excellence in medical education · supported by melissa haskins, until recently the academy’s...

Values of Medical Educators

Excellence in Medical Education

Issue 1: October 2011



Excellence inMedical Education 2



EditorDr Vimmi Passi, Academy of Medical Educators

Deputy EditorDr Kieran Walsh, Clinical Director, BMJ Learning

Executive DirectorAndrew Gardner, Chief Executive, Academy of Medical Educators

Aims and ScopeThe Academy of Medical Educators (AoME) was established in 2006. The main aspiration of the AoME is to improve clinical care through teaching excellence. Excellence in Medical Education has been designed with this aspiration in mind. The first five issues will focus on the AoME Professional Standards with invited expert reviews. Future issues will be based on specific educational themes with invitations to submit articles with a peer review process.

Excellence in Medical Education has been designed for the active busy medical, dental and veterinary teacher. The aim is to highlight important educational topics, discuss challenging and controversial issues and stimulate debate. The series embraces 21st Century medical education with expert reviews, interviews and specialist articles. The series will provide an inspirational and thought provoking journey into the exciting field of medical education. We welcome articles and reviews for future issues so if you would like to contribute or comment please contact the Editor, Dr Vimmi Passi, at: [email protected]

Subscription InformationExcellence in Medical Education is available online to Associate Members, Members and Fellows of the AoME.

DespatchExcellence in Medical Education will be produced quarterly.

DisclaimerThe AoME cannot be held responsible for errors or any consequences arising from the use of information contained in this journal.

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Contents PageWelcome from the President of the AoME .................................................................. 4

Welcome from the Editor .............................................................................................. 5

1. The AoME Professional Standards ............................................................................. 6

2. Professional Standards: Values of Medical Educators .............................................. 7

2.1: Professional Integrity ....................................................................................... 8

2.2: Respect for Patients .......................................................................................... 10

2.3: Respect for Learners .......................................................................................... 12

2.4: Continuing Professional Development ............................................................ 15

2.5: Equality of Opportunity and Diversity ............................................................ 17

2.6: Commitment to Medical Education ................................................................ 20

3. A View from a Specialist: The Values of Dental Educators ....................................... 22

4. An International Perspective: The Values of Medical Educators .............................. 24

5. The Expert: Interview with Professor Dame Lesley Southgate ................................. 26

6. Authors ...................................................................................................................... 29






Welcome from the President of the AoME

Professor Sean Hilton, President of the AoME

I am very pleased to welcome you to the first quarterly version of Excellence in Medical Education, an important new educational product for members of the Academy of Medical Educators.

My thanks and congratulations are due to: Dr Vimmi Passi, Editor in Chief and to Dr Kieran Walsh, Deputy Editor. They have done the majority of the thinking and the work to bring this together and have been ably supported by Melissa Haskins, until recently the Academy’s Office Manager. Melissa has left us to take a place to study graduate entry medicine at Southampton from September 2011. Congratulations and good wishes to her, and we are also pleased to welcome her as new student Associate Member of the Academy!

We want this new publication to provide much of what has been requested by members during the discussions we have had about the form of a regular publication for the Academy. Our Council has also given a lot of thought to what is appropriate for the AoME to publish, given our resources; the market and our desire to work in collaboration with established organisations in the field of medical publishing who share many of our aims. At this time we feel that a web based quarterly journal of this kind is right. Vimmi Passi’s introductory article describes the approach and the features that we will include regularly in Excellence in Medical Education.

As a young organisation we are still defining our identity and our constituency. Certainly, it is our wish to be relevant and supportive to all those who have a career in medical education, whether part or full time. We want to bring added value, and to complement rather than compete with the products of other organisations involved in medical education, whether government, regulators, Royal Colleges or learned societies. We can improve continuously and develop new projects, but only with your feedback and input.

Professor Sean Hilton

This is a critical time for the AoME as we move into the next stages of our development as an organisation. It is challenging yet exciting. I am sure of three things. First, there is a lot of interest, nationally and internationally, in the standards to improve quality that we define as a professional organisation. Secondly, we will achieve more if we work effectively in collaboration with the many like-minded organisations in the field. Thirdly, we need the support and ideas of our membership in order to be successful.

Excellence in Medical Education provides a new way of interacting with members and partners, and I hope you will take advantage of it. You can also contact the Academy directly at any time with your views and suggestions. Please write to me at: [email protected] or to our new Executive Director: [email protected]

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Welcome from the Editor

Dr Vimmi Passi

Dr Vimmi Passi, Editor of Excellence in Medical Education

It is a great pleasure to welcome you to the first quarterly edition of Excellence in Medical Education, an exciting new educational product for members of the Academy of Medical Educators (AoME). The series embraces 21st Century medical education with expert reviews, interviews and specialist articles. The series will provide an inspirational and thought provoking insight into the exciting field of medical education.

The Academy of Medical Educators was established in 2006. The main aspiration of the AoME is to improve clinical care through teaching excellence. Excellence in Medical Education has been designed with this aim in mind. The series will highlight important educational topics, discuss challenging and controversial issues and stimulate debate.

The first five issues will focus on the AoME Professional Standards with expert reviews. Future issues will be based on specific educational themes with invitations to submit articles. The Professional Standards have been designed to provide the basis upon which a curriculum for medical educators can be developed and act as a framework against which professional progression as an educator can be planned. The AoME Standards are a tool designed to assist medical educators to work towards excellence.

This opening issue on ‘Values of Medical Educators’ will lead you on a motivational journey that explores and sheds light on the core values required by medical educators. It includes: thought provoking expert reflections on professional integrity; respect for patients; respect for learners; continuing professional development equality of opportunity and diversity; and a commitment to medical education. In addition, it compares and contrasts the values of dental educators, before continuing its journey with an intriguing international perspective on the values of medical educators. The final destination is an inspiring interview with Professor Dame Lesley Southgate, who describes her own educational journey.

I am very pleased to announce that each issue of Excellence in Medical Education will be combined with a corresponding AoME Masterclass. The AoME Masterclass on the Values of Medical Educators will be held in 2012. Excellence in Medical Education has been an exciting new venture and I am very grateful to Kieran Walsh, Deputy Editor and Andrew Gardner, Executive Director for all their support. Finally, I would like to thank all our expert authors for their thought provoking and fascinating articles. We welcome articles and reviews for future issues, so if would like to contribute or comment, please contact me at [email protected].

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Theme 1

Values ofmedical

educators

Theme 2

Educationalscholarship

Theme 3

Teaching andsupportinglearners

Theme 4

Assessmentand feedback

to learners

Theme 5

Design andplanning of

learningactivities

Theme 6

Educationalmanagement

andleadership Improving

clinical carethroughteaching

excellence

Professional Standards 20098

Application of the StandardsThe Professional Standards are divided into themes.

Each theme provides details of the knowledge, understandingand practice that underpin the roles of those involved in medicaleducation. The themes are divided into levels that aim tofacilitate progression of individuals throughout their careers.The levels will be used by the Academy of Medical Educators indetermining whether to award Membership (mostly level 2) orFellowship (mostly level 3). Associate members may be meetingsome elements at level 1, but this is not required.

AoME_FINAL:Layout 1 08/12/2009 10:50 Page 8

1. The AoME Professional Standards

The Themes of the Professional Standards:

The Academy of Medical Educators (AoME) is a charitable organisation developed to advance medical education for the benefit of the public through:

A. The development of a curriculum and qualification system;

B. Undertaking research for the continuing development of medical education; and

C. The promotion and dissemination of best practice in medical education.

In order to achieve these objectives, the AoME’s Professional Standards have been produced. These standards have been designed to provide the basis upon which a curriculum for medical educators can be developed. They act as a framework against which professional progression as an educator can be planned and measured. The Standards are a tool designed to assist medical educators to work towards excellence.

To be engaged in effective and appropriate professional development is an integral part of Membership and Fellowship of the AoME. The Standards aim to help clarify the professional characteristics that should be maintained and built on for the variety of roles undertaken by medical educators. The Professional Standards are divided into themes and each theme provides details of the knowledge, understanding and practice that underpin the roles of those involved in medical education.

The Standards may be used by organisations to identify the skills and competencies required of those who undertake or fulfil an educational role. Organisations may also use the Standards to develop and offer a framework for training and continuing professional development in support of medical education. The Standards could be considered when setting objectives in performance and appraisal and used for assessing the performance of individuals within organisations.






