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A study of the impact of a resident teacher education program on teaching self-efficacy, beliefs about… Arseneau, Richard R. 1994

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A STUDY OF THE IMPACT OF A RESIDENT TEACHER EDUCATIONPROGRAM ON TEACHING SELF-EFFICACY, BELIEFS ABOUTTEACHING, AND SELF-REPORTED TEACHING BEHAVIOURSbyRICHARD R. ARSENEAUM.D., University of Toronto, 1987F.R.C.P.C., University of Toronto, University of British Columbia, 1991A THESIS SUBMIEFED IN PARTIAL FULFILLMENT OFTHE REQUIREMENTS FOR THE DEGREE OFMASTER OF ARTSinTHE FACULTY OF GRADUATE STUDIESDepartment of Curriculum and InstructionWe accept this thesis as conformingto t re ed standardTHE UNIVERSITY OF BRITISH COLUMBIAAPRIL, 1994© Richard R. Arseneau, 1994In presenting this thesis in partial fulfilment of the requirements for an advanceddegree at the University of British Columbia, I agree that the Library shall make itfreely available for reference and study. I further agree that permission for extensivecopying of this thesis for scholarly purposes may be granted by the head of mydepartment or by his or her representatives. It is understood that copying orpublication of this thesis for financial gain shall not be allowed without my writtenpermission.(Signature)______________Department of ( )The University of British ColumbiaVancouver, CanadaDate 2m(DE-6 (2188)11ABSTRACTDespite the fact that few residents have any specific training inteaching skills, the majority of them have significant teachingresponsibilities throughout their residencies. Althoughresidents have a positive attitude towards teaching, and lookforward to their teaching role, a number of observationalstudies have found that few residents exhibit teaching skillsconducive to learning. This research study reports thedevelopment, implementation, and evaluation of a residentTeacher Education Program (TEP), and examines its impact oninternal medicine residents, more specifically, on residents’(1) sense of teaching self-efficacy, (2) self reported teachingbehaviours, (3) beliefs about teaching, and (4) interest inteaching. A quasi-experimental design was used andassignment of subjects (i.e., residents) was based on theexisting Clinical Teaching Unit (CTU) rotation schedule.Theoretical guidelines for program development were basedon several perspectives of adult education, and psychology.Most importantly, teaching self-efficacy was used as amotivational paradigm (Ashton, 1984), and was used as themain outcomes measure. The treatment group (n= 11)attended weekly one hour seminars longitudinally over thecourse of their CTU rotation (for a total of six sessions). Theprogram was run a total of three times over the course of111three rotations. General internal medicine residents had apositive outcome expectancy for teaching (i.e., teachingefficacy subscale). However, their efficacy beliefs concerningtheir own abilities as teachers was not rated as highly (self-efficacy subscale). Overall, residents had a positive attitudetowards teaching. The resident TEP had no effect on residents’teaching efficacy beliefs which were already positive. It did,however, have a statistically significant effect on their teachingself-efficacy scores which was twice that seen in the controlgroup (0.4 vs. 0.2). A significant pre- and- post difference wasfound for 5 of 15 questions on beliefs about teaching (vs. 1 of15 for the control group), and for 2 of 4 questions on interestin teaching (vs. 0 for control group). Residents participatingin the TEP had a large and statistically significantimprovement in self-reported teaching behaviours scores (vs.no difference in control group). A correlation coefficient of0.21 was found for the associated changes between teachingefficacy and self-reported teaching behaviours. A correlationcoefficient of 0.66 was found for the associated changesbetween teaching self-efficacy and self-reported teachingbehaviours.ivTABLE OF CONTENTSABSTRACT.iiTABLE OF CONTENTS ivLIST OF TABLES ixLIST OF FIGURES xiACKNOWLEDGEMENTS xiiCHAPTER ONE: THE PROBLEM 1Introduction: Statement of the Problem 1Rationale and Purpose of the Study 2Background of the Problem 6Development and Theoretical Basis of the Study 8Constructivism 8Self-efficacy 11Questions to be Answered 14Definition of Terms 15Overview of the Study 21CHAPTER TWO: REVIEW OF THE LITERATURE 23Introduction 23Research on Clinical Teaching in Medical Schools 24Theoretical Perspectives Pertinent to Resident Teps 28Introduction 28Andragogical Perspective 28Constructivism 32Introduction 32Learning 36Teaching 40Factors Influencing Learning 44Limitations of a Constructivist Perspective 48Conclusions 50Reflection 51Beyond Reflection - Transformative Perspective ofAdult Education 64Social Situated Perspective 67VIntroduction.67Cognitive apprenticeship 73Self-Efficacy 77Teaching Efficacy 85Empirical Perspectives Pertinent to Resident Teps 93Improving Teaching 94Residents as Teachers 98Empirical Research on Resident TEP5 108Participation 111Specialty 111Level 112Goals and Objectives 112Methodology 114Format 115Timeline 116Content 118Program Evaluation 118Study Results 119Impact of resident TEPs 119Need for reinforcement / long term effect 121“Confidence” / self-efficacy 122Importance of attitude 127CHAPTER THREE: METHODS 129Overview / Introduction 129Rationale for Study Design 133Instrument 136Rationale 136Instrument Development 141Teaching Efficacy 142Self-Reported Teaching Behaviours 144Data Collection and Analysis 145Program Description 148Identification of Goals and Objectives 148Design of Program and Selection and Development ofContent, Process, and Materials 151Time line 152Program Format 153Content 155Process 158viCasemethod.161“Tasks for the Week.” 166Other 169Materials 169Implementation 170Program Evaluation 171CHAPTER FOUR: RESULTS 173Introduction 173Instrument Validation 175Sections I & III: Self-Efficacy and Self-Reported BehaviourScales 177Student t-Tests 179Teaching Efficacy (TE) 181Teaching Self-Efficacy (TSE) 182Self-Reported Teaching Behaviours (SRB) 183“Retro-”: Self-Reported Teaching Behaviours (SRB) 184Teaching Efficacy 185Teaching Self-Efficacy 185Self-Reported Teaching Behaviours 186Internal Consistency Reliability of Scales 187MANOVA 188Teaching Efficacy 195Teaching Self-Efficacy 195Self-Reported Teaching Behaviour 195Correlation of Self-Efficacy with Self-ReportedBehaviours 196Sections II: Beliefs About Teaching 197Section 1V. Interest in Teaching 216Program Evaluation 223CHAPTER FIVE: DISCUSSION AND CONCLUSIONS 227Introduction 227The Resident TEP Curriculum 229Statement of Results 237Instrument 237Study Results and Discussion 239Research Questions 2391. What attitude do general internal medicineresidents have towards teaching (i.e., self-efficacy,viibeliefs about teaching, and interest in teaching)? .. 