teaching the consultant teachers: identifying the core content

Teaching methods

Teaching the consultant teachers: identifying the core content

David Wall1 & Sean McAleer 2

Objectives To determine the key themes for teaching

hospital consultants how to teach.

Design 1. In-depth interviews with a total of 19 experts,

consultants and junior doctors to identify key topics.

2. Literature review from 1969 to obtain the main

themes from the medical educational literature.

3. Analysis of the main themes in 11 `Teaching the

teachers' courses. 4. Triangulation of interview data,

literature themes and teaching courses content to gen-

erate 15 criteria for a questionnaire. 5. Questionnaire

study to 593 senior and junior hospital doctors.

Setting Hospitals in the West Midlands Region in

England.

Subjects Consultants and junior hospital doctors.

Results Overall, 441 doctors replied (74% response

rate). The top ®ve themes were giving feedback con-

structively, keeping up to date as a teacher, building a

good educational climate, assessing the trainee and

assessing the trainee's learning needs. Results showed

no statistically signi®cant differences in the order of

themes for all groups analysed, including seniority,

gender, specialty, origin by medical school and con-

sultants of different ages.

Conclusions Consultants need teaching in these topics.

There are implications for funding and providing these

courses for postgraduate deans, Royal Colleges and

universities. Further research is needed to evaluate

whether such an initiative does produce better teaching

and learning, and a better educational climate in hos-

pitals.

Keywords Consultants, *education; curriculum; medical

staff, hospital, education; teaching, *standards.

Medical Education 2000;34:131±138

Introduction

There has been concern at the standard of clinical

teaching in hospitals in the United Kingdom for some

time.1,2 Teaching by humiliation and ritual sarcasm

and the demotivating effect this may be having on

junior doctors and medical students have been

described.3 Similar problems exist in North America,

where a literature review4 showed that undergraduate

and postgraduate medical teaching was variable,

unpredictable, lacked continuity and gave virtually no

feedback. In Canada, where it was concluded that there

was little reward for teaching excellence, a system of

awards for excellent teaching was instituted in Toron-

to.5 In Australia, problems of little feedback, poor

supervision and haphazard assessment of junior doctors

have also been described,6 worse in large teaching

hospitals. Several editorials7±9 in the medical education

literature have called for a `Training the Trainers'

strategy. In 1990 the requirement to teach was included

in the new contract for hospital consultants. At this

time, several new initiatives were beginning in hospital

medicine. The General Medical Council re-examined

the undergraduate curriculum, and made new recom-

mendations for the pre-registration year in its publica-

tion entitled The New Doctor.10 For higher specialist

training, the Chief Medical Of®cer set up a working

group to make recommendations on the training of

hospital specialists,11 and the Standing Committee

on Postgraduate Medical Education (SCOPME)

commissioned a working party to examine `ways

in which the teaching of postgraduate educational

methods to hospital doctors can be facilitated'.12

The ®rst SCOPME report in 199212 concluded that

it was an appropriate time to reassess the quality of

teaching in hospitals, and that teacher training would

only improve if a better learning environment was

created. The report made several recommendations

and emphasized the importance of providing those who

1Deputy Regional Postgraduate Dean, Postgraduate Dean's Of®ce,

The Medical School, University of Birmingham, Edgbaston,

Birmingham B15 2TT and 2Lecturer in Medical Education, Centre

for Medical Education, University of Dundee, Scotland, UK

Correspondence: Dr David Wall, Deputy Regional Postgraduate Dean,

Postgraduate Dean's Of®ce, The Medical School, University of

Birmingham, Edgbaston, Birmingham B15 2TT, UK

Ó Blackwell Science Ltd MEDICAL EDUCATION 2000;34:131±138 131

train junior doctors with opportunities to acquire the

skills necessary to teach.

Following this publication, there was an upsurge in the

level of professional debate about the need to improve

clinical teaching.13,14 In a review of current medical

education, Coles15 concluded that a change in educa-

tional and teaching methods, rather than a rearrange-

ment of course content, was needed. He drew attention

to the teaching culture, and advocated methods which

re¯ected the aims and objectives of the curriculum and

the principles of adult learning, more small-group work

and problem-based learning. It is imperative that

teachers understand the principles of adult learning,

curriculum development, evaluation and assessment.