Element Core values

1.1 Professional integrity

1.1.1 Demonstrates a standard of professional and educational practice consistent with the requirements of the General Medical Council (UK)

1.1.2 Demonstrates an ability to discharge educational responsibilities within an intellectual framework and educational philosophy consistent with the GMC’s Good Medical Practice, PMETB Generic Standards for Training (if relevant to the professional background) and the standards expected by the Academy of Medical Educators

1.1.3 Demonstrates an understanding and awareness of his/her own professional motivation, educational theory, philosophy and values, and reflects on practice

1.1.4 Demonstrates an awareness of the implications of his/her philosophical and cognitive frameworks and the impact of educational behaviours and decisions in terms of the governance and effectiveness of education and its place in a wider societal framework

1.1.5 Demonstrates an ability to understand and work within a coherent framework of professional ethics relevant to education

1.2 Respect for patients

1.2.1 In discharging educational duties, acts to maintain the dignity and safety of patients at all times

1.2.2 Demonstrates the use of medical education to enhance the care of patients

1.2.3 Balances the needs of service delivery with education

1.3 Respect for learners

1.3.1 Demonstrates consideration for learners and their professional and personal development needs

1.3.2 Acts to promote such consideration and appropriate behaviours in others

1.3.3 Acts with due consideration for the emotional, physical and psychological wellbeing of learners

1.4 Continuing professional development

1.4.1 Demonstrates a commitment towards his/her own personal educational development

1.4.2 Demonstrates a willingness to advance his/her educational capability through continuous learning

1.4.3 Demonstrates an active engagement as appropriate with debates within medical education

1.5 Equality of opportunity and

diversity

1.5.1 Acts to ensure equality of opportunity for students, trainees, staff and professional colleagues

1.5.2 Actively promotes diversity in discharging his/her educational responsibilities

1.6 Commitment to Medical Education

1.6.1 Acts to enhance and improve educational provision through evaluation of his/her practice

1.6.2 Demonstrates an ability to develop and promote appropriate behaviours in others through faculty development or other processes such as role modelling and mentoring

1.6.3 Demonstrates a willingness to become involved in wider medical educational activities such as accepting positions of responsibility within universities, NHS organisations, learned societies, Royal Colleges, academies and other educational providers

1.6.4 Contributes to educational policy and development at local or national levels

1.6.5 Acts to foster an enthusiasm for, and ability in medical education in students and colleagues through faculty development or other processes such as role modelling or mentoring

2. Professional Standards:Values of Medical Educators






2.1 Professional Integrity

The AoME’s first edition of professional standards lists six values under its first theme – the ‘Values of Medical Educators.’1 These are: professional integrity; respect for patients; respect for learners; continuing professional development; equality of opportunity and diversity; and commitment to medical education. This brief review will argue that professional integrity is pre-eminent amongst these – indeed that it is difficult or impossible to espouse the others without integrity.

A great deal has been written about integrity, whether in life, in professionalism or in education, and much of it is inspiring. However, it is important not to drift into high mindedness or piety when claiming integrity as a hallmark of one’s occupation. For one thing, it tends to put people off if they think you’re assuming the high moral ground (rather like the arguments that question use of the term altruism as a key component of professionalism). More importantly, integrity is not some lofty ideal for educators. It is fundamental, it is essential in order to function effectively.

Education is a transmission of learning, a two way process not a one way transfer from teacher to learner. Respect for learners (another Academy value) requires that which the educator brings is genuine and believed. Without this, trust in the educator by the learner is vulnerable, and respect from the educator for the learner is undermined. Thinking of teachers who have inspired me, it has been because of their integrity – they are ‘at one’ with what they are transmitting. They have been very different in style or personality, but they have all had integrity. Because of that they were ‘comfortable in their own skin’ which enabled me, as a learner, to respond to precisely what was being presented. We can’t all be inspirational teachers, at least not all of the time, but we can be ‘at one’ with the teaching, supervision, feedback and learning that we are involved with.

Definition‘At one’ has been used twice in the above section to represent integrity. The word itself stems from the Latin adjective integer (whole, complete). In this context, integrity is the inner sense of ‘wholeness’ deriving from qualities such as consistency of character and action. The English word integer is defined as ‘undivided quantity’ or a ‘thing complete in itself.’ Professional integrity is purely integrity

applied in a professional context. It is almost tautologous, given that it is difficult to behave professionally without integrity.

In The Courage to Teach, one of a number of books by Parker Palmer, an outspoken writer on teaching and education, he bases his book on the simple premise that: ‘good teaching cannot be reduced to technique; good teaching comes from the identity and integrity of the teacher.’2 By identity he refers to the multiple influences – genetic, cultural and experiential – that make us the person we are. By integrity he refers to the sense we make of identity, by acting in ways we hold as correct. He argues that only this brand of integrity – an ‘undivided self’ in teaching and educating will overcome the natural (or inbred) cynicism of students about the motives and outcomes for learning. He writes that, as a teacher: ‘I pay a steep price when I live a divided life – feeling fraudulent, anxious about being found out, and depressed by the fact that I am denying my own selfhood. The people around me pay a price as well, for now they walk on ground made unstable by my dividedness.’3

Medical ProfessionalismMany medical educators have the dual role of educator and clinician. With respect to medical professionalism, defined in many ways, integrity is central.4 My own view is that professionalism incorporates several domains: respect for patients; ethical practice; self awareness; teamwork and social responsibility.5 All of these demand integrity for optimum expression.

Challenges to integrity threaten the attrition of ideals and values – something that is ever present in a pressurised health care environment and that which makes the hidden curriculum such an important influence. Further, it threatens the fiduciary relationship between doctor and patient (and by extension between clinical educator and learner). Fiduciary refers to that relationship based on trust, nowhere better summed up, in my view, than in the famous 1960s statement by the paediatrician Sir James Spence: ‘The essential unit of medical practice is that moment in the intimacy of the consulting room when a patient who is ill, or believes himself to be ill, confides in a doctor who he trusts. This is a consultation and all else in medicine derives from it.’

Professor Sean Hilton






Research and Scholarship in Medical EducationProfessional integrity is not only fundamental to the delivery of medical education. Carr argues for integrity in educational research, making the point that without values educational research is meaningless – ‘those that claim they are adopting a “disinterested” stance are…simply failing to recognise certain features of their work.’6 Alan Bleakley, John Bligh and Julie Browne – three Fellows of our Academy – have written a thought provoking book on the future of Medical Education..7 They argue that medical education sets out to construct an identity in the learner – one that is appropriately informed and positioned by historical, cultural and social interactions.

ConclusionProfessional integrity is what gives us legitimacy, credibility and stature, whether as educators or health care professionals. From another world, Dee Hock is a fascinating and inspirational figure in finance and management, whose effort as leader of the Visa organisation transformed the anarchic early days of the credit card industry. He places integrity at top of a hierarchy of qualities required in colleagues. ‘Hire and promote first on the basis of integrity; second, motivation; third, capacity; fourth, understanding; fifth, knowledge; and last and least, experience. Without integrity, motivation is dangerous; without motivation capacity is impotent; without capacity, understanding is limited; without understanding, knowledge is meaningless; without knowledge experience is blind. Experience is easy to provide and quickly put to good use by people with all the other qualities.’8 Claiming integrity for oneself as a medical educator is not to seek the moral high ground, it is to assert the most important value of a teacher.

References1. Academy of Medical Educators. Professional Standards.

London: Academy of Medical Educators; Dec 2009

2. Palmer P. The Courage to Teach: exploring the inner landscape of a teacher’s life. San Francisco: Jossey Bass; 1998. p.10

3. Palmer P. A Hidden Wholeness; the Journey toward an Undivided Life. San Francisco: Jossey Bass; 2004. p.5

4. RCP Working Party. Doctors in Society. Medical professionalism in a changing world. Clin Med. Nov-Dec 2005; 5 (6 Suppl 1): S5-40

5. Hilton SR, Slotnick HB. Proto-professionalism: how professionalism occurs across the continuum of medical education. Medical Educ. 2005; 39 (1): 58-65.

6. Carr W. For Education. Towards Critical Education Enquiry. Buckingham: Open University Press; 1998, p.88

7. Bleakley A, Bligh J, Browne J. Medical Education for the Future: Identity, Power and Location. London: Springer; 2011. p.107

8. Hock D. http://www.good2work.com/article/90 ((2007) accessed 25 September 2011)

http://www.good2work.com/article/90






2.2 Respect for Patients

Mr Chris Wiltsher

recognise the benefits to doctors and their future patients of practise with real live patients during training, and are willing to be involved in this. Their willingness depends on being treated with respect as patients and persons. Being treated as a specimen, an object for the attention of a group of trainees is never appealing. Being surrounded by groups of people not directly involved in one’s care can be intimidating, and submitting to a series of examinations by inexperienced people can be tiring for a sick person. Respect for patients in medical education requires the creation of an environment in which patients feel comfortable about being involved with trainees, and in which current practice is challenged and improved.

A key aspect of a supportive environment is good communication with patients about the educational aspects of their involvement with trainees. It should be made clear to them that the additional persons present for consultations and procedures are not-yet-qualified doctors, avoiding euphemisms like ‘junior doctor’; and patients should be told explicitly what trainees will be doing and how this will help their development as doctors. Patients must be reassured that their care remains the responsibility of qualified professionals, and their diagnosis and treatment will not be compromised by their involvement in training activities. A particular concern for patients is that trainee involvement might compromise their safety, and they need to be reassured that trainees will be adequately and effectively supervised. Patients should be asked in advance for their express consent to the involvement of trainees, and consent should be sought sufficiently far in advance for them to consider the issue before responding. It should be made clear to patients and carers that they can decline to have trainees present, without this affecting their treatment.

This enhanced practice means that the involvement of patients in educational situations demands extra time and effort on the part of the medical educator, and needs careful planning. Some advocate a system under which patients are assumed to have given consent at the outset for the involvement of trainees in their care at all stages, and are assumed to have been given all relevant information.6 This approach poses problems for particular groups of patients.7 Further, from this patient’s perspective, a failure to seek express consent and give the patient clear and comprehensive information about the educational aspects of their care does not show respect for patients as patients or individuals.

‘Patients contact lies at the heart of medical education.’1

The benefits to ‘doctors in training’ of working with live patients, ‘real’ and ‘simulated,’ have been demonstrated clearly and are widely acknowledged. These benefits include exposure to a range of patients from a variety of backgrounds and exposure to a range of conditions, including long-term conditions and complex presentations.1 They also include the opportunity to develop and practise attitudes appropriate to high quality patient care.