239Results 240I. Teaching scale (self-efficacy) 241II. Residents as teachers - opinion (beliefs aboutteaching) 2421V. Interest in teaching 2442. What is the effect of a CTU rotation and associatedteaching responsibilities on residents’ sense ofteaching self-efficacy, self-reported teachingbehaviours, beliefs about teaching, and interest inteaching? 244Results 246I. Teaching scale (self-efficacy) 246II. Residents as teachers - opinion (beliefs aboutteaching) 247III. Teaching skills (self-reported behaviours). .. 248IV. Interest in teaching 2483. What is the impact of a TEP on residents’ sense ofteaching self-efficacy, self-reported teachingbehaviours, beliefs about teaching, and interest inteaching? 248Results 251I. Teaching scale (self-efficacy) 252II. Residents as teachers- opinion (beliefs aboutteaching) 253III. Teaching skills (self-reported behaviours). .. 254TV. Interest in teaching 2554. Is a change in self-efficacy (i.e., attitudesubconstruct) associated with a change in self-reported teaching behaviours? 255Program Evaluation 257Limitations of the Study 258Recommendations for Further Research 259REFERENCES 263APPENDIX A: STUDY INSTRUMENTS 287Pilot Instrument 289Study Instrument 295Study Instrument - “Retro” 301viiiAPPENDIX B: PROGRAM EVALUATION 307Program Evaluation Instrument 308Item Response Statistics 311Attendance and Session Relevance 313Program Evaluation: Open Ended Questions 316APPENDIX C: SESSION CONTENT 323Session 1Introduction: Teaching and Learning 324Session 2Work Rounds and One Minute Teaching Skills 339Session 3Feedback and Evaluation 360Session 4Questioning and Non-Facilitating Teaching Behaviours ... 381Session 5Cognitive Learning Principles and Problem Solving 393Session 6 - Small Group Teaching 410APPENDIX D: SESSION HANDOUTS 429Effective Feedback: Checklist 430Session 1Introduction: Teaching and Learning 431Session 2Work Rounds and One Minute Teaching Skills 433Session 3Feedback and Evaluation 435Session 4Questioning and Non-Facilitating Teaching Behaviors 437Session 5Cognitive Learning Principles and Problem Solving 439Session 6Small Group Teaching 441Student Evaluation of Resident Teaching Form 443APPENDIX E: ITEM STATISTICS - FINAL INSTRUMENT 445APPENDIX F: SCORES - RAW DATA 449APPENDIX G: CONSENT FORM 455ixLIST OF TABLESTable IInternal Consistency Reliability of Pilot Instrument 175Table IIInstrument Validation: Pearson’s r 177Table IIIt-tests: Teaching Efficacy 181Table 1Vt-tests: Teaching Self-Efficacy 182Table Vt-tests: Self-Reported Behaviours 183Table VIt-tests: “Retro-” Self-Reported Behaviours 184Table VIIInternal Consistency Reliability of Instrument Scales 187Table VIIIMANOVA: Teaching Efficacy 189Table IXMANOVA: Teaching Self-Efficacy 190Table XMANOVA: Self-Reported Behaviours 191Table XIMANOVA: Teaching Efficacy (- #14) 192Table XIIMANOVA: Teaching Self-Efficacy (- #14) 193xTable XIIIMANOVA: Self-Reported Behaviours (- #14) 194Table XIVBehaviours 196xiLIST OF FIGURESFigure IPre- & Post- Teaching Efficacy Scores 189Figure IIPre- & Post- Teaching Self-Efficacy Scores 190Figure IIIPre- & Post- Self-Reported Behaviours Scores 191Figure IVPre- & Post- Teaching Efficacy Scores (- #14) 192Figure VPre- & Post- Teaching Self-Efficacy Scores (- #14) 193Figure VIPre- & Post- Self-Reported Behaviours Scores (- #14) 194xiiACKNOWLEDGEMENTSI would like to thank the following individuals for their helpin completing this thesis:My thesis advisor, Dr. Kip Anastasiou, for his encouragementand support during this long project.Dr. Gordon Page for his input as my co-advisor.Lianne Kinnaird for her hard and meticulous work on almostevery aspect of the project.Shelley Cunningham for her help in proofing this largedocument.Dr. John Ruedy for his encouragement and support in gettingthis project (and my degree) started in the first place.Without the care and assistance of the above individuals, thisproject would have been impossible.1CHAPTER ONE: THE PROBLEMIntroduction: Statement of the ProblemThis research study reports the development, implementation,and evaluation of a Teacher Education Program (TEP), andexamines its impact on internal medicine residents1,morespecifically, on residents’ (1) sense of teaching self-efficacy,(2) self-reported teaching behaviours, (3) beliefs aboutteaching, and (4) interest in teaching.A quasi-experimental design was used and assignment ofsubjects (i.e., residents) was based on the existing ClinicalTeaching Unit (CTU) rotation schedule. A needs assessmentwas carried out on the control group (n=8) over the course oftwo rotations - the results of which are reported elsewhere(Arseneau, 1993). The content of the TEP was developed tomeet residents’ needs as determined by structured interviewsand participant observation of the control group, as well as areview of the literature. Theoretical guidelines for programdevelopment were based on several perspectives of adulteducation, and psychology. Most importantly, teaching selfefficacy was used as a motivational paradigm (Ashton, 1984),1 See page 15 for definitions of unfamiliar terms2and was used as the main outcomes measure. The treatmentgroup (n= 11) attended weekly one hour seminarslongitudinally over the course of their CTU rotation (for atotal of six sessions). The program was run a total of threetimes over the course of three rotations.Rationale and Purpose of the StudyClinical medical education follows the old adage of “see one,do one, teach one”, and much of the teaching is done by thetrainees themselves. Residents carry the majority of thisburden. Not only are they responsible for the daily aspects ofpatient care and their own education, but they are alsocharged with the supervision and teaching of junior housestaff(i.e., interns and medical students).Successful “faculty” development programs, therefore, shouldacknowledge the important role of