In 1994 SCOPME followed its ®rst report with

Teaching Hospital Doctors and Dentists to Teach.16 This

paper identi®ed the changes happening in medical

education, including the changes to the pre-registration

year following the new undergraduate curriculum, the

Calman report's changes to specialist registrar training of

hospital specialists,11 and the new emphasis on medical

and clinical audit, patient expectations and account-

ability. Postgraduate deans have played an increasing

role in managing postgraduate medical and dental edu-

cation, including monitoring of standards of teaching

and learning for all junior doctors and dentists.

Several initiatives for `Training the trainers' or

perhaps the better-named `Teaching the teachers' are

already in place.17 The Universities of Dundee and of

Wales (in Cardiff) have had courses leading to quali®-

cations in medical education for many years, even before

the SCOPME reports were published beginning in

1992. Several Deaneries and Royal Colleges are now

beginning to run courses to help consultants improve

their teaching skills.18 There is an increasing interest in

the need for training in teaching skills but little or

nothing on the curriculum for such courses. Using adult

educational principles,19 the learners (that is, the con-

sultants) should be involved in setting the curriculum for

such courses, and the trainees should also have an input.

The aim of this study is an attempt to ®nd out what

consultants and junior doctors think are the key topics

in teaching the consultants to be better teachers. Only

then may courses be designed to cover the needs of

doctors in this important area of medical education.

In addition, there may be differences between

different groups of doctors. Some of these have been

looked for in this study. For example, there may be

differences between senior consultants' and junior

doctors' perceptions of what it is like being a junior

doctor in the 1990s. There are suggestions from

Australia6 that there are differences in teaching and

non-teaching hospitals in their quality of teaching

experienced by junior doctors. Do perceptions of female

and male doctors differ? Females are more often the

victims of humiliation and harassment.3 Do doctors in

different specialities differ in their perceptions? For ex-

ample, do doctors in the practical specialities such as

surgery, obstetrics and anaesthetics place a greater em-

phasis on practical skills teaching than do those in other

specialities? Do doctors trained in different parts of the

world have different ideas? The teaching may be dif-

ferent in the rest of Europe and overseas, and perhaps

doctors' perceptions re¯ect this. Finally, do older doc-

tors prefer a different style, perhaps a teacher-centred

approach, compared with their younger colleagues?

These are some of the questions which this study has

set out to try to answer.

Methods

1 Development of the themes

Literature review

A literature review was carried out using the four key

words `training', `trainer', `teaching' and `teacher' on

MEDLINE using CD-ROM back to 1969. Lists were

sorted to identify relevant publications, and abstracts of

these were read. From these, reprints were obtained

from the local medical library, other libraries and the

British Library. In addition, a further search on the

educational database ERIC was carried out. These

searches did not reveal many references. Therefore a

hand search of three medical education journals was

also carried out. These were Medical Education, Medical

Teacher and Postgraduate Medical Journal, going back

10 years. Further reports from expert bodies all added

to the literature on the topic.

Thirty-two papers and reports were analysed by the

authors for detailed descriptions of what was needed for

`Teaching the teachers' for the key teaching themes.

For each publication, the main themes were listed.

From these, a simple addition of the number of times

the theme was mentioned in the 32 papers gave a list

ranking the themes in order of frequency they were

mentioned in the literature. As a reliability check, ®ve

key papers were analysed independently by a doctor

with a quali®cation in medical education. This gave

good agreement of the key themes in these articles. The

results of these were aggregated and a ranked order

produced of these key themes.

Analysis of `Teaching the teachers' courses

Discussions with individuals with an interest in medical

education gave some information on various `Teaching

Ó Blackwell Science Ltd MEDICAL EDUCATION 2000;34:131±138

Teaching the teachers · D Wall & S McAleer132

the teachers' courses. Also, there was information in the

literature of courses run by the Royal Colleges of

Surgeons of England and of Edinburgh. This was by no

means an exhaustive study, but it was dif®cult to obtain

much information in this area (hence this research

study). In all the courses analysed the one common

factor was an educational course designed to help

doctors teach their juniors (trainees). A total of 11

national and regional courses on the theme of `Teaching

the teachers' were obtained and the course timetables

and aims and objectives (where stated) were analysed

for the key themes, and results aggregated and ranked.