Trainee doctors learn appropriate attitudes and their underpinning values partly through instruction, partly through immersion in a culture which exemplifies and supports those attitudes and values, and partly, but importantly, through the example of medical educators involved in their training. There is clear evidence that doctors in training learn much from observation of their trainers, not just in watching the performance of procedures but also in watching and listening to the trainers’ interactions with patients.2

Thus in carrying out their educational role, medical educators must exemplify the values which support best practice in both patient care and the involvement of patients in medical education. These values are summed up in the phrase ‘respect for patients.’

Respect for patients in medical education includes all the attributes which are recognised as important for high quality patient care: good communication between doctor and patient; high priority for patient safety; the need to maintain the patient’s dignity at all times; attention to issues of confidentiality; recognition of issues of equality and diversity; and the balancing of quality of care against considerations of cost and efficiency. All of these are embedded in the curricula of medical education and the guidance given to medical educators.3,4 There is a considerable body of research describing how curriculum requirements are put into practice in patient-centred learning, with descriptions of innovative approaches and exploration of the responses of students.5 However, there is very little material which considers medical education from the perspective of the patient.

The patient in medical education is first and foremost a patient, a person seeking professional help and expecting professional care. For the patient the provision of experience for trainee doctors is secondary. Nevertheless most patients






The growing focus on patient-centred health care and the involvement of patients in decisions about their own care brings further challenges for medical educators.8 Respect for patients now requires an attitude which accepts patients as partners in the delivery of health care. In educational situations, in particular, this means talking to patients, not over them. Trainers and trainees may be happy to discuss ‘a body’ or ‘a condition’, but for the patient it is ‘my body’, ‘my condition’. Patients appreciate involvement in discussion between trainers and trainees because it helps them to understand better their own condition and make more informed decisions.9 Full involvement of patients in discussions also helps trainees, educators and patients to appreciate and reflect on the enhancement of patient care through medical education, and provides real opportunity for immediate patient feedback. Patients are experts on how they feel and on how it feels to be questioned, examined or treated by a trainee. Their expertise is a valuable resource for trainer and trainee and should be acknowledged and used.

Involving patients in decisions about their own care includes accepting that patients can and do make decisions which are contrary to professional advice. Inculcating attitudes to support this is a challenge for medical educators in a training environment which properly emphasises a professional responsibility to make decisions about diagnosis and treatment on the basis of the best available evidence.

The challenges of inculcating appropriate values and attitudes are exacerbated by pressure on resources. Respect for patients in medical education takes time and effort. Medical educators, especially educational supervisors, have little time dedicated to this activity, and the time and availability of trainees is increasingly constrained. There is pressure to maximise resources by involving more trainees in each patient interaction. Balancing educational requirements with the demands of service delivery and high quality patient-centred care is a growing challenge.

A further challenge is maintaining the supply of patients willing to be involved in medical education. Some have detected a trend for more patients to decline involvement. Good communication with patients about educational aspects of their interaction with trainees, careful management of the expectations of patients and trainees,

and concern for the dignity of patients at all times – in short, respect for patients – will go a long way to encouraging patients to remain central to medical education.

References1. British Medical Association Medical Education

Subcommittee. Role of the patient in medical education. London: British Medical Association; 2008

2. Jacobsen L, Hawthorne K, Wood F. The ‘Mensch’ factor in general practice: a role to demonstrate professionalism to students. Brit J Gen Pract. 2006; 56 (533): 976-979

3. General Medical Council. Tomorrow’s Doctors. London: General Medical Council; 2009

4. General Medical Council. Patient and public involvement in undergraduate medical education: advice supplementary to Tomorrow’s Doctors. London: General Medical Council; 2009

5. Spencer J, Blackmore D, Heard S, McCrone P, McHaffie D, Scherpbier A, Gupta TS, Singh K, Southgate L. Patient-centred learning: a review of the role of the patient in the education of medical students. Medical Educ. 2000; 34: 851-857

6. Draper H, Ives J, Parle J, Ross N. Medical Education and patient’s responsibilities: back to the future. J Med Ethics. 2008; 34: 116-119M

7. Hoekstra KA. Medical education and a patient’s ‘rights.’ J Med Ethics online. 13 March 2008

8. Picker Institute Europe, Principles of Good Medical Education and Training: Response to the GMC’s Consultation. Picker Institute Europe; 2004. www.pickereurope.org

9. Howe A, Anderson J. Involving patients in medical education. Brit Med J. 2003; 324: 326-328

http://www.pickereurope.org






2.3 Respect for Learners: Philanthropia and Philotechnia

Sir William Osler (1849-1919) is renowned for his achievements in medical education, which were based on the belief that teaching and care for patients were inextricably linked. Shortly before his death, Osler said (referring to that other great medical teacher Hippocrates) that the highest aim for all medical teachers is both to embody and to inculcate in their students: ‘the love of humanity associated with the love of [their] craft — philanthropia and philotechnia.’1 Just as doctors have a duty to show consideration and respect towards patients, so medical educators, if they value their profession, must respect and value learners, whether these are medical students, doctors in training or members of the other health care professions studying and working with doctors.

Respect for learners is viewed by the Academy of Medical Educators as a core value for all teachers – a professional attitude that medical educators share, and that they should demonstrate in their working lives whether they are teachers, researchers or managers.2 Within ‘Values of Medical Educators,’ the first theme of the Academy’s Professional Standards respect for learners is defined as:

· demonstrating consideration for learners and their professional and personal development needs;

· acting to promote such consideration and appropriate behaviours in others; and

· acting with due consideration for the emotional, physical and psychological wellbeing of learners.

How this works-out in practice is fundamentally about relationships: an individual educator’s relationship with the student. The way such relationships are approached will vary between medical educators and depends to some extent on their style of interaction with others – should one be formal or informal, critical or supportive, familiar or reserved? To help us work our way through the everyday issues that this moral and professional imperative places upon us, we can consider respect for learners in terms of what we already understand about medical ethics in general.

The Four Principles approach is a widely accepted framework for thinking about ethical issues in health care.3 Its chief benefit is that it is culturally neutral, yet relatively simple to understand and easy to apply.4,5 It may be summed up in four basic principles: respect for autonomy, beneficence, non-maleficence and justice.

Professor John Bligh

1. Respect for autonomyThis is usually cited first because it is the key principle that informs our understanding of patient consent. Respecting a patient’s autonomy (his or her right to choose or refuse treatment) is absolutely fundamental to ensuring high-quality patient care. Respecting learners’ autonomy is equally fundamental, and sometimes, equally difficult to navigate in practice. However as Emerson said: ‘The secret of education lies in respecting the pupil. It is not for you to choose what he shall know, what he shall do. It is chosen and foreordained and he only holds the key to his own secret.’6 Indeed, as Tomorrow’s Doctors makes clear, it is the student who is ultimately responsible for his or her own learning.7

Some effects of viewing the learner as autonomous are known to be associated with excellence in medical education. Gunderman and colleagues sum this up neatly: ‘People who choose careers in medicine tend to place a high premium on personal autonomy. They resent instructional strategies that treat them as if they were children and tend not to respond well to situations that allow them little or no choice.’8

A teacher who respects learner autonomy is much more likely to start where the learners are – to discover and respect what they already know, to engage with their questions and challenges, to tailor learning experiences to suit individual styles of learning and to collaborate with them to identify their learning needs. After all, it is hardly respectful to consider that ‘teacher always knows best’, nor that what you want to teach should always take priority over what the learner needs to learn. Seeing learners as largely responsible for their own learning can sometimes be difficult and frustrating; but browbeating people, even where it appears to be for their own good, is never acceptable. Just as a doctor must respect patients’ autonomy by helping them to choose the right treatment for them and offering support even where the final decision is to refuse treatment, so a medical educator must ultimately respect learners’ autonomy, even in those extreme cases involving failure to do what is necessary to pass a course.






2. Non-maleficence All doctors are familiar with the axiom ‘primum non nocere – first, do no harm.’ This is a guiding principle of medical practice, and should also be uppermost in the minds of medical educators. There are many ways a teacher, supervisor or manager can harm a student. Some are active harms (such as bullying, harassing, humiliating, imparting wrong information and so on), but some are more subtle, passive types of harm that may never have a direct object but which might create a net harmful atmosphere. Unfortunately, medical educators have considerable power to make learners’ lives unpleasant through things that they unthinkingly fail to do. The list is long, and includes, but is not limited to, things such as:

· not encouraging the learner to learn; not creating a good learning environment and so putting the learner off learning;

· not respecting the learner’s time and effort (for example, keeping students waiting, not providing timely, constructive or adequate feedback, not relating teaching to what students need to know and so on);

· not role modelling appropriate behaviour; this is relevant to all medical educators, but can be particularly harmful in clinical environments where what students learn will be reflected in how they themselves subsequently treat patients and colleagues9; and

· not keeping up to date with one’s subject; not working to improve one’s skills; not helping colleagues in difficulty.