residents as instructorssince they provide the majority of clinical instruction (Brown,1970). Knight (1988) argues that no one is more available orbetter suited to teach medical students than residents.Although students may think that most of their learning isdone through lectures or from pearls of wisdom passed onfrom attending physicians, the real basics of medicine are3acquired through the guidance and teaching of residents.Residents’ proximity, in terms of level of training, to medicalstudents make them ideal teachers. Residents also benefitfrom the educator role. Steward and Feltovich (1988) discussthe importance that teaching plays in residents’ acquisition ofclinical skills and knowledge. It also prepares them forteaching patients, and even for academic careers. Stritter,Shahady, and Mattern (1988) emphasize the important rolethat teaching plays in residents’ professional development.The roles and responsibilities of residents can be likened to athree legged stool where balance must be struck to keep thestool from toppling over: (1) self education, (2) patient care,and (3) teaching. These three elements should not be seen asseparate and distinct, however, as the interplay between themis important and the total is more than the sum of its parts.One could argue that the best education comes from activeinvolvement in patient care and in the teaching of others.Patient care may also be improved through the activediscussion between residents and students, and from theteaching and learning activities that ensue.The teaching role of residents is not redundant with that offaculty (Stritter, et al., 1988). The roles of residents andfaculty should be seen as complimentary. Residents tend toconcentrate on daily patient care issues on a large number of4patients, whereas, faculty tend to stress in depth discussionand problem solving skills on a small number of patients.That residents spend more time with students and are “closer”to their level does not necessarily make them effectiveteachers. Wilkerson, Lesky, & Medio, (1986) studied theteaching skills of residents during work rounds. They foundthat “residents exhibited few of the teaching behaviours thatcan enhance learning in a patient care setting” and that“resident(s) appeared to conceptualize teaching as a classroomactivity and equate it to lecturing...” (p. 827). Lewis andKappelman (1984) noted that residents most frequently usean authoritarian lecture style in teaching. Ironically, this wasthe residents’ least favourite approach as learners. Medio,Wilkerson, Lesky, and Borkman, (1988) observed residentsduring work rounds, and noted that “. ..residents did not oftenintentionally use daily patient encounters for teaching” andwhen they did, they usually provided brief lectures,highlighting residents limited repertoire of teaching skills andthe frequency of missed teaching opportunities (p. 215). Itseems that residents fail to recognize and take advantage of“teachable moments” (Meleca & Pearsol, 1988, p. 188).Residents should be encouraged to improve their teachingskills, and must learn to identify and take advantage of the5teaching opportunities during daily work rounds. Numerousresident teacher training programs have been reported in theliterature (Bing-You & Greenberg, 1990; Camp & Hoban, 1988;Edwards, Kissling, Brannan, Plauche, & Marier, 1988; Lawson &Harvill, 1980; Lazerson, 1973; Medio, et al., 1988; Meleca &Pearsol, 1988; Pristach, Donoghue, Sarkin, Wargula, Doerr,Opila, et al., 1991; Sobral, 1989). Greenberg, Goldberg, &Jewett (1984) emphasize that the most important aspect ofthese programs is fostering, among residents, an awareness of,and a positive attitude towards, residents’ roles as teachers.The rationale for this study rests in the important role thatresidents play in the education of junior housestaff and theintimate relationship that teaching has with residents’ otherroles and responsibilities (i.e., self education and patient care).Yet evidence exists that residents may not be well prepared fortheir teaching role and that they may not appreciate itsimportance in their own education. Changing residents’“attitude” towards teaching has been suggested as the key tosuccess of TEPs (Lawson & Harvill, 1980). However, the use ofthe word attitude remains nebulous in the medical educationliterature. The purpose of this study is to examine the impactof a TEP on internal medicine residents’ attitude towards theirteaching role. This requires a working definition of “attitude”within the context of residents’ roles as teachers. It also6requires a reliable and valid instrument to measure changes inattitude as defined for the purpose of this study. Choosingattitude change as the major goal of a TEP has otherimplications. Defining and measuring changes in behaviouralobjectives may not be the most appropriate way to documentchanges in attitude. Other educational perspectives are likelymore appropriate (e.g., constructivist, situated/social,andragogy), and will be reviewed in terms of programdevelopment. It remains important, however, to determinewhether or not changes in attitude towards teaching areassociated with changes in teaching behaviours. This will alsobe addressed as a research question in the study.The content of the TEP was determined by the results of theneeds assessment (Arseneau, 1993) and a review of themedical education literature, whereas the process of the TEPwill be based on perspectives of adult education that promotechanges in attitude towards teaching.Background of the ProblemDespite promoting the importance of attitude, there has beenno consensus on its definition as it pertains to residents’attitude towards teaching. Furthermore, none of the above7studies on resident TEPs specifically address “how” to changeattitude.Teaching “attitude” has been used as a catch all in studies ofresident teaching. One study (Skeff, Campbell, Stratos, Jones,& Cooke, 1984) defined it as: a desire to evaluate and improveteaching; satisfaction with teaching, enthusiasm for teaching,awareness of teaching strengths, and awareness of teachingproblems. Another group of investigators (Greenberg, et al.,1984) divided attitude into the following categories: (1)General attitude towards teaching, (2) Perceptions of(residents’) role as a teacher, (3) Attitude towards teachingmethods, and (4) Attitude towards improving