The interviews

Seven experts in medical education, ®ve hospital con-

sultants and seven junior doctors (two house of®cers,

two senior house of®cers, two specialist registrars and

one GP registrar) were interviewed. The experts were

chosen as individuals who had experiences of running

`Teaching the teachers' courses, and were studying or

had obtained a quali®cation in medical education. The

consultants were chosen from the list of clinical tutors

in the West Midlands, using a random numbers

method. The junior doctors were chosen by asking

a further three clinical tutors, chosen at random, to

select junior doctors who would be prepared to be

interviewed.

All interviews were carried out by DWW. Each doctor

was approached in writing, the study explained, and

permission asked to do the interview and record it for

transcription and analysis. An assurance was made of

privacy and con®dentiality. All interviews were done on

a one-to-one basis, at a time and place convenient to the

interviewee. Each interviewee was asked the one ques-

tion, `What do you think should be the curriculum for

teaching the consultant teachers for hospital doctors?'

All interviews were tape recorded (with permission),

transcribed verbatim and analysed for content, using

methods of grounded theory and, for narrative (stories),

using the methods of Labov.20 A verbatim transcript

and analyses were sent to each interviewee for

comments and amendments, before the key themes

from each interview were aggregated together.

Construction of the questionnaire

The data from the literature, the courses and the

in-depth interviews (Table 1) were combined to pro-

duce a list of 15 key themes common to the three sets

(Table 2). A one-to-®ve Likert scale (1 � `no impor-

tance' to 5 � `extremely important') was used to rate

each of the 15 items. The question stem for each of

these themes was:

`What teaching abilities should consultants possess?

Please give a score for each of the topics: Please give your

rating of its importance as part of an educational pro-

gramme for consultant trainers within the West Midlands.

In addition, questions about the doctor's grade, age,

gender, specialty, year of quali®cation and university

were included, with some space for free comments.

2 Pilot study

The questionnaire was pilot tested in two hospital

Trusts (not taking part in the main study). These were

selected using a random numbers method from the list

of all 44 hospital Trusts within the West Midlands. The

pairs of questionnaires were sent to 30 doctors, and

they were asked to ®ll in one at that time and return it,

and the other 1 week later, and return it. The results

were analysed using a test±retest method, and analysed

using weighted kappa scores and also by rank order of

comments on the ®rst and second questionnaires.

3 Main study

The main study was carried out in three hospital Trusts

within the West Midlands Region in England.

A teaching hospital Trust, a large urban district general

hospital and a smaller rural district general hospital

were selected at random from each hospital of this

category. Lists of all consultants and junior doctors

were supplied by medical staf®ng departments, and

a database of these doctors was constructed with

a unique code for every doctor.

A coded questionnaire, letter of explanation and a

reply envelope were sent out to all 593 consultants and

junior doctors in the three Trusts (four hospitals, since

the teaching Trust has two separate hospital sites). Each

doctor was asked to read the explanation of the study, to

®ll in the questionnaire scoring each of the 15 themes

according to how important they thought that particular

theme was `as part of an educational programme for

consultant trainers within the West Midlands'. After

completion, the doctors were asked to return the

questionnaire in the reply envelope addressed to their

clinical tutor in their local postgraduate centre. These

were then collected at intervals by DWW. Responders

were identi®ed by code on the database, and two

further mailings sent to non-responders.

4 Data analysis

The 15 themes on the one-to-®ve Likert scale were

analysed using a computer statistical program. They

Teaching the teachers · D Wall & S McAleer 133


were then ranked in terms of decreasing mean score of

themes. Rankings were produced for all doctors, and for

separate groups of consultants, junior doctors, teaching

hospital doctors and non-teaching hospital doctors,

males, females, UK, European or overseas graduates,

the different specialities, and younger (age under

45 years) or older (age over 45 years) consultants.

Comparisons of mean scores of the different themes

was done using the Z-value,21 with a Z-value of 3 taken

to indicate an outlier.

Results

1 The pilot study

Of 30 sets of questionnaires sent, 13 complete pairs and

six single questionnaires were returned. The pilot study

results showed close agreement between the ®rst and

the second sets of questionnaires, with a weighted

kappa score as a whole of 0á55, giving moderate

agreement between ®rst and second responses. In

addition, the ranking of the themes in the two sets of

questionnaires showed agreement between all ®ve

lowest scores, and in four out of the ®ve highest scores.

