as communication and team-working, as well as specialised knowledge and skills
relevant to each specialty. Assessment increasingly focuses on actual performance
and therefore on the competencies of a trainee. 
There are several models that describe these competencies. For ICU training, a
competency-based programme is described within the CoBaTrICE project and this
should form the basis for the assessment. 
As far back as 1990, Miller drew his famous pyramid to illustrate the shortcomings of
assessment in medical education (see illustration, below). Knowledge assessment is
at the base of his pyramid, not because it is most important, but because it is done the
most: in written or oral form we test what the student knows. Skills assessment is the
next step of his pyramid: students ‘show how’, e.g. in skills stations. This type of
assessment is done quite a lot, but less often than knowledge testing. Trainees’
performance in clinical practice is not assessed very often nor adequately. And we
hardly ever assess the top of the pyramid: the actual performance of responsible
doctors.
Miller’s message was that we need far more assessment, as we get higher up the
pyramid. As a consequence, the pyramid should become more of a chest of drawers
with all drawers equally filled. By 2014, more ways of assessing clinical performance in
practice (‘does’) have indeed been developed, but not always implemented.
 References
Miller GE. The assessment of clinical skills/ competence/performance.
Academic Medicine 1990;65:563-567.
 
6. 4. Who is assessing?
The clinical teacher may not be the only person who does the assessment. Of course
the principal clinical teacher is responsible for assessments taking place, and has the
final responsibility for summative assessments. Other people that are or can be
involved are:
Staff members of several departments (assessing parts of the programme)
The trainees themselves (reflective self-assessment reports)
Peers (when they have been working together or at least been able to observe
each other)
Paramedical and allied healthcare professionals (e.g. nurses, paramedics,
physiotherapists, nurse practitioners, physician assistants)
Patient evaluations (specific aspects of trainees performance)
 Note
 
Self-, peer- and co-assessment are important ways to prepare for lifelong
learning and to involve new doctors in team-learning
Gathering information from different sources is called multi source or 360 degree
feedback. The different perspectives give special value to this information. Peers,
other health care professionals, and patients may each note other things then staff
does. A positive as well as a negative assessment is made stronger when different
https://collaboration.esicm.org/dl104?display
sources are in agreement. When sources are not in agreement it is important for
everyone to find out what causes the differences in evaluation, especially before it is
used in a summative way.
It may also happen that the assessment by different sources conflicts with a trainee’s
self-assessment. You may find those who overestimate and those who underestimate
themselves. In the first case you will need a more firm approach to make sure the
trainee understands and accepts the assessment, and is prepared to work on
improvement. When a trainee underestimates her/himself, you also need to make sure
s/he understands and accepts the assessment, in this case so that s/he will be ready
to move on to a next level of competency with more self-confidence.
6. 5. What ways of assessment do you use?
There is no one perfect way of assessing a trainee’s competence and performance.
You need a mix of different methods and sources to arrive at an adequate assessment,
just like you use quantitative and qualitative information from different sources when
you are evaluating a patient’s condition.
Methods of assessment off the job include ways to assess knowledge, such as
standardised oral exams, written and internet-based exams (multiple choice questions
like the European Diploma in Intensive Care (EDIC) exam), and ways to assess
technical or communication and interpersonal skills, such as the Standardised Patient
Examination (SPE) or OSCEs (Objective Structured Clinical Examination).
Other methods are more appropriate to assess performance on the job, where
knowledge, skills and attitudes need to be integrated into behaviour. Such methods
are usually based on observation of performance in practice. It is useful to base
assessment on repeated observation of different situations by different observers, to
make the assessment more valid and reliable. (See below). Possible methods include
the MiniCEX (Clinical Examination), patient presentation evaluation, short
questionnaires (for multi source feedback), critical appraisal of a topic (CAT), Objective
Structured Assessment of Technical skills (OSAT) and logbooks.
 References
Norcini J. Workplace assessment. In: Understanding medical education. Ed.
Swanwick T 2014: 279-292
Jolly B Written assessment In: Understanding medical education. Ed.
Swanwick T 2014: 255-277
Boursicot KAM, Roberts TE and Burdick WP Structured assessments of
competence In: Understanding medical education. Ed. Swanwick T 2014:
293-304
Question: what kind of rating of practice observations are more accurate: global rating
scales or checklists? Give arguments
6. 5. 1. Portfolio and personal learning plans
A portfolio is a collection of evidence which, when taken together, demonstrates
competence and expertise. In addition to the formal acquisition of competencies which
form the core of the CoBaTrICE programme, there are many other aspects of clinical
practice and professional development which can be included, such as research and
audit activities, teaching received or delivered, courses attended, work-place based
assessments, case summaries, log books, personal reflections or letters from patients
and relatives. CoBaTrICE has produced the CoBaFolio template as a means of
enabling trainees to collate evidence of competence.
A portfolio is also a suitable way to organise your assessment programme (overall
formative and summative assessment). The trainee is asked to write a self evaluation
report, in which s/he summarises the results of the various assessments and reflects
on these assessment data. Formative discussions with your trainee result in plans for
learning in the period ahead. You agree