clinical teaching.The categories variously include self-efficacy (e.g.,confidence), self-reported behaviours, self-evaluation, interestin, and enjoyment of teaching among others. More recently,Bing-You and Harvey (1991) studied the relationship betweenresidents’ attitude (as measured by a questionnaire) andstudent ratings of the residents’ teaching skills. The authorscomment that they have included two questions “to measure ateacher’s sense of self-efficacy defined by Ashton (1984)” (p.96). Interestingly, several other items from their questionnairecould be interpreted as measuring self-efficacy. However, noattempt was made to group these items into a “self-efficacyscale.” Like other investigators the attitude items of the8questionnaire included a mixture of perception, self-reportedbehaviour, interest, and enjoyment.In many studies, the term attitude has been usedindiscriminately and often mistakenly. I will use the word“attitude” to broadly describe all objectives that have to dowith affect, feelings, values, and beliefs (Henerson, Morris, &Fitz-Gibbon, 1987). The study and TEP described in this thesisdiffers from those described above in two significant ways.First, it is based on a constructivist perspective of teachereducation (cf., behaviourist). Second, it is concerned withchanging (and measuring) one specific attitude: self-efficacy(Bandura, 1977). However, other aspects of residents’ attitudetowards teaching (i.e., perceptions of teaching role, andinterest in teaching), as well as self-reported teachingbehaviours were measured.Development and Theoretical Basis of the Study.Cons.tructivi.smPhilip C. Candy (1991), in his book, Self Direction for LifelongLearning, discusses the implications of shifting from abehaviourist to a constructivist paradigm in education. From9the constructivist perspective learning is viewed as aqualitative transformation of understanding rather than aquantitative accretion, and learners are seen as activeconstruers and “makers of meaning” (p. 250). Theconstructed system of personal meanings becomes thelearners’ guide for behaving. “Clearly it is one of theeducator’s roles to help learners to recognize incorrect, biased,or dysfunctional personal beliefs, so that the learner has thechance to change. This is a subtle and intricate process,however, which is not accomplished simply by confronting thelearner, but it involves careful exploration in a non-threatening environment....Thus, constructivism in educationis concerned with two things: how learners construe (orinterpret) events and ideas, and how they construct (build orassemble) structures of meaning. The constant dialecticalinterplay between construing and constructing is at the heartof a constructivist approach to education...” (Candy, 1991, p.266-272).Therefore, from a constructivist perspective, “teaching”cannot really occur except by facilitating growth ofunderstanding in the learner.The constructivist perspective has several importantimplications for the development of a resident teacher10training program. It downplays the importance of facts andbehaviours (as well as behavioural objectives). If the programis to have a lasting impact, new behaviours are important onlyin that they reflect a restructuring of the residents’understanding and belief system. Lectures are unlikely toachieve this end. Residents need to explore and define theircurrent understanding of their roles as teachers. They need tobe challenged to expand this “world view” in the hopes thattheir elaborated definition will impact on their behaviour. Thiscan be accomplished by means that actively involve residentsin the learning process, including discussion, brainstorming,role play, and microteaching.Constructivism is not a single theory, rather, it is a group ofperspectives that espouse many of the same underlyingassumptions (see above). Donald A. Schon (1987), in hisbook, Editcating the Reflective Practitioner, uses aconstructivist perspective to develop a model for teaching“artistry” in the professions. He introduces the concept of“reflection-in-action”. Rather than automatically doingsomething (i.e., without thinking about it), he points out thepower of reflecting in the midst of action while one can stillmake a difference to the situation at hand. He suggests that.what distinguishes reflection-in-action from other kinds ofreflection is its immediate significance for action. In11reflection-in-action, the rethinking of some part of the (usuallyautomatic process) leads to on the spot experiment andfurther rethinking what we do...” (p. 29).One of the main goals of the TEP is to have residents thinkabout the teaching/learning process, “reflection-on-action”, aswell as thinking during teaching, “reflection-in-action.”Hopefully, this will serve as a stimulus for continued growth.Self-efficacyAlthough the construct of self-efficacy (Bandura, 1977) isusually considered within a situated / social perspective ofeducation, like constructivism, it aspires to move beyondbehaviourism by highlighting the importance of the cognitiveprocess and the development of beliefs as a guide for actions.Bandura’s social learning theory (1977) is based on theassumption that individuals develop outcome expectationsand efficacy beliefs concerning their ability to cope (orperform) based on life experiences. Efficacy expectationscome from four sources: (1) performance accomplishments,(2) vicarious experience, (3) verbal persuasion, and (4)emotional arousal. Performance accomplishments are the most12powerful source of efficacy expectations given that they arebased on personal mastery experiences. Successes lead to anenhanced sense of self-efficacy, whereas, failures tend toextinguish it.The cognitive processing of information is important indeveloping efficacy beliefs (cf., constructivism). Individualunderstanding of information (i.e., perception) is moreimportant than the “objective” information. Successes must beviewed as resulting from skill rather than chance. Similarly,the perception of ability is important. Individuals who viewsuccess as the result of ability are more likely to strengthenefficacy expectations than those who view achievement as aresult of extreme effort.Patricia Ashton (1984) reviews the concept of teacher efficacyas a motivational paradigm for effective teacher education.She defines a teachers’ sense