2 The main study

A total of 441 completed questionnaires were returned,

an overall response rate of 74%. There were replies from

194 consultants (78% response), 69 specialist registrars

(86%), 107 senior house of®cers (64%), 26 house

of®cers (67%) and from 45 others (78%). These results,

together with the gender and specialty of the doctors

responding, appear in Table 3. The categories were

similar to those used by the Medical Royal Colleges and

faculties. For example, within medicine and medical

Table 12 Rank order of themes in the literature review, the educational courses and the interviews. This table has been constructed as

indicated below for each of the three themes:

(1), Literature review : rank order of number of publications in which the theme appears; (2), courses: rank order of number of courses

(of 11) in which the theme appears; and (3), interviews: rank order of number of interviewees who mentioned that theme in their interview

Literature review Educational courses Interviews

Teaching methods 15 Educational methods 10 Teaching methods 16

Educational climate 8 Giving feedback 8 Educational climate 12

Giving feedback 8 Assessment 8 Giving feedback 11

Small group teaching 8 Adult education principles 6 Teacher as a learner 9

Educational theory 7 The educational cycle 6 Assessing learning needs 9

Evaluation 6 Setting objectives 6 Assessing the trainee 9

Assessment 6 Identifying learning needs 6 Educational cycle 9

Setting aims/objectives 5 Practical teaching exercises 5 Helps and hinders learning 9

Attitude of trainers 5 Small group dynamics 4 Designing a course 9

Practical teaching skills 4 Educational climate 3 Evaluation 8

Adult learning 4 Johari window 3 Learner-centred education 8

Tutorial skills 2 Learning contracts 3 Levels of teaching skills 7

Good and bad teaching 3 Learning styles 6

How adults learn 2 Communication skills 6

Experiential learning cycle 2 Inappropriate teaching 5

Educational supervisor role 2 Adult learning principles 5

Practical skills teaching 2 Re¯ection 5

Evaluation 2 Protected teaching time 5

Problems with trainees 2 Setting objectives 5

Service-based learning 4

Beliefs 4

Attitudes of trainers 4

Cascade teaching/learning 4

Relations with learners 4

Strategic maps/models 3

Explaining why 2

Learning contract 2

Study skills 2

Educational supervisor 2

Study skills 2

Success breeds success 2

Con®dence in teacher role 2



specialities, the specialities of neurology, gastroenterol-

ogy and diabetes (for example) were included.

For undergraduate origin of doctors, there were 296

United Kingdom doctors, 20 other European Union

doctors, and 104 overseas doctors in the responders.

These percentages match almost exactly the distribu-

tion of doctors in these categories in the Statistical

Bulletin 199722 produced by the Department of Health.

The results for all doctors have been presented in

Table 4, for all consultants and for all juniors in

Table 5. The results for the 15 main themes was very

similar in all the groups analysed. The rank order, and

the top ®ve and bottom ®ve themes were remarkably

constant for all groups. Looking at the consultants'

results and the juniors' results, the main difference

appears to be the rank order of one of the themes

`Doing practical teaching skills and exercises', which

the juniors ranked ®fth, with a mean score of 4á19. On

the other hand, the consultants rated it down at 11th,

with a mean score of 3á69.

This difference between the juniors and the consul-

tants for this theme gave a Z-value of 2á15.21 This score

did not quite reach the value of an outlier, so this dif-

ference does not quite reach statistical signi®cance.

Nevertheless, the difference does stand out when

comparing the juniors and the consultants mean scores

and rankings.

The results for UK graduates, European graduates

(excluding UK) and overseas graduates did not differ

signi®cantly, both in terms of mean scores and rank

order.

The results for gender did not show signi®cant dif-

ferences in mean scores or in rank order between female

and male doctors.

The results for doctors in the teaching hospital and

doctors in the non-teaching hospitals did not show

signi®cant differences in mean scores or in rank order

between female and male doctors.

The results in the different specialities did not show

signi®cant differences between the `practical' speciali-

ties such as surgery, obstetrics and anaesthetics

discussed in the introduction, and other specialities,

especially when looking at practical skills training issues.

