Notes for the Primary Care Teacher: Quality Assurance in Teaching

This is the last article in the series on Notes for the Primary Care Teachers. We hope that new primary care teachers and mentors have benefited from the series and the “older” teachers have also refreshed their understanding through reading and helping to write and review the articles.

In the initial stages a new teacher is busy learning new ways of teaching and applying and putting it into practice. As we progress a time will come when we ask ourselves, how effective are we as teachers and how can we improve further.

There are a number of ways we can evaluate ourselves, which includes self reflection and analysis of our teaching in response to external evaluations such as peer review of teaching and student evaluation. As teachers and part of an institution for teaching and learning, be it in an Academy such as the Academy of Family Physicians or a college or university, we need to be clear of our role and possible contributions to its quality assurance activities.

Each teacher should try to ensure that:

• every lesson (tutorial / lecture) is prepared with aims and objectives clearly stated and achieved

• the best teaching methods and learning strategies are identified and implemented, taking into consideration the principles of adult learning.

• students’ feedback and peer observation are in place and the teacher is receptive of comments made by his/her students and peers.

• self evaluation is done regularly with commitment to change for the better.

• an attempt is made to attend further training in medical education.

For general practitioners (GPs) taking in medical students, the objective of the GP attachment may be just to expose the students to what a GP does and the kind of patients seen. GPs are thus free to teach around cases presenting to their clinics.

However in some programs, medical students are attached to primary care doctors including GPs in both their first and final clinical years. The learning objectives will be different. The teacher need to ensure the teaching is according to the course objectives and appropriate to the students’ level of experience. For example the learning objectives for first clinical year students will include learning basic clinical and diagnostic skills whereas for final year students the emphasis will be more on management. Some courses may also require primary care doctors including GPs to give tutorials to the students on specified topics. Teachers will need to follow the syllabus and the learning objectives stated.

Student evaluation of teaching

Students’ feedback is very important. It is not enough to ask at the end of a course or teaching session for comments from students as few students would want to openly criticize a teacher or course coordinator. A semi structured questionnaire can be constructed for evaluation by students and fellow tutors and it provides an objective means of monitoring teaching. To get frank and honest comments, teachers must ensure the evaluation is truly anonymous and individual students cannot be identified. The comments should be compiled by the course coordinator and circulated confidentially amongst the relevant teaching staff. Action need to be taken to rectify any deficiencies and a written report is submitted to the relevant person in charge. In the written report all adverse comments should be addressed, even if for some no further action could or need to be taken.

For teachers in private or public primary clinics, who may be assigned one student at a time, it will be more feasible to ask for the student’s comments and suggestions to improve clinic teaching and learning at the end of their feedback session with the student on his / her performance. However do liaise with the course coordinator to get a copy of the compiled students’ course evaluation and if it is not already part of the evaluation, request that a specific section of the student evaluation be on clinic postings and teaching. You will be able to get an overall picture of the students’ evaluation on the course and further feedback by students on clinic teaching.

Peer review of teaching

Besides student feedback, another method is peer observation or review of teaching. This means a fellow teacher (usually a more senior one) will sit into the session and objectively evaluate the teaching using a standardized format. Preferably the teacher to be assessed is allowed to choose the assessor among a list provided. The exercise is not aimed at fault finding but to help the teacher improve further. Usually prior notice is given to the teacher if peer review is carried out. Confidentiality is maintained with only the head of the program and official external assessors such as a visiting National Accreditation team having access to details of such reports.

Unlike countries such as UK, peer review of teaching is not widely used locally. Perhaps it is time for academic primary care in local universities/colleges to look further into the barriers to its implementation.

Even if peer review of teaching is not in place, new teachers can still request a more experienced colleague to sit in and observe their teaching and give constructive criticisms. The new teacher may also request to sit in, observe and learn from a senior colleagues’ teaching session.

Professional development of teachers

Professional development of teaching staff is essential to ensure quality in teaching. All new teachers should undergo a basic teacher training course and subsequently have access to further courses in teaching and assessments.

Similar to best evidence medical practice, we now have best evidence medical education (BEME). For those interested, systematic reviews on teaching and learning are available on the BEME website.1

Provision of a conducive environment to promote student learning

Students learn best in a non-threatening, comfortable environment where they feel they are cared for and they are receiving guidance and support and are respected by their teachers.2 Therefore teachers need also review the environment they are teaching in and their own attitudes towards the students to ensure meaningful and optimal learning by students.

Self evaluation and accountability, teaching portfolios

As teachers we teach students the need for self evaluation, reflective practice and life long learning. We ourselves need to do the same, not only to update ourselves in clinical practice but to systematically reflect and analyse our own teaching and be prepared to modify and improve our teaching methods to promote student learning.

In clinical practice this may include the maintenance of practice diaries, performing clinical audits to assess the quality of our patient care and having regular significant event analysis discussions. For medical students and family medicine trainees, logbooks and portfolios are maintained to record the completion of assigned tasks, their own achievements, self assessment and reflection and their learning activities to overcome deficiencies.

Similarly for teachers, keeping a record or diary or a teaching portfolio is useful. Whether you are a full time lecturer or primary care doctor teaching students in your clinic, it is a good idea to maintain a record of your teaching sessions with a summary of what was discussed.

One GP tutor who was teaching medical students actually submitted his record with a detailed discussion of his teaching sessions with his student. It was a highly commendable effort.

A teaching portfolio3 is a more formalized and structured record for a teacher’s own reflection and evaluation of his/her teaching and provides documentation on how effective he/she is as a teacher.

In some institutions teaching portfolios has become part of their peer review of teaching and departmental review for the purpose of appraisal, promotion and tenure.

Items that may be considered for inclusion into a teaching portfolio3 are:

1. Personal materials such as statement of teaching responsibilities, personal teaching philosophy, strategies and objectives, personal teaching goals for the next 5 years, description of steps taken to evaluate and improve one’s teaching, self evaluation and publications on teaching

2. Materials from others such as statements from colleagues who have observed your teaching, student and course evaluations which showed improvements in teaching, awards and other recognition, invitations from outside agencies for papers on teaching, documentation of participation in teaching development within your discipline, videotape of your teaching and student scores

3. Products of good teaching such as student essays, publications, creative work, course related work, statements from alumni and record of students who succeeded to advanced courses in discipline.

The above suggestions in quality assurance are meant for individual teachers in primary care. For an institution, ensuring quality in teaching involves reviewing many more aspects such as assessing the curriculum design, organization, implementation and review; the institutional strategies for teaching, learning and assessments; student support, guidance and achievements, learning resources, external assessors’ and external examiners’ reports, feedback from stakeholders and former students etc,4,5 which are beyond the scope of this article.

CRP: any role in cardiac risk assessment?

You have just ordered a CRP as part of the health screening package for a healthy adult. It comes back as 3.5 mg/L (normal <3.0). What should you do?

This review concluded that CRP should not be done as part of the health screening package.

Wong MS. Health screening packages: the place of measuring C-reactive protein Singapore Med J. 2006; 47(10):827-829. http://www.sma.org.sg/smj/4710/4710e1.pdf

This review concluded that CRP adds little on top Framingham risk score. But for those with intermediate risk (Framingham 10 year-risk 10-20%), high CRP may indicate high risk and need for more intensive therapy.

Lloyd-Jones DM, Liu K, Tian L, Greenland P. Narrative Review: Assessment of C-Reactive Protein in Risk Prediction for Cardiovascular Disease Ann Intern Med. 2006; 145(1):35-42. http://www.annals.org/cgi/reprint/145/1/35.pdf