of efficacy as “the extent towhich teachers believe that they have the capacity to affectstudent performance” (p. 28). She comments that teachers are“surprisingly unreflective about their work”, and that thisshould be a specific goal of teacher education programs(emphasis mine) (p. 31). This is in keeping with the conceptsof “reflection-on-action / reflection-in-action” as goals within aconstructivist approach to education. Reflection allows13teachers to gain insight as to what works and what doesn’t,thereby, helping them identify specific sources of efficacybeliefs.Gibson and Dembo (1984) undertook a study to provideconstruct validation support for teacher efficacy. They factoranalyzed a 30 item 6 point Likert scale and identified twodimensions that corresponded to Bandura’s (1977) efficacyexpectations. A belief in “teaching efficacy” (i.e., that teacherscan make a difference) corresponded with Bandura’s “outcomeexpectancy”, whereas, a belief in “personal teaching efficacy”(i.e., that they personally can effect change as teachers)corresponded with Bandura’s “self-efficacy.” The results werealso compatible with Ashton and Webb’s (1986) twodimensional model of teaching self-efficacy.Ashton and Webb (1986), in their book, Making a Difference:Teachers’ Sense of Efficacy and Student Achievement, neatlysummarize Bandura’s theory as it applies to teachers:According to Bandura, self-efficacy is a cognitivemechanism that regulates behaviour. A sense of selfefficacy develops as an individual acquires a convictionof personal competence; that is, when the individualbelieves he or she has mastered the behaviours14necessary to achieve a desired outcome. The strength ofan individual’s sense of self-efficacy determines whetherhe or she will initiate and sustain a behaviour in the faceof difficulty. Thus, the individual’s expectations ofpersonal efficacy influence future learning andmotivation. Contrary to behaviourist assumptions,Bandura contends that behaviour is controlled by theindividual’s personal efficacy beliefs rather than by thepresence of reinforcing consequences (p. 8).Acknowledging the importance of efficacy beliefs onbehaviour, it is possible that a TEP could be detrimental to ateachers’ sense of self-efficacy by emphasizing shortcomings.Given that many residents have not given much thought toteaching, they may be overwhelmed by “all there is to know”and how “few skills they actually possess.” A TEP focusing ondeveloping teaching self-efficacy also needs to includeopportunities to cultivate personal mastery experiences.Questions to be Answered1. What attitude do general internal medicine residents havetowards teaching (i.e., self-efficacy, beliefs about teaching, andinterest in teaching)?152. What is the effect of a CTU rotation and associated teachingresponsibilities on residents’ sense of teaching self-efficacy,self-reported teaching behaviours, beliefs about teaching, andinterest in teaching?3. What is the impact of a TEP on residents’ sense of teachingself-efficacy, self-reported teaching behaviours, beliefs aboutteaching, and interest in teaching?4. Is a change in self-efficacy (i.e., attitude subconstruct)associated with a change in self-reported teaching behaviours?Definition of Termsandragcgy_(andragogical perspective of adult education): “theart and science of helping adults learn, in contrast topedagogy as the art and science of teaching children”(Knowles, 1980, p. 43). Andragogy is based on fourassumptions about how adults differ from children: (1) theirself-concept moves from one of being a dependent personalitytoward being a self-directed human being; (2) theyaccumulate a growing reservoir of experience that becomes anincreasingly rich resource for learning; (3) their readiness tolearn becomes oriented increasingly to the developmental16tasks of their social roles; and (4) their time perspectivechanges from one of postponed application of knowledge toimmediacy of application, and accordingly, their orientationtoward learning shifts from one of subject-centredness to oneof performance centredness.aendiug_(tndimgpkysician): faculty member in charge ofpatient care and responsible for supervision and teaching ofresidents, interns, and medical students providing patientcare.attitude: used broadly to describe all objectives that have todo with affect, feelings, values, and beliefs.bedside teaching: teaching that occurs at the patient’sbedside. Usually related to physical examination or otherdiagnostic and patient management issues.Clinical Teaching Unit (CIII): the “location” (may or may notbe physically separated from the rest of the hospital, i.e. aseparate ward) where housestaff (i.e., residents, interns, andmedical students) admit and take care of patients under thesupervision of an attending physician (i.e., faculty).17clinical teaching: medical education is generally divided intobasic science (i.e., pre-clinical) and clinical teaching. Clinicalteaching can occur in the classroom (e.g., undergraduatecardiology) or in the hospital.constructivist perspective of adult education (consiruciivisiu):from the constructivist perspective, learning is viewed as aqualitative transformation of understanding rather than aquantitative accretion, and learners are seen as activeconstruers and “makers of meaning” (Candy, 1991). Theconstructed system of personal meanings becomes thelearners’ guide for behaving. Thus, constructivism ineducation is concerned with two things: how learners construe(or interpret) events and ideas, and how they construct (buildor assemble) structures of meaning. The constant dialecticalinterplay between construing and constructing is at the heartof a constructivist approach to education...” (Candy, 1991, p.272).CTU rotation: medical training is divided into “blocks” of timein specific specialties - rotations. The CTU (clinical teachingunit) rotation refers to the general internal medicine rotation.CTU: see Clinical Teaching Unit18general internal medicine: the branch of medicine having todo with the non-surgical (i.e., “medical”) care of adults.hcusestaff: residents, interns, and senior medical studentsworking in the hospital and responsible for patient care.intern: individual in their first year of post graduate training(i.e., PGY 1)internal medicine: the branch of medicine having to do withthe non-surgical (i.e., “medical”) care