The results comparing younger (age under 45) and

older consultants (age over 45) did not show signi®cant

differences in mean scores or in rank order between

younger and older consultants.

Discussion

The overall response rate of 74% (78% for the con-

sultants and 74% for the juniors) was very good, and

with the views of 441 doctors the results can be relied

Table 23 The 15 key themes derived from the triangulation. This

table lists the 15 key themes which have been derived from a

triangulation of the analysis of key themes in the educational

literature, data from 19 in-depth interviews and analysis of 11

educational courses on the subject of `Teaching the teachers',

as listed in Table 1

1. Knowing and using various teaching methods

2. Giving feedback constructively

3. Assessing the trainee

4. Building a good educational climate (atmosphere)

5. Evaluating the teaching that we do

6. Understanding the principles of adult learning

7. Assessing the trainee's learning needs

8. Setting aims and objectives for learning

9. Understanding the educational cycle

10. Doing practical teaching skills and exercises

11. Being able to run a small group

12. Knowing the attributes of good and bad teaching

13. Setting a learning contract with trainee

14. Designing and planning a course

15. Keeping up to date as a teacher

Table 3 Grade, gender and specialty of doctor by category on the

questionnaire

Grade of doctor Responders (%)

Non-

responders

Consultant 194 (78%) 55

Specialist registrar 69 (86%) 11

Senior house of®cers 107 (64%) 60

House of®cer 26 (67%) 13

Others 45 (78%) 13

(Staff grades, associate specialists, hospital practitioner,

clinical assistants)

Total 441 (74%)

Gender of doctor

Female 130 (72%) 51

Male 311 (76%) 98

Total 441 (75%)

Specialty of doctor Number of doctors

Medicine and medical

specialities

139

Surgery and surgical specialities 92

Obstetrics and gynaecology 30

Radiology 12

Pathology 26

Paediatrics 40

Anaesthetics 54

Accident and emergency

medicine

21

Ophthalmology 11

Others 13

Total 438



upon to be reasonably valid, without the biases of lower

responses, with large numbers and percentages of non-

responders.

Hospitals were chosen at random, using a random

numbers method, but to re¯ect teaching and non-

teaching hospitals, as Rotem's study6 did describe

worse teaching in the teaching hospitals than in the

non-teaching hospitals. Within the hospitals chosen, all

doctors were sent questionnaires. Perhaps a better

method would have been to list all the 5000 doctors in all

44 hospitals within the West Midlands, and choose

doctors from all these entirely at random. With 44 hos-

pitals, each with their own staff database, this would have

proved very dif®cult to manage. In addition, perhaps the

study was too heavily biased in the ®rst place towards

educational sophistication. Two of the three sources of

the statements used in the triangulation to construct the

questionnaire were either course designers or the authors

of educational papers. Perhaps a ®rst step could have

been an interview study of junior doctors asking them

about good and bad teaching, and what were the char-

acteristics of each. Nevertheless, the `educational'

themes such as the educational cycle and understanding

the principles of adult learning19 came at the bottom end

of the rankings chosen by all the doctors. Thus the

doctors were able to discriminate in relation to what they

thought was important for them in a practical sense.

Looking at the top themes, in Table 4, `giving feed-

back constructively' was top of the ranking. This was

encouraging, especially since there have been many

previous accounts of poor teaching in the United

Kingdom, North America and Australia.1±6,13,14 Often,

Table 5 Rank order of the 15 themes from all consultants and all junior doctors in all hospitals. This table shows the 15 educational

themes ranked in descending order of their mean score, from answers to the questionnaire supplied by all 194 consultants who replied,