The overall result of proving a damaging and ineffective educational experience is potentially incalculable; the net cost of poor medical training is ultimately in patients’ lives.10,11

3. Beneficence By contrast to ‘non-maleficence’, beneficence entails an active effort to do good. Teachers tend automatically to assume that they are providing net benefit, since education is seen as an ‘absolute good’. Osler himself said: ‘I desire no epitaph…than the statement that I taught medical students in the wards, as I regard this as by far the most useful and important work I have been called upon to do.’1 But to provide real benefit, educators must do more than merely

provide routine teaching; they must strive towards the sort of excellence that is characterised by philotechnia (love of one’s craft). Developing excellence in medical education involves educational scholarship. This is the process by which medical educators (and this includes educational managers, researchers and teachers) deliberately and continuously improve the quality of their service to learners by using the best available evidence to design, apply and evaluate the methods and interventions they use, seeking feedback from colleagues and students on their work, and then, crucially, making use of what they find to develop a better educational environment.12

4. JusticeDoctors apply the principle of justice when making clinical decisions that involve the weighing up of benefits, risks and costs of treatments; and they are expected to adhere to the principle that patients in similar positions should be treated in a similar manner.13

The concept of justice is important in medical education terms too. It isn’t just about making sure that assessment is fair, impartial and consistently applied, of course; justice needs to pervade everything that medical educators do. In terms of respect for learners, we already know it is important to ensure that learners and colleagues are treated impartially without regard to gender, race, disability, cultural origins, age or religious beliefs. But sometimes the differences are so subtle that is it difficult to remember this in practice. For example, some students are easy to like, and some are not; but excellent teachers use the principle of justice to see past their personal preferences to ensure fair treatment to all. They understand that ‘being nice’ and failing to point out areas for improvement is ultimately just as unfair on a student as being overly critical.

Contained in the principle of justice is the idea of reciprocity and equality: teachers should treat students as they themselves expect to be treated. In such a constructive, collaborative environment, the teacher becomes ‘a senior student anxious to help his juniors.’1






ConclusionSometimes it is necessary to balance more than one of Beauchamp and Childress’s principles against each other, which is a constant challenge for medical educators. Take, for example, a formerly high achieving student who develops a problem that seriously affects her fitness to practise. In such circumstances, her teachers and course managers may have to weigh the principles of autonomy, beneficence, non-maleficence and justice against each other to work constructively with the student (as an autonomous individual) to decide on the best course of action. Medical educators will of course want to provide a struggling student with plenty of appropriate support and, as far as possible, to respect that student’s wishes and desires. However, they have to consider this in the context that to do so may be unfair to other students, especially if rules or resources are applied unequally. In addition, harm might also be caused to both patients and others – and ultimately to the individual student – if he or she is allowed to pass the course without satisfying the necessary checks.

Medical education is a complex business and in circumstances such as the one described there can be no hard and fast rules. Each student must be respected as an individual, but this is much easier to achieve where there is an appropriately considerate and professional environment. Providing a supportive and stimulating learning environment is how medical teachers show respect for learners. They do it for the benefit of society and through pride in their profession as medical educators – thus demonstrating for a new generation of doctors the timeless virtues of philanthropia and philotechnia.

References 1. Osler W. Aequanimitas, With Other Addresses to Medical

Students, Nurses and Practitioners of Medicine. 4th edn. London: The Keynes Press; 1984

2. Bligh J, Brice J. Further insights into the roles of the medical educator: the importance of scholarly management. Academic Medicine. 2009; 84 (8), 1161-5

3. Beauchamp TL, Childress JF. Principles of biomedical ethics. 3rd edn. New York, Oxford: Oxford University Press; 1989

4. Gillon R. Medical Ethics: four principles plus attention to scope. Brit Med J. 1994; 309: 184-8

5. Sokol D. William Osler and the jubjub of ethics; or how to teach medical ethics in the 21st century. J Roy Soc Med. 2007; 100, 544-546

6. Emerson RW. Education. In: Lectures and Biographical Sketches. In: Emerson EW, ed. The Complete Works of Ralph Waldo Emerson. Boston: Houghton Mifflin; 1883. pp.125-59

7. General Medical Council, Tomorrow’s Doctors. London: General Medical Council; 2009

8. Gunderman RB, Williamson KB, Frank M, Heitkamp DE, Kipfer HD. Learner-centered Education. Radiology. 2003; 227 (1), 15-17

9. Knight LV, Bligh J. Physicians’ Perceptions of Clinical Teaching: A Qualitative Analysis in the Context of Change. Advances in Health Sciences Education Theory and Practice 2006; 11 (3), pp. 221-234. Available at: http://www.ncbi.nlm.nih.gov/pubmed/16832706 (accessed 25 September 2011)

10.Bligh J. The editorial imperative. Med Educ. 2005; 39 (12), 1174-1175

11.Walsh K, ed. Cost Effectiveness in Medical Education. Oxford: Radcliffe Medical Publishing; 2010

12.Corrigan O, Ellis K, Brice J, Bleakley A. Quality. In: Swanwick T, ed. Understanding Medical Education. Oxford: Blackwell; 2010

13. General Medical Council, Good Medical Practice. London: General Medical Council; 2006

http://www.ncbi.nlm.nih.gov/pubmed/16832706






2.4 Continuous Professional Development

Dr Kieran Walsh

‘The education of the doctor which goes on after he has his degree is, after all, the most important part of his education.’ 1

John Shaw Billings

Writing over one hundred years ago John Shaw Billings showed remarkable foresight into the importance of Continuous Professional Development (CPD). It is vital that all doctors take active part in CPD activities and medical educators are no exception. There are a number of reasons for this. First, we will benefit personally from the experience of updating our skills in medical education. Secondly, our learners and their patients and the public at large will gain enormously from having medical educators who are up to date and confident in their teaching practice. Thirdly, as educators we must set a good example to all doctors – for if medical educators cannot be trusted to continuously develop their own skills and practice, then no group can.

The standards set out by the AoME in the field of CPD are explicit.2 Members and fellows are expected to:

· demonstrate a commitment towards his/her own personal educational development;

· demonstrate a willingness to advance his/her educational capability through continuous learning; and

· demonstrate an active engagement as appropriate with debates within medical education.

This short article looks at what medical educators should do to continually develop their skills and practice. The Chartered Institute of Personnel and Development (CIPD) defines CPD as: ‘the conscious updating of professional knowledge and the improvement of personal competence throughout your working life. It is a commitment to being professional, keeping up to date, and continuously seeking to improve.’ But how are medical educators to actually do this in practice?

The first AoME Standard requires a commitment towards one’s own personal educational development. The key word here is personal – faculty development programmes for educators play an important role in medical education but an educator shouldn’t just choose an off-the-peg course. Rather they should think about their own personal learning needs and how these should be met. Ideally

these needs should be mapped to the needs of students and patients or communities. The needs will also depend on the exact stage of the medical educators’ career. Many faculty development programmes focus on teaching skills – for example how to facilitate small groups or become a mentor.3 This may not be helpful to someone who needs to redesign a curriculum or set up new assessment structures at their institution. Ideally the needs of the individual educator and their institution should be aligned – for example a medical educator working for an institution whose ethos is one of interprofessional learning will set out in their personal development plan their need to develop their skills at facilitating small groups composed of learners from different backgrounds. Courses on medical education should ideally be flexible and modularised – enabling the educator to choose elements of a programme that meets their own particular need. Those who mentor or appraise medical educators should encourage an eclectic approach amongst appraisees as to how they fulfil their needs.

The second AoME Standard requires that educators advance their ‘educational capability through continuous learning’. This standard relates to educators learning about medical education with the explicit purpose of putting what they have learned into practice. Between learning and practice there are a number of commonly encountered pitfalls and for CPD to ‘work’ for medical educators, then we must avoid them. Perhaps the most common pitfall is to view CPD as a practice that can be carried out in isolation from other activities. Medical educators may develop their skills but unless the infrastructure is in place for them to practise their new skills, then they will become frustrated and demotivated. This problem is not unique to medical education and we can learn from change management techniques that have been implemented in other domains and apply these in our own particular sphere.

Another pitfall is to forget the many conflicting pressures that medical educators are under. The majority of those who work in medical education also work as clinicians, managers or leaders in other branches of health care and thus they will have to do CPD in order to help develop their clinical, managerial and leadership skills. So, for the purpose of developing medical educational skills, we must cultivate links with all faculties within medicine to ensure that CPD is recognised, protected and can enable the individual taking part to accrue credits or points if they






need to (in relation to the particular CPD scheme that they are signed up to).

A third and final pitfall is to avoid looking at CPD as simply a formal activity. In this way, it is vital to ensure that one does not miss out on the rich and varied development opportunities available to educators whilst on the job. Too often we go on our ‘train the trainer’ course and feel that we have ticked the required box and indeed gone to considerable expense and trouble to do so. And yet at the same time we can miss out on the opportunities to learn from praise or complaints about our teaching practice or look at critical incidents where things went wrong or nearly went wrong. The rich tapestry of medical education can provide ample content for lifelong learners.

The third and final Standard is to: ‘demonstrate an active engagement as appropriate with debates within medical education’. This Standard recognises clearly that the field of medical education is still in a state of flux and, as of yet, is very far from being a fait accompli. There is room for debate in a wide range of topics within medical education and we hope that the series Excellence in Medical Education will become a forum where such debate will take place. The role of e-learning in CPD generally, and in CPD for medical educators specifically, is one such hot topic. E-learning has been the new kid on the block for over ten years now so it has become timely to look critically at the progress that has made.4,5 One question amongst many might be what role if any should e-learning play in the CPD of medical educators?

This article is centred on what I hope is an evidence based view of the standards but inevitably some of it is tinged with my own interpretations. No doubt others will have differing interpretations and Excellence in Medical Education would be delighted to publish letters or other forms of communication with differing views. Come and join the debate!

References 1. Billings JS. Cited in Manning PR, Debakey L. Medicine:

Preserving the Passion. New York, Springer –Verlag, 1989.