of adults. The specialtyof internal medicine can be divided into subspecialtiesincluding general internal medicine, cardiology, etc.MSL(medical student intern): final year medical student.Often referred to as clinical clerks.PGY (post-graduateyear): level of postgraduate training forresidents. For instance, PGY 2 would be a second yearresident.resident: individual involved in postgraduate medicaltraining.rotation: medical training is divided into “blocks” of time in19specific specialties - rotations.rounds: one of the most overused words in medical educationwith different meanings in different contexts. Overall, itmeans the gathering of a group of physicians or housestaff forthe purpose of teaching or other patient care related activities.Examples include teaching rounds, work rounds (see below),etc.self-efficacy: “According to Bandura, self-efficacy is acognitive mechanism that regulates behaviour. A sense of self-efficacy develops as an individual acquires a conviction ofpersonal competence; that is, when the individual believes heor she has mastered the behaviours necessary to achieve adesired outcome. The strength of an individual’s sense of self-efficacy determines whether he or she will initiate and sustaina behaviour in the face of difficulty. Thus, the individual’sexpectations of personal efficacy influence future learning andmotivation. Contrary to behaviourist assumptions, Banduracontends that behaviour is controlled by the individual’spersonal efficacy beliefs, rather than by the presence ofreinforcing consequences (Ashton & Webb, 1986, p. 8).social / situated perspective of adult education: thisperspective of adult education focuses on the relationship20between learning and the social situation in which it occurs.Lave and Wenger (1991) view situated learning as anintermediary between learning as an individual cognitiveprocess and learning as a characteristic of social practice. Intheir view, “learning is not merely situated in practice - as if itwere some independently reifiable process that just happenedto be located somewhere; learning is an integral part ofgenerative social practice in the lived-in-world” (p. 35).teachingatfinid: the operational definition of this constructfor the purpose of this study included: information aboutteaching self-efficacy (i.e., teaching attitude subconstruct),beliefs about teaching, and interest in teaching.teaching self-efficacy: “the extent to which teachers believethat they have the capacity to affect student performance”(Ashton, 1984, p. 28). See also self-efficacy.TEP: Teacher Education ProgramTB: Teaching EfficacyISE: Teaching Self- Efficacywork rounds: usually refers to housestaff going around as a21group, under the leadership of the resident, for the primarypurpose of taking care of patients (as opposed to teaching asthe primary purpose).Overview of the StudyThe balance of this thesis is organized in four chapters.Chapter two reviews the relevant theoretical and empiricalliterature. It begins with an overview of research on clinicalteaching in medical schools. Next, theoretical perspectivespertinent to the development, implementation, and evaluationof a resident TEP are presented, specifically, andragogy, aconstructivist perspective of education, the role of reflection,and self-efficacy will be addressed. Finally, empirical researchon resident TEPs will be considered.Chapter three describes the research methodology. Thisincludes a description of the research design and samplingmethod. The development and piloting of the self-efficacy/attitude/self-reported behaviour instrument will be describedin detail. Finally, data collection and analysis issues will beaddressed.Chapter four reports the impact of the TEP on residents’ senseof teaching self-efficacy, self-reported teaching behaviours,22beliefs about teaching, and interest in teaching as compared tocontrols.Finally, chapter five will discuss the results and address theresearch questions posed in chapter one. The theoretical andpractical implications of the results will be discussed andsuggestions for further research will be proposed.23CHAPTER TWO: REVIEW OF THE LITERATUREIntroductionThis chapter begins with a brief review of the literature onclinical teaching in medical school. The predominant portionof this chapter is divided into two sections: “TheoreticalPerspectives Pertinent to Resident TEP5,” and “EmpiricalPerspectives Pertinent to Resident TEP5.” The theoreticalsection is mainly concerned with perspectives of adulteducation. The andragogical perspective is reviewed brieflybefore undertaking a more elaborate review of constructivism.The role of reflection in learning will be gone over in somedetail including a brief survey of the transformativeperspective of adult education. The theoretical sectionconcludes with the social / situated perspective of adulteducation. A brief overview of the perspective is undertakenbefore discussing cognitive apprenticeship. Considerableemphasis will be placed on self-efficacy, as part of Bandura’s(1986) social cognitive theory, and teaching efficacy.The section on Empirical Perspectives Pertinent to ResidentTEP5 begins with a short introduction on improving teaching.Several studies on resident teaching will be reviewed before24going on to a detailed analysis and critique of existingresearch on resident TEPs.Research on Clinical Teaching in Medical SchoolsThe first significant formal effort to investigate the process ofteaching in medical schools was the “Project in MedicalEducation” at the University of Buffalo in the late 1950’s(Miller, 1956). The author, with the help of professionaleducators, investigated the practices and problems associatedwith medical “pedagogy.” He commented on the lack ofreliable information on the practices and attitude of medicalteachers.Jason (1962) soon followed with an exploratory study of“what” medical teachers were doing (as opposed to “how well”they did it, or “what effect” it had on the students). Heexamined the characteristics of the teacher (e.g., age, rank,etc.), the type of medical school (e.g., private/state, universityaffiliated/non-affiliated, part-time/full-time faculty, etc.), andthe teaching setting (e.g., lecture, tutorial, ward rounds, etc.)with respect to the observed frequency of seven teachingbehaviours: (1) attitude to difference; (2) sensitivity tophysical