and by all 202 junior doctors who replied

Consultants Junior doctors

Rank Theme Mean (SEM)* Rank Theme Mean (SEM)*

1. Giving feedback constructively 4á23 (0á051) 1. Giving feedback constructively 4á53 (0á047)

2. Assessing the trainee 4á22 (0á055) 2. Building good educational climate 4á35 (0á053)

3. Keeping up to date as a teacher 4á21 (0á062) 3. Keeping up to date as a teacher 4á29 (0á062)

4. Building good educational climate 4á08 (0á057) 4. Assessing the trainee 4á20 (0á054)

5. Knowing good and bad teaching 4á03 (0á058) 5. Practical teaching skills/exercises 4á19 (0á059)

6. Assessing trainee's learning needs 3á95 (0á062) 6. Assessing trainee's learning needs 4á17 (0á057)

7. Evaluating the teaching that we do 3á85 90á053) 7. Setting aims/objectives for learning 4á11 (0á058)

8. Knowing and using teaching methods 3á83 (0á063) 8. Knowing good and bad teaching 4á00 (0á064)

9. Setting aims/objectives for learning 3á82 (0á060) 9. Evaluating teaching that we do 3á92 (0á057)

10. Being able to run a small group 3á70 (0á058) 10. Knowing/using teaching methods 3á80 (0á063)

11. Practical teaching skills/exercises 3á69 (0á071) 11. Designing and planning a course 3á79 (0á063)

12. Designing and planning a course 3á65 (0á069) 12. Being able to run a small group 3á70 (0á070)

13. Understanding adult learning 3á29 (0á068) 13. Understanding adult learning 3á47 (0á066)

14. Understanding educational cycle 3á059 (0á068) 14. Set learning contract with trainee 3á35 (0á081)

15. Set learning contract with trainee 3á058 (0á074) 15. Understanding educational cycle 3á31 (0á068)

* SEM = standard error of the mean.

Table 4 Rank order of the 15 themes from all 458 doctors in all

hospitals. This table shows the 15 educational themes ranked in

descending order of their mean score, from answers to the ques-

tionnaire supplied by all 458 doctors in the study

Rank Theme Mean (SEM)*

1. Giving feedback constructively 4á37 (0á033)

2. Keeping up to date as a teacher 4á28 (0á040)

3. Building a good educational climate 4á2004 (0á037)

4. Assessing the trainee 4á1996 (0á036)

5. Assessing the trainee's learning needs 4á07 (0á039)

6. Knowing attributes of good and bad

teaching

4á00 (0á040)

7. Doing practical teaching skills and

exercises

3á99 (0á044)

8. Setting aims and objectives for learning 3á98 (0á040)

9. Evaluating the teaching that we do 3á89 (0á037)

10. Knowing and using various teaching

methods

3á81 (0á041)

11. Designing and planning a course 3á74 (0á043)

12. Being able to run a small group 3á70 (0á043)

13. Understanding the principles of adult

learning

3á37 (0á044)

14. Setting a learning contract

with the trainee

3á190 (0á051)

15. Understanding the educational cycle 3á188 (0á044)

* SEM = standard error of the mean.



one of the criticisms in these papers has been lack of

feedback, or feedback given destructively. Giving

feedback constructively can improve learning outcomes

and can improve competence.23

Second was `keeping up to date as a teacher'.

Looking back at the derivation of this theme, this came

from the in-depth interviews but was not really

addressed in the literature or in the educational courses.

Perhaps this does counter the criticism made above

about educational sophistication. There was little in the

educational literature or in the courses about this

theme, yet it was rated very highly by all the doctors.

Perhaps this does need to be emphasized in future

teaching courses.

`Building a good educational climate' was third

overall. If the climate supports scholarship, encourages

friendliness, co-operation and support for both teachers

and learners, then perhaps some of the accounts of poor

teaching, humiliation and harassment3,4,6,13 described

in the literature will become a thing of the past.

Àssessing the trainee' and àssessing the trainee's

learning needs' were ranked fourth and ®fth. There is

now a great emphasis on assessment issues,10,11 both

formative and summative, and on setting aims and

objectives for learning. Assessment of all grades of

junior doctor, especially specialist registrars,11 is a new

responsibility for consultants and they have realized the

importance of training in these areas. However, it is

surprising that two closely allied themes, namely

`setting aims and objectives for learning' and `setting a

learning contract with the trainee' have been ranked

much lower. Perhaps doctors have not yet accepted that

this is now a mandatory requirement.11

Ùnderstanding the educational cycle' and ùnder-

standing the principles of adult learning' were at the

lower end of the rankings. There was some evidence in

the numbers who did not answer the educational cycle

question, and a number who wrote `What does this

mean?' that many did not understand this concept

(however simple this model is to educationalists). We

need to remember that even simple educational terms

and concepts may pose dif®culties to doctors struggling

to come to terms with these ideas.