2. http://medicaleducators.org/index.cfm/profession/profstandards/ ( accessed 1 Aug 2011).

3. Steinert Y. Staff development. In: Dent JA, Harden RM, eds. A Practical Guide for Medical Teachers. Oxford: Churchill Livingstone; 2009. pp.391-397

4. Ellaway R. E-learning: Is the revolution over? Medical Teach. Apr 2011; 33 (4) 297-302

5. Sandars J. It appeared to be a good idea at the time but…A few steps closer to understanding how technology can enhance teaching and learning in medical education. Medical Teach. Apr 2011; 33 (4), 265-267






2.5 Equality of Opportunity and Diversity

Dr Roger Worthington and Mr Mekbib Gemeda

Respecting human rights requires one person to acknowledge and respect the cultural identity of another, which applies equally to medical students and trainees as it does to members of the public. Personal values are often culturally defined, and in the context of aspiring to excellence in standards of medical education, the cultural aspect of professionalism needs to be seen as an integral part of training to be a competent physician. In the paper that follows the authors consider these issues and argue that training physicians to work to high standards of patient care necessarily requires them to become culturally competent. It is not enough for educators to provide occasional lectures on related topics in order to meet legal minima – it requires imagination, hard work and commitment to be able to integrate cultural competency into curricula in ways that are meaningful and relevant. The goals outlined require a proactive strategy to be adopted by leaders in medical education. Understanding the place of cultural values in medical education is a significant part of personal and professional development, and showing respect for diversity and equality of opportunity is a necessary legal and moral requirement for trainees and experienced clinicians alike.

Cultural Values and Personal Professional Development

Background Following a masterclass at the Academy of Medical Educators on ‘Cultural Dimensions of PPD: Developing an Integrated Approach’ (September 2010), we write to identify and share some learning outcomes and reflections from that event. While there is limited time and space in medical education programmes in which to explore interplays between culture, equity, and diversity and quality of care, we argue that this is an important and under-researched area. In sharing these thoughts we hope that readers will join in discussions on how better to address these issues within the context of personal and professional development. Although aspects of the topic are covered by human rights law, the law always tends to be reactive, even where it stipulates for institutions to adopt proactive policies.1 To be forward thinking, therefore, the law is not the only thing that needs to be considered.

Patient care occurs in a social and cultural context. The clinical problem at hand and the congruent or diverging

perspectives that patients and providers have provides a framework for much of the patient care experience. While divergence of cultural perspectives is commonly associated with differences in ethnic, racial or national origin of the patient and provider, it also applies to the cultural context of where the doctor/patient encounter takes place. In the U.S., efforts to understand and enhance physician patient interaction have in the last 30 years tended to focus on two concepts: patient-centeredness and cultural competency.1 While the two concepts overlap they are based on different premises.

Patient-centeredness embraces the core idea of the patient as a unique person and the importance of shared decision-making. Cultural competency, on the other hand, which evolved in the 1990s, was driven by studies demonstrating major racial and ethnic health disparities. The focus of cultural competency was on patients as members of ethnic or racial groups as being underserved by health care systems. While both approaches aimed at improving quality of care, they emphasised different aspects – one centred on individualized care, the other on equitable care to disadvantaged populations to try and address serious ethnic and racial disparities. However, there is a commonality between the two, as individualized care is essential to providing culturally competent care that takes full account of patients’ social and cultural perspectives.

Health care outcomes resulting from divergences between patient and provider and health care systems can be alarming, and recommendations contained in a report by the U.S. Institute of Medicine Study, stress the need for: ‘greater diversity in the health professions to expand the disciplines’ ability to conceptualize and respond to the health needs of increasingly culturally and linguistically diverse population.’2 The likelihood of cultural difference being a factor in the doctor-patient setting is high, and this can influence patient outcomes in terms of how decisions are made and the cultural expectations that influence patient behaviours.3 Overall the place of cultural competence within medical education is presently not well defined in the U.K., with different schools giving it different degrees of emphasis, and sometimes it is up to individual teachers to fight for a corner of the curriculum.






Review pointsKey points raised by delegates during the workshop (when responding to podcasts of patient interviews) include:

a. When caring for patients from ethnic minority backgrounds physicians must learn to be self-reflective and look for signs showing when a patient (or patient advocate) is not actively participating in discussions about a proposed treatment.

b. The real cause of a problem may be as much social as clinical; listen to colleagues, including juniors, who might have insights that the responsible clinician could miss.

c. Avoid making unfounded judgments based on false assumptions; build a rapport with patients and make extra efforts to communicate.

d. Be curious to explore social boundaries that limit meaningful communication; be prepared to work hard to negotiate an acceptable outcome, especially with so-called ‘heart-sink patients’.

e. Humour can be a valuable ingredient in the patient-physician encounter.

f. Be aware of burnout and physician fatigue; loss of curiosity is a telling sign.

Some key points from presentations at the workshop include:

i. Medicine is practised ‘in context,’ and diversity can be in conflict with requirements for uniform ethical and legal standards.

ii. There may or may not be a distinction between private and professional values; while a doctor does not need to surrender his/her personal identity, s/he should comply with normative standards applicable in the place of work; international medical graduates may have to adapt in order to meet local standards.

iii. Cultural competency is a way of defining who we are, not just what we perceive as ‘difference’ in terms of race, ethnicity, culture, language, gender or social inequality; influences of culture and ethnicity on professional practice are often subtle and complex.

iv. Cultural norms vary between ethnic groups and between countries, giving rise to different expectations from

professionals (e.g. in India where the role of family and the degree of respect for patient autonomy differs markedly from in the U.K.).

v. Assumptions brought to a clinical consultation reflect a range of different values, beliefs and cultural norms; a mix of cultural values adds richness to society and a range of moral values can be accommodated, provided that universal rights are respected, including boundaries between personal and professional autonomy.

vi. Cultural aspects of medical professionalism need to be recognised by educators; we argue that an integrated approach to teaching and learning ethics, professionalism, and cultural competency is intellectually coherent and benefits individuals as well as the public interest.

vii.Efforts to address health disparities in the U.S. were propelled by social and legal transformations, such as the civil rights movement and affirmative action laws; the rationale for diversity and cultural competency in medical education evolved from efforts to achieve population parity and improved health care outcomes.

Challenges in medical education Despite growing recognition of the need to increase cultural competency in undergraduate medical education, there is a lack of uniformity and cohesion in the development and delivery of cultural competency teaching.5 Educational approaches vary greatly in terms of time commitment, target audience, curricula content and methods of assessment. A 2003 study found that while the proportion of U.K. and Irish medical schools teaching cultural diversity had increased to 70%, such education remained ‘fragmented, unsystematic, and lacking in clarity.’6 By contrast, in the U.S. there is a requirement to ensure the inclusion of cultural competency in medical curricula, backed by guidance provided by the Association of American Medical Colleges.7

As with other curriculum areas, medical schools are free to determine policies, methods, and practices for teaching cultural diversity, and consistency is not generally prized other than to determine high level learning outcomes. Programmes additionally have to overcome learner resistance, and the necessity of acquiring cultural competence skills is at times questioned by students as well as faculty.6 In creating conceptual frameworks to teach






these skills institutions must be aware of how they portray certain cultural groups to avoid simply reinforcing cultural stereotypes.8,9 Some people have difficulty viewing culture other than in terms of race, ethnicity and religion, and there is a misplaced assumption that if one possesses good interpersonal and communication skills there is no need to learn specific cultural skills, as if somehow they were to emerge naturally like common sense.

An oft-cited weakness is the lack of a standardised method to measure a curriculum’s lasting impact and whether or not such assessment can be achieved in an objective way.5,8 This problem is not unique to issues of cultural competence, but in thinking about ways to improve teaching, some people argue that the first step towards demonstrating commitment to improving cultural competence education is through the development of an institutional policy, aimed at sending a message that the acquisition of these skills is an essential part of students’ medical education.5

As far as attitudes are concerned it is worth considering the influence of role-modelling and the ‘informal curriculum’ and additional faculty training in cultural competency may well be required.5 Self-reflection is another useful tool to address learner resistance and students may need support in understanding their personal values, biases and prejudices.5,8 Teaching outside the classroom and hospital setting through medical school community partnerships is a useful way of exposing students to culturally diverse patient populations. Through extended engagement with communities, students have opportunities to acquire deeper insights into patients’ lives.5 Although creating adequate assessment tools to determine the effectiveness of these efforts remains a challenge, regardless of the obstacles, institutions must strive towards achieving cultural competency in medical education for the benefit of students, faculty, and most importantly, patients.