setting; (3) attitude to students; (4) use of25instructional materials; (5) reaction to students’ needs; (6) useof teaching methods (e.g., lecture, discussion, etc.); and (7) useof challenge. In another observational study, Reichsman,Browning, & Hinshaw (1964) noted the frequency of certainteaching behaviours: e.g., Was the patient seen as part of thecase presentation?; Did the staff member directly observe anypart of the history or physical examination?; Was a correlationbetween basic science and clinical medicine made?; etc.. Theauthors reported that “many (staff members) seem to havetwo central difficulties: (a) in focusing, on the spur of themoment, on the more relevant, and (b) in making explicit,without premeditation, what they want to communicate” (p.160). Like other studies of this early period (e.g., (Adams,Ham, Mawardi, Scali, & Weisman, 1964)), the authors describe,rather than evaluate, the process of medical education.Studies then began to focus on the refinement of observationalinstruments and started to look at correlations. Stritter, Ham,& Grimes (1975) developed an instrument to survey medicalstudents regarding effective teaching behaviours. Expandingon general educational research, Irby (1978) helped toestablish the important dimensions of a clinical teacher. Heremarked that the usual standardized classroom rating formswere not applicable to clinical teaching “because of the uniqueaspect of clinical instruction” (p. 808). An analysis of student26responses to the characteristics of the “best and worst” clinicalteachers, revealed six independent factors (i.e., dimensions):(1) organization/clarity; (2) group instructional skills; (3)enthusiasm/stimulation; (4) knowledge and analytic ability;(5) clinical supervision; and (6) clinical competence. In asubsequent study, Irby and Rakestraw (1981) validated theinstrument by assessing each dimension on a 5 point scale.They found high overall inter-rater reliability. Overallteaching effectiveness correlated most strongly withenthusiastic and stimulating (0.80), establishes rapport (0.77),actively involves student (0.76), and provides direction andfeedback (0.75). In a review of both the medical and non-medical literature, Rippey (1981) describes a similar 6dimension instrument: (1) subject matter expertise; (2)pedagogic skill; (3) charisma-stimulation-popularity-civility;(4) empathy; (5) effort seriousness; and (6) judgement.Bad clinical instructors are often thought to be those that lacksome of the dimensions above. However, acts of commissionmay also render a teacher ineffective. Napell (1976)describes 6 common “non-facilitating” teaching behaviours:(1) insufficient “wait time;” (2) the rapid reward; (3) theprogrammed answer; (4) nonspecific feedback questions; (5)fixation at a low level of questioning; and (6) the teacher’s egostroking and classroom climate. This last behaviour sounds27similar to what Brancati (1989) calls “the art of pimping.”Pimping questions are political rather than educational innature. These difficult (usually obscure) questions are askedto boost the attending’s self-esteem and to maintain the teamhierarchy.More recently, the emphasis has shifted to facultydevelopment and the usefulness of workshops and othermethods for improving teaching skills (e.g., Adams, Ham,Mawardi, Scali, & Weisman, 1974; Bazuin & Yonke, 1978;Cassie, Collins, & Daggett, 1977; Patridge, Harris, & Petzel,1980; Sheets & Henry, 1984; Skeff, Campbell, Stratos, Jones, &Cooke, 1984). Investigators have also become more interestedin the actual dynamics of the teacher/student interaction.Foley, Smilansky, & Yonke (1976) studied the nature and thecognitive level of the verbal interaction between medicalstudents and teachers. Their data suggests that teachers wereless than effective at helping students develop problem solvingskills. For the most part, students were passive and receivedlow level factual information.Investigators have started correlating process (teacherinteraction) and product (learner outcomes) (e.g., Petzel,Harris, & Masler, 1982). They have also examined theeffectiveness of the seminar method (for improving clinical28teaching) on the process/product relationship (Skeff,Campbell, & Stratos, 1985).Like most areas of inquiry, the results of early studies haveraised more questions than they have answered.Theoretical Perspectives Pertinent to Resident TepsIntroductionBefore discussing the existing literature on resident TEPs, areview of the adult education literature pertinent to designingand implementing such a program, will be reviewed. One ofthe major problems with those programs described is that fewhave made explicit the epistemological beliefs that informedtheir programs. Androgogy, constructivism, reflection, selfefficacy, and the social situated perspective of adult educationwill be reviewed as they pertain to a resident TEP.AndragoLgical PerspectiveKnowles (1973) credits his introduction to the concept (andlabel) of andragogy to the Yugoslavian adult educator, DusanSavicevic, in 1967. Knowles introduced the concept and label29into the American education literature in 1968 with his paper,“Androgogy [sic] Not Pedagogy,” in Adult Leadership. As thetitle of his paper implies, Knowles suggests that adults aresomehow different than children when it comes to teachingand learning, and this is the essential assumption underlyingandragogy. Originally, he defined “andragogy as the art andscience of helping adults learn, in contrast to pedagogy as theart and science of teaching children” (italics mine) (Knowles,1980, p. 43). In response to criticism and challenges fromeducators who argued that andragogy also applied to children,Knowles now sees andragogy as another set of assumptionsabout learners in contrast to the assumptions of pedagogy. Hesees both models occupying the ends of a spectrum.Andragogy is based on four assumptions about how adultsdiffer from children: (1) their self-concept moves from one ofbeing a dependent personality toward being a self-directedhuman being; (2) they accumulate a growing reservoir ofexperience that becomes an increasingly rich resource forlearning; (3) their readiness to learn becomes orientedincreasingly to the developmental tasks of their social roles;and (4) their time perspective changes from one of postponedapplication of knowledge to immediacy of