Despite the above, none of the 15 themes was ranked

lower than 3á118 (indicating that even the lower-ranked

items were still viewed as being of some importance).

This does need to be remembered when doctors have

rated more practical themes of more importance to

them than the theoretical models of the principles of

adult learning and the educational cycle. The in-depth

interviews, the literature and the educational courses all

have contributions from people with educational

expertise to give their views. This study is different, in

that it has shown how the views of the òrdinary'

doctors themselves differs from those of the experts.

What was surprising to us was the great consistency

of views expressed throughout the groups. We had

expected the views of the junior doctors to be very

different from the consultants, as we had thought there

would be differences in perceptions between senior

consultants and young junior doctors of what it is like to

be a junior doctor in the 1990s. On the whole, with one

notable exception, this was not the case. `Teaching

practical skills' was ranked ®fth, with a mean score of

4á19 by the junior doctors, but ranked 11th with a mean

score of 3á69 by the consultants. Although this differ-

ence just failed to reach statistical signi®cance, never-

theless this is a striking difference. Perhaps what the

junior doctors are saying is that, as the recipients of

practical teaching, this is not done as well as the

consultants think they are doing. Otherwise, the rank-

ings were extremely consistent throughout all groups

analysed. There seems to be some consistent themes for

teaching consultants, common to all groups.

Therefore these common themes of `giving feedback

constructively', `keeping up to date as a teacher',

`building a good educational climate', àssessing the

trainee' and àssessing the trainee's learning needs', and

adding in `practical teaching skills' (see above) may be

considered the key themes arising from this study.

How can we implement the process of teaching the

consultant teachers of the junior doctors? This study

reinforces the point that both the consultants and the

junior doctors feel it is important that consultants learn

about certain important themes if they are to be better

teachers of junior doctors. However, having arrived at

certain common themes, there is still a long way to go.

This is only a ®rst step. Looking at curriculum theory,

Laxtal24 stressed the need to set criteria and establish

standards based on the recommendations of experts.

Such planning included expert opinion of specialist

teachers, the observations and preferences of learners,

use of pre- and post-knowledge tests in self-evaluation,

review of the appropriate medical literature and local

epidemiological data. Three of these principles have

been part of this study. Harden25 described the needs to

set aims and objectives, choose the teaching methods,

organize the content, manage the educational strate-

gies, choose and use the best educational methods and

evaluate the whole process.

Also, there is a need to convince others, provide and

maintain a positive educational climate and manage the

whole process, including the funding issues. Broom®eld

and Bligh26 made these points in their account of man-

aging curriculum change in the medical school of the

University of Liverpool. They stressed the problems to



be overcome and the need for qualities of leadership with

individuals who could see the project through to the end.

This study has only started the process, by beginning

to tease out the main themes, so we can now go on to

set aims and objectives for consultants to learn about

teaching.

Will the `Teaching the teachers' movement gain

strength? There are some signs that this may be beginn-

ing. The changes to specialist registrar training,11 the

new approach to the pre-registration year10 and the new

Royal College curricula are all evidence of some chan-

ges beginning to happen.

Finally, there are still major questions about the

effectiveness of such an educational strategy. Will it

work? Is there the time to do it, with everyone so busy

and under such great service pressure? Will it produce

better, more skilled and effective teachers, with the

appropriate attitudes? Will it be cost-effective? How will

all consultant teachers be taught? Will all consultants

continue to be teachers? Will all consultants want to be

teachers, or will some opt out? Will it produce better

doctors? Finally, and most important, will it produce

better care for patients?

Like many research studies, this study has produced

some answers. It has also raised many more questions;

but these are the origins for further studies in medical

education.

Acknowledgements

We thank Professor John Temple, regional postgraduate

dean for the West Midlands, for ®nancial support for

this project. We thank Miss Glenda Adams and Miss

Helen Booth for typing the verbatim transcripts in the

interview study. We thank Dr Ian Campbell for his help

with the statistical analysis of the data. We thank the

clinical tutors in the four hospitals for their help with this

project, Dr Liz Hughes, Dr Norman Mitchell, Dr Bob

Palmer and Dr Peter Wallis. Finally we thank all the

doctors who replied to the questionnaires we sent.

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1Received 23 October 1998; editorial comments to authors 11 January

1999; accepted for publication 3 February 1999



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