References1. Beach M, Saha S, Cooper L. The Role and Relationship

of Cultural Competence and Patient-Centeredness in Health Care. Quality Commonwealth Fund; 2006, pub. no. 960

2. Smedley BD, Stith AY, Nelson AR, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington DC: National Academies Press; 2003

3. Worthington R, Gogne, A. Cultural Aspects of Primary Healthcare in India: A case-based analysis. Asia Pacific Family Medicine. 2011; 10:8 doi:10.1186/1447-056X-10-8

4. Equality Act, 2010. Draft Code of Practice on Further and Higher Education. http://www.equalityhumanrights.com/legal-and-policy/equality-act/equality-act-consultations/closed-consultations/ (accessed 25 September 2011)

5. Dogra N. Twelve tips for teaching diversity and embedding it in the medical curriculum. Med Teach. 2009; 31 (11): 990-3

6. Dogra N, Connin S, Gill P, Spencer J, Turner M. Teaching of cultural diversity in medical schools in the United Kingdom and Republic of Ireland: cross sectional questionnaire survey. Brit Med J. 2009; 330: 403-4

7. American Association of Medical Colleges. Cultural Competence Education. https://www.aamc.org/download/54338/data/culturalcomped.pdf ((2005) accessed 25 September 2011)

8. Boutin-Foster C, Foster JC, Konopasek L. Physician, know thyself: the profession culture of medicine as a framework for teaching cultural competence. Acad Med. 2008; 83 (1): 106-11

9. Chun, MB. Pitfalls to avoid when introducing a cultural competency initiative. Med Educ. 2010; 44 (6): 613-20

http://www.equalityhumanrights.com/legal-and-policy/equality-act/equality-act-consultations/closed-consultations/



https://www.aamc.org/download/54338/data/culturalcomped.pdf

https://www.aamc.org/download/54338/data/culturalcomped.pdf






2.6 Commitment To Medical Education

Professor Ed Peile

crippled airliner on the Hudson River), or system failures (as in the case of Baby P, Maria Caldwell et al), Atherton invokes Gawande to claim that: ‘In such closely-coupled systems, personal reflection is—beyond the recognition of gross personal mistakes—pretty futile.’

I don’t think I could ever call reflection futile. Dithering may be, but the skilled combination of reflection-on-action and reflection-in-action,2 (Schön, 1987) combined with deliberate practice3 undoubtedly lead to individual quality improvement. Teams are made up of individuals and although much remains unknown about the processes that go on in the black box of quality improvement at systems level,4 I find it hard to believe that the influence of individuals on cultures does not play a strong part. This is recognised in the draft which I have seen of the ‘new standards’ which talk about commitment to: ‘enhancing the practice of medical education through analysis and reflection.’ They go further in recognising the importance of developing an educational philosophy – something which I strongly welcome in view of the importance to individuals and organisations of having a shared vision incorporating explicit values.5

Mentoring and Role ModellingThe first version of Professional Standards cites role modelling or mentoring as important evidence of commitment to medical education. It is mentioned twice: firstly to ‘develop and promote appropriate behaviours in others’ and secondly to ‘foster an enthusiasm for, and ability in medical education in students and colleagues.’ Neither mentoring nor role-modelling are mentioned in the draft revisions which refer instead to supporting ‘colleagues in their personal and professional development.’ I believe strongly that role-modelling is a vital component of this support,3 and that mentoring, be it peer-to-peer mentoring of junior learners, or upward mentoring of our seniors, all involve us in modelling. Mentoring has long been recognised as playing an important part in the systems that develop professionalism.6

Involvement in the wider spheres of medical educationThe original Professional Standards asked that medical educators: ‘Demonstrate a willingness to become involved

What do we mean by commitment?In my time as Lead Assessor for the Academy, I have had to think a lot about commitment: it is the defining term for all the assessments of fitness to become a member of the AoME. All members need to demonstrate their commitment to medical education, as must Fellows, who must also demonstrate solid achievement.

The Latin word committere meant ‘to put together or join.’ Committen, a verb, entered the English language in the 14th century meaning ‘to give in charge or entrust.’ Whereas until the last century dictionaries referred to commitment in terms of ‘a pledge or promise element’, more modern definitions emphasise a somewhat altruistic giving of one’s own resources. The (now defunct) Encarta definition of commitment was: ‘something that takes up time or energy, especially an obligation, devotion or dedication, e.g. to a cause, person, or relationship.’ As an assessor, I am looking at applications for evidence of dedication, in terms of time and energy, to the cause of enhancing the care of patients through medical education.

The original version of Professional Standards1 accords commitment to medical education a place as a defined value with five dimensions listed. In redrafting the Professional Standards2 these dimensions are no longer grouped together in this way. Perhaps more effectively, they are now incorporated into the other descriptors of core values and into the other domains. Commitment to medical education is re-envisaged as commitment to people. The people are the stakeholders in medical education: the public; patients; learners; and colleagues. I am going to straddle this period of transition in the guidance of our academy and select four domains that help me to focus on a person’s commitment to medical education.

Quality improvement and reflection on practiceThe original version of Professional Standards makes a direct link between enhancing and improving educational provision and evaluation of one’s own practice. Is that causal assumption justified? Atherton1 thinks not. Referring to system successes (as in the safe landing of the

1 The original ‘Professional Standards’ is the one on which this edition is based, unless otherwise stated.

2 The new version of ‘Professional Standards’ is due for release 25th October, 2011






in wider medical educational activities such as accepting positions of responsibility within universities, NHS organisations, learned societies, Royal Colleges, academies and other educational providers.’ They went on to look for a contribution: ‘to educational policy and development at local or national levels.’ At the time of writing, the revision of Professional Standards is likely to condense this to: ‘Is an advocate for medical education.’ Is that all that needs to be said?

For me the wider involvement is not a sine-qua-non. ‘They also serve who only stand and wait’ is no excuse for idle inactivity. Rather it is, I believe, Milton’s way of affirming that quiet, reflective, service can be as important as highly visible, high status activities on the world stage. How then does one interpret commitment? I think we have to look at the whys and wherefores of accepting offices, committee roles and positions of responsibility. In between the two poles of egotism and altruism lies the constructive position where able individuals can serve both self (ego) and others (altrui), by using their talents not only to advance their careers but also genuinely for servant leadership.7

‘Someone’s got to do it’ is a refrain of some of the falsely modest professionals who jog the corridors of power and rush upstairs. The test for the AoME assessment group is not what roles someone holds, but what they do in that role. What have you achieved as leader of this or chair of that? How imaginatively have you discharged your responsibilities? That’s what I understand by commitment in this respect, and it can be demonstrated at the lowest or the highest of levels.

Provision of safe and effective learning at all times I welcome this addition to the ‘new standards’. But let’s dig a little deeper into what this commitment involves. Safety is not an absolute quality; it is a relative one, bearing in mind the dangers in over-protection and the need to balance learner safety against patient safety. Implicit in the concept of effective learning for me is that the learner constructs the learning. Thus I believe that our commitment is to the provision of the environment and to enhancing the climate for the learning. This can sometimes be difficult to demonstrate.

ChallengesIn some respects defining ‘commitment’ is like trying to define ‘good doctoring’ or ‘good nursing’. It provokes the response: ‘I can’t define it, but I know it if I see it.’ To take this forward in the Academy we need to apply scholarship to the following issues. We need to demonstrate more clearly the importance of individual self improvement to collective quality improvement in medical education. We need to provide more evidence of what effective mentoring can achieve for medical education and patient care, in order to get institutional buy-in to this form of commitment. We need to reflect together on how best to use the time and the energy that medical educators are prepared to commit to the enterprise – we may find that ‘more at the bedside’ and ‘less in committee’ is the optimal use of resources.

References1. Atherton JS. Doceo; Reflection; an idea whose time is

past. Lincoln: University of Lincoln; 2010. In http://www/doceo.co.uk/heterodoxy/reflection.htm (accessed 23 September 2011)

2. Schön DA. Educating the reflective practitioner: Toward a new design for teaching and learning in the professions. San Francisco: Jossey-Bass; 1987

3. Cruess SR, Cruess RL, Steinert Y. Role-modelling – making the most of a powerful teaching strategy. Brit Med J. 2008; 336: 718-721. Ericsson KA. Deliberate practice and the modifiability of body and mind: Toward a science of the structure and acquisition of expert and elite performance. Int J Sport Psychol. 2007; 38: 4-34

4. Arah OH, Klazinga NS, Delnoij DMJ, Ten Asbroek AHA, Custers T. Conceptual frameworks for health systems performance: a quest for effectiveness, quality, and improvement. Int J Qual Health C. 2003: 15; 377–398

5. Pendleton D, King J. Values and Leadership. Brit Med J. 2002: 325; 1352

6. Reynolds PP. Reaffirming professionalism through the education community. Ann Intern Med. 1994: 120; 609-614

7. Greenleaf R. The Power of Servant Leadership. San Francisco: Berrett-Koehler; 1998






3. A View from a Specialist: The Values of Dental Educators

Gareth Holsgrove and Raj Rajarayan

At first sight this might be seen as a largely irrelevant section because there is little distinction between the core values of dental educators and those of medical educators. Nevertheless, it is helpful to look at these from the perspective of dental education, even though there are various reasons for, and many educational advantages of, this congruence between medical and dental education. For example, the medical and dental professions have many common features, including providing good patient care, being competent and up to date in clinical practice, and adhering to strict standards of professional regulation and governance. Moreover, it is a medical royal college – the Royal College of Surgeons of England – that is home to the professional faculties for both Dental Surgeons and General Dental Practitioners.

Similarities are also to be seen in undergraduate and postgraduate education. For example, undergraduate medical and dental students might work in integrated groups for parts of their course, and a number of postgraduate courses and Continuing Professional Development (CPD) activities are open to both doctors and dentists. There are also a small number of specialists such as maxillo-facial surgeons who hold both medical and dental qualifications.

Since there are many common aspects of medical and dental practice, it is unsurprising that there are also many points in common between medical and dental educators. Indeed, in some instances educationalists specialise in both medical and dental education and are thus in a particularly good position to share best educational practice between the two professions.

There are, though, two particular respects in which dental education is different from medical education. The first is that interdisciplinary training involving different General Dental Council (GDC) Regulated Dental Care Professionals (DCPs) is common in dentistry. For example, dentists and dental nurses are often trained together in such areas as crisis management, medical emergencies and four-handed dentistry. Work based training is becoming increasingly relevant and prominent in dentistry and this brings special features and challenges because most dentists carry out all aspects of dental surgery in the primary care setting.

‘Values of Medical Educators’ is structured around six themes and the two regulatory bodies – the General Medical Council1 (GMC) and the GDC – both reflect them clearly

in their professional standards documents and require that professional training curricula are based on them. In dentistry, the core documents that indicate the values of dental educators are The First Five Years2 and Standards for Dental Professionals.3

The First Five Years was first published in 1997 and while it was being developed the Chief Dental Officer established the Dental Curriculum Support Scheme (a sister programme to Kenneth Calman’s Undergraduate Medical Curriculum Support Scheme) to prepare dental schools for the necessary changes to their curriculum, its delivery and assessment, by providing an educational perspective and facilitation on the content, values and outcomes of dental education for the 21st century.

Subsequent editions of The First Five Years followed in 2002 and 2008. The first two editions were particularly notable, for the first set out the broad curriculum areas for undergraduate dental education and the second went ‘well beyond the first edition’ providing: ‘a holistic picture of the context as well as the content of the undergraduate dental curriculum and the product of that curriculum i.e. the: ‘caring, knowledgeable, competent and skilful dentist.’4

The current edition emphasises that:‘the GDC puts professionalism at the heart of its agenda. The scope of what Council requires of undergraduates goes beyond academic achievement, and incorporates the attitudes, values and behaviours needed for registration...All dental students must have knowledge of our ethical guidance, Standards for Dental Professionals, and its associated guidance, and demonstrate their professionalism.’2

It also emphasises that dental schools are required to take account of: ‘the fact that the primary dental degree or diploma represents only the first stage and curricula must prepare students to carry out self-directed learning to keep their knowledge and skills up-to-date throughout their professional lives.’2

Standards for Dental Professionals5 sets out six key principles that dental professionals are expected to follow:

1. putting patients’ interests first and acting to protect them;

2. respecting patients’ dignity and choices;






3. protecting the confidentiality of patients’ information;

4. co-operating with other members of the dental team and other health care colleagues in the interests of patients;

5. maintaining professional knowledge and competence; and

6. being trustworthy.

These themes underpin the values of dental educators and are developed in Essential Skills for Dentists6 which highlights key competencies in the clinical context with a view to delivering a curriculum aimed at producing a self-reflective and competent professional who can respond to the challenge in an evolving, team-oriented profession.7

These aims are related to The First Five Years in a way that is relevant to the development of the truly professional mind in dental undergraduates. Essential Skills for Dentists also describes how key aspects of dental professionalism can be assessed and developed in integrated dental care and, once more, highlight the values of dental educators.8

There are many similarities between the values of medical and dental educators as well as the standards and regulation of the two professions. However, the nature of dental education means that much of it takes place in multidisciplinary teams and in primary care settings. This, in turn, means that the six elements considered in ‘Values of Medical Educators’, while highly relevant to both medical and dental educators, might show a different balance between the two.

References 1. General Medical Council, Good Medical Practice.

London: General Medical Council; 2006

2. General Dental Council, The First Five Years. 3rd edn. London: General Dental Council; 2008

3. General Dental Council, Standards for Dental Professionals. London: General Dental Council; 2006

4. Mossey P. The First Five Years: Dawn of a new era? Brit Dent J. 2003; 194, 350-351. Published online: 12 April 2003 | doi:10.1038/sj.bdj.4809986

5. General Dental Council, Standards for Dental Professionals. London: General Dental Council; 2005

6. Mossey P, Holsgrove G, Stirrups D, Davenport E. eds. Essential Skills for Dentists. Oxford: Oxford University Press; 2006

7. Davenport E, Holsgrove G, Mossey P, Stirrups D. Teamwork. In: Mossey P, Holsgrove G, Stirrups D, Davenport E. eds. Essential Skills for Dentists. Oxford: Oxford University Press; 2006. pp.497-507

8. Holsgrove G, Stirrups D, Mossey P, Davenport E. eds. Key Skills in Integrated Dental Care. In: Essential Skills for Dentists. Oxford: Oxford University Press; 2006. pp.469-480






4. An International Perspective: The Values of Medical Educators

Professor Judy McKimm

‘If you are involved in teaching you must develop the skills, attitudes and practices of a competent teacher.’1

The importance of teachers and educators in ensuring the quality of medical and health professions’ education is widely acknowledged internationally.1-4 .However, the values that all medical educators (whether they be doctors, biomedical or social scientists, or other health professionals teaching in all contexts) need to demonstrate tend to be implicit and assumed rather than explicit, and are typically associated with the professional competences and attitudes that practising doctors are expected to display.

The professionalization of medical educationAs medical education becomes increasingly professionalised and professionalism itself is addressed in medical curricula, defining the values of medical educators as influencers and change agents is important. The UK Academy of Medical Educators (AoME) is one of the first organisations in the world to explicitly define core values in its Professional Standards:5

1. Professional integrity

2. Respect for patients

3. Respect for learners

4. Continuing professional development

5. Equality of opportunity and diversity

6. Commitment to medical education.

The General Medical Council (GMC) suggests that teachers’ core characteristics include being able to: support, motivate, encourage and mentor students, and enthuse them about caring for patients; possess good communication and listening skills; provide constructive feedback; have a flexible approach; remain open to change; and act as a good role model.3

An international perspective Although values of medical educators are not specified explicitly in international standards, a range of documents emphasise that teachers need to be experts in their own area of medicine. They also need to keep up-to-date with both clinical and educational knowledge and skills; recognise the vital importance of teacher development;

practise collaboratively and inter-professionally, and understand that a core goal of education is to improve the health of all peoples, in terms of access, quality and outcomes.1 International standards explicitly foreground demographic and cultural contexts and their definitions of ‘professionalism’ includes ‘altruism, service to others...justice and respect for others.’6

As the world becomes smaller and more connected, teaching needs to acknowledge the importance of global health and social accountability. We live in multicultural, diverse societies and the doctors whom we educate will work in other countries and with people from a range of cultures and backgrounds, including migrants and refugees. In many rural and remote areas of the world, achieving the Millennium Development Goals seems far away with high levels of poverty and non-communicable and communicable diseases, variable access to healthcare, few specialised services and poor maternal and child health.

Educators need to produce doctors who can practise medicine in an ever-changing and unpredictable world, who are clinically and culturally competent and use their global knowledge and experience to improve health and well-being, irrespective of where they eventually work. They are tomorrow’s leaders and change agents, serving as advocates of people’s rights to access resources, education and healthcare with a sense of social justice.7

Conflicts and challenges‘A teacher affects eternity; he can never tell where his influence stops.’

Henry Brook Adams

In an increasingly regulated and bureaucratic world, many educators struggle to balance the need for: assuring educational quality with supporting individual growth and development; and demonstrating proficiency against a focus on the core values that underpin effective learning.

It is not enough to be able to understand the theoretical principles behind curriculum design, blended or workplace based learning, if the curriculum is devoid of opportunities for the necessary discussion and development that facilitates being and becoming a doctor.8 The thoughtful, reflective






and truly scholarly educator pays as much attention to considering and researching value-based issues as they do to ensuring the statistical reliability of assessments.

In medical education the ‘product’ is a professional who is bound by codes of professional standards that are underpinned by core values. Teachers display these core values every day in bedside teaching and classrooms and we can all recollect the influence and impact of teachers from our past.

What is it about them that inspired us and made us want to learn? Our response would probably include: a certain passion for their ‘subject’; a particular critical curiosity about why and how things work; humility in knowing that there is more that they don’t know than they do; and a drive to make a difference, to make things better: for patients, for health systems, for students. These values motivate teachers to pass on their knowledge and skills to support learners to fly further and to achieve more than they did and to take up leadership positions, so that they can influence wider system changes and improve the student and patient experience.

What can we learn from educators around the world?Wherever we live and work, we encounter ‘natural’ teachers who are part of communities of practice, working with learners to enable them to become excellent and expert practitioners. Some might not have much knowledge of educational theory or finely honed teaching skills, but they genuinely want to pass on their clinical skills and knowledge so that learners become better doctors able to practise both the art and the science of medicine and improve health care.

I have learned that we in the West have not got it all right, that we need to be open to new experiences and ways of working and that we can make a difference. Around the world, good teachers: demonstrate cultural sensitivity and competence; acknowledge indigenous peoples’ rights, beliefs and practices, the role of traditional practitioners and healers, spirituality and the place of religion and faith in people’s lives; demonstrate respect and tolerance (for other cultures, religions and health practices) through compassionate care; work with very limited resources and in difficult conditions; work and learn inter-professionally and collaboratively; balance scholarly practice (underpinned

by theory and evidence) with facilitating the authentic, intuitive, relational process between teacher and learner; are reflective practitioners who provide wise counsel and good role models for learners; show passion – with an ability to inspire, to nurture, to challenge and confront; and display servant leadership and a sense of stewardship that leaves a legacy for the next generation. For me, these are some of the core educator values that transcend international boundaries.

References1. General Medical Council. Good Medical Practice.

London: General Medical Council; 2006. http://www.gmc-uk.org/guidance/good_medical_practice.asp (accessed 22 September 2011)

2. World Federation for Medical Education Basic Medical Education. Global Standards for Quality Improvement. Denmark: World Federation for Medical Education Office; University of Copenhagen; 2003

3. General Medical Council. Developing teachers and trainers in undergraduate medical education. London: General Medical Council; 2011. http://www.gmc-uk.org/education/undergraduate/8837.asp (accessed 22 September 2011)

4. Australian Medical Council. Assessment and Accreditation of Medical Schools: Standards and Procedures. Kingston: Australian Medical Council; 2010. http://www.amc.org.au/index.php/ar/bme/standards (accessed 20 September 2011)

5. Academy of Medical Educators. Professional Standards. London: Academy of Medical Educators; 2011. http://medicaleducators.org/index.cfm/profession/profstandards (accessed 23 September 2011)

6. World Federation for Medical Education. Global Standards for Quality Improvement in Medical Education: European Specifications; For Basic and Postgraduate Medical Education and Continuing Professional Development. Denmark: World Federation for Medical Education Office; University of Copenhagen; 2007

7. McKimm J, McLean M. Developing a global health practitioner: time to act? Med Teach. 2011; 33 (8): 626-631

8. Dall’Alba G, Barnacle R. An ontological turn for higher education. Stud High Educ. 2007; 32 (6): 679-691.






5. The Expert: Interview with Professor Dame Lesley Southgate

Who were your most influential teachers?I have been lucky to be taught by so many people, most of whom did not realise they were doing it! The most influential clinical teacher was Paul Julian, a partner in the Hackney Academic Practice that started the Barts department of General Practice, where I worked for many years, including the time I was head of the GP department at Barts/London. Over the years I discussed patients with him, was a member of a Balint group with him, saw him deal with all manner of clinical and managerial problems, and taught alongside him. He was always full of surprises and sharp common sense and a deep thinker. I think we learned together.

In my academic life I have become knowledgeable about assessment. Many people have taught me and have been generous with their support. But the most influential teacher, by example and through joint working, is John Norcini, now President of the Foundation for Advancement of International Medical Education and Research (FAIMER). He is very well known for his scholarship, research,

Professor Dame Lesley Southgate is Professor of Medical Education

at St George’s Hospital Medical School. She is known internationally and nationally for her work on the assessment of competence and performance of physicians and in 2008 was awarded the prestigious Hubbard award by the U.S. National Board of Medical Examiners (NBME) for outstanding contribution to assessment of competence and performance of doctors in the international arena. Professor Dame Lesley Southgate

clarity and determination to support the next generation, especially in less developed settings. I am fortunate in that he has become a life-long friend as well as a teacher.

There are so many others, including some of my students, but I must mention Donald Irvine. During his time as president of the GMC I worked closely with him in developing the performance procedures. He showed me how to keep my nerve and keep going in the face of political and personal criticism. He remains amazing.

Please describe the most defining moments in your career?As I sit here today, several occur to me. I moved to Canada after my house jobs and did the first part of a residency programme in anaesthetics at McMaster. It was my first experience of problem based learning. But we returned to England because I was expecting my daughter and my husband was still studying. It was a fraught time, nowhere to live, no money and a small baby. And so I drifted into general practice, completely untrained, joining a practice near to my parents






politically, taught me how to differentiate an opponent from an enemy, crucial for leadership roles. It is possible to work constructively with opponents.

Please describe your current rolesCurrently I am:

· Professor of Medical Education at St George’s University of London. I am often away and my roles at George’s are examining, chairing the examination Board for the Physician Assistant course, occasional teaching and some PBL tutoring. I joined George’s very late in my career but have found a true academic home there;

· Assessment lead for the Department of Health programme Modernising Scientific Careers. This is a major project and my current emphasis is on training new trainers in workplace assessment;

· Trustee of the Thalidomide trust. This work is demanding and interesting. For the first time in my career I am working with very senior lawyers and finding it educational and fun; and

· Council member of the Royal Veterinary School. I love this connection with the vets which is active and a huge learning experience for me. I completely support the welcome we will give to vets as they join the AoMed Ed.

Please describe your international roles· I am one of few non-North Americans who is a member of

the U.S. National Board of Medical Examiners (NBME). This is a significant commitment as I also chair a subcommittee of the Board and am a member of two others. I consider the work of the NBME to be a gold standard for assessment in medicine, but am also pleased and proud to attempt to introduce different ways of looking at testing aspects of medicine other than the knowledge base.

· I am currently working with a group of European medical schools and postgraduate organisations to set up a not-for-profit organisation to improve the quality of assessment programmes in European medicine. The work will involve cooperation with the NBME and is based in Rome. I chair the executive committee which also involves Professor Cees Van der Vleuten and Professor Walter Ricciardi.

house where we were staying. It was a terrifying experience, especially the many home deliveries, but I learned to work with a primary health care team, particularly the midwives on the district who knew a thing or two!

Something in me made me want to get some training, and so I studied for the MRCGP which was a newish exam at that time. I worked alone, but passed and was astonished to gain a distinction. I had no sense of the standard or my own ability to reach it. After several years as a principal in practice I made a crucial decision that changed my direction. I went as a graduate student to the University of Western Ontario for a two year programme in family medicine. It finally gave me the academic grounding in research methods and education that set me on my way in academic practice. On my return to the U.K. I joined the Barts department of general practice and primary care.

At first my research interests centred on chlamydial infection in women seen in practice and a defining moment came when a paper was rejected by the BMJ principally because one of the reviewers, well known in the STD field, implied that the data from practice could not be true. I fought that because I was effectively being accused of lying. The paper was published and I realised what a cut throat world academia could be. I have published and reviewed many papers since then and always try to be fair and encouraging.

The years in Barts/London, and working in the Well Street Practice gave me the basis for another change in direction. I became convenor (chief examiner) of the MRCGP and also chaired curriculum development committees in the medical school. My interest in assessment led me to join an international group in a series of Cambridge Conferences, which brought another defining moment in my career. Since those days I have led national projects in assessment and increasingly I now have many international links and projects that are of major importance to me and feel so fortunate in the colleagues and friends that I have met and made along the way. Alongside that theme, I have been President of the RCGP, Vice Chairman of the Academy of Medical Royal Colleges, President of the Association for the Study of Medical Education (ASME), Advisor to Kenneth Calman when he was Chief Medical Officer (CMO) and an unlikely advisor to Lord Mawhinney when he was Minister of Health. Taking on each of those roles is a story in itself, but they were all defining moments. Brian Mawhinney, a complete opposite to me






· I am an internal development advisor to the Egyptian Board of Medical Specialties through a programme run by the RCGP to support family medicine assessment via the Egyptian MRCGP Int. I will visit Cairo next in December 2011.

· From time to time I am invited to assist in or lead QA for other medical schools. I have done this work for the AMC (Oz!) and for the RSCI (Dublin) with whom I have an ongoing connection.

· A very significant role is as a key expert on curriculum for an EU funded programme to improve the quality of life and care for people and families living with HIV/AIDS in Libya. I have been in Libya for significant periods of time over the last two years. The programme addresses all aspects of care for HIV/AIDS from clinical care, laboratory standards, procurement of drugs and supplies, and stigma and discrimination to education and training. Becoming a member of a tight-knit multinational team of experts has been a wonderful experience and is a defining experience I could not have predicted. We are currently suspended because of the war, but we hope to return as soon as conditions allow. I worry daily about the situation of some of my Libyan medical colleagues.

How do you foresee the future of medical education in the U.K.?There are inevitably pitfalls ahead associated with health care reforms and funding constraints, but I remain optimistic about the future for U.K. medical education. My principle reason for saying this is the enthusiasm that is becoming apparent within trainees and new specialists. They have had a different experience at medical school and during training and many of them want to take part in further shaping of curricula, assessments, quality assurance and making sure that patients get a good deal. There will be more public involvement in decisions about priorities, and resolving urgent ethical issues associated with rapid advances in science, and I think it too will be welcomed.

What are the most important values of medical educators?Not in order of importance, but as they occurred to me:

· Putting the patient in the centre when designing curricula.

· Recognising the importance of good role models.

· Value the science which underpins medical education and medical practice.

· Encourage students but don’t stifle them.

· Be ready to lead or to follow as the situation requires.

· Be open to different cultures.

· Learn how to give and receive feedback as a first priority.

What advice would you give to a new educator?· Find a group of people who are starting out and share the

pleasures and pain.

· Don’t get too upset over one session that went wrong.

· Prepare.

What remains as a professional ambition?To return to Libya and finish what we started. To see the European assessment work flourish including the instigation of a series of small conferences that will have the same impact on the next generation as the Cambridge conferences did on me.

What are your aspirations for the Academy of Medical Educators?I founded the Academy with Kenneth Calman. I am so pleased we have got this far, but I want it to grow and be a natural home for all of those thousands of doctors who are teaching and training who feel isolated and undervalued. I would like to see the website developed so that interest groups can be in touch with each other, and my ambition would be to start an international one for educators interested in education and global health. Most of all I hope for a constructive partnership with the ASME. The organisations are different but complementary and I presently see signs that are very encouraging.




6. Authors

Professor Sean Hilton – President of AoME.

Mr Chris Wiltsher – Lay representative of AoME Council.

Professor John Bligh – Dean of Medical Education Cardiff University School of Medicine.






Dr Kieran Walsh – Clinical Director of BMJ Learning.

Dr Roger Worthington – Assistant Professor of Medicine at Yale University, USA

Professor Ed Peile – Emeritus Professor of Medical Education, Warwick Medical School.






Dr Gareth Holsgrove – Chairman and Managing Director, Holsgrove Associates Ltd.

Dr Raj RajaRayan – Associate Dean of Postgraduate Dentistry at the London Deanery.

Professor Judy Mckimm – Dean and Professor of Medical Education, Swansea University.



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