application, andaccordingly, their orientation toward learning shifts from oneof subject-centredness to one of performance centredness30(Knowles, 1980, P. 44-45).These four assumptions have considerable implications forpractice (Knowles, 1973; Knowles, 1978; Knowles, 1980). Thelearning climate takes on particular significance from anandragogical perspective; the physical, and more importantlythe psychological environment must be relaxed and conduciveto risk taking. Preservation of self-esteem and self-conceptoften take precedence over learning when learners fearridicule. It also becomes important that learners feelrespected by the teacher. Adult learners are most motivatedto learn those things they feel a need to know; self-diagnosis oflearning needs, therefore, becomes an important part of thelearning process. It also follows that learners are more likelyto “buy-in” when they are involved in the planning process.From an andragogical perspective, learning should takeprecedence over teaching given that one cannot be forced tolearn. The teachers’ role, thus, becomes one of facilitatinglearning rather than teaching. Andragogy places considerableemphasis on prior experience as a rich and importantresource in the learning process. Adults’ self-concept is oftenintimately tied to their life experience. Experiential learningwith an emphasis on practical application is emphasized. Thecontent should be problem-centred or performance-centredrather than subject-centred and should focus on the31immediate interests and concerns of the learners.Knowles theory of adult education has remained popular overthe years despite its flaws. Perhaps its persistance has to dowith its seductive intuitive logic, and the fact that it isconsistent with the beliefs of many adult educators. Possiblyits most serious flaw has to do with the fact that it is a theoryof learning that purports to be in contradistinction to howchildren are taught (see my italics of Knowles quotation in thefirst paragraph). One must make a leap of faith to assume thathow children are taught accurately reflects how they learn,and more importantly how they learn best. Many of thecriticisms of Knowles theory tackle his assumptions of howadults differ from children (e.g., Tennant, 1986). Knowleshimself, tries to remedy the situation by changing hisdefinition of andragogy to one that includes children(Knowles, 1980) (see above). Despite this disclaimer, his workis replete with discussions of how adults differ. Hartree(1984) criticizes attempts at presenting a unified theory ofadult education. “The most notorious (of which) is probablyMalcolm Knowles’ theory of andragogy” (p. 203). Shequestions whether it is a theory of learning or teaching, andeven its status as a theory at all. She regards Knowles workmore as a philosophical position rather than a descriptivetheory. Several other criticisms of Knowles theory, and32assumptions underlying andragogy, exist but are beyond thescope of this dissertation. Despite its flaws, Knowles workoffers many practical insights into the planning andconduction of adult education.ConstructivismIntroductionThe concept of constructivism is somewhat difficult to grasp.The difficulty may be due, in part, to the paradigm shift andrethinking of tacit assumptions required to fully understandconstructivism. Assumptions about the nature of reality, truthand knowledge, and the implications these assumptions haveon what it means to “know,” to “learn,” and to “teach.” Theshift in thinking required to understand constructivism can belikened to the historical paradigm shifts described by Kuhn(1962) in his book, The Structure of Scientific Revolutions.Progress in science (or education) does not always follow anincremental linear increase in understanding and knowledge.At some point, existing models are no longer helpful; we have“hit a wall.” If progress is to occur, a major rethinking of the(often tacit) assumptions must be undertaken: what isrequired is a shift in paradigm. Constructivism represents one33such paradigm shift. A new way of looking at reality, truth,knowing, learning, and teaching (among other things).A second difficulty with understanding constructivism lies inthe varied applications of the concept. Constructivism is morethan an educational perspective or epistemology. It hasbeginnings and connections with such diverse areas asphilosophy, sociology, literature, and anthropology (Candy,1987). It is beyond the scope of this dissertation to review theorigins and development of constructivism across disciplines.However, the principles of constructivism will be reviewedfrom an educational perspective, more specifically, itsimplications for the development of a resident TEP. Candy(1987) reminds us that constructivism “is not a singlemonolithic theory, but rather a cluster of perspectives unitedby underlying similarities in world view” (p. 297). Aheterogeneous group of educational theories can be gatheredunder the rubric “constructivism.” Furthermore,constructivism serves as a foundation for a number of othereducational perspectives (e.g., situated/social, feminist,transformative), some of which will be discussed in moredetail later in this chapter.The major tenets of constructivism have to do with howindividuals come to “know” the world (and things about it).34Although constructivists acknowledge the existence of anexternal reality, individuals are not seen as simply observingor experiencing an objective reality. Rather, by interactingwith the world, individuals construct representations ofreality. These representations (or constructions) allow themto interpret (or construe) events or ideas. The acts ofconstructing and construing are iterative with no definitiveend point. When prior constructions are used to construe newevents or ideas, these new ideas may become incorporatedinto a new and elaborated construction. Therefore,individuals are continually trying to make sense (or “makemeaning”) of events and ideas. In fact, from a constructivistperspective, meaning is imposed by the individual rather thanbeing objectively discovered (or residing in the event or idea).This implies that each individual is actively involved inmaking meaning and that each individuals’ representation ofthe world is personal and idiosyncratic. Duffy and Jonassenremind us that “(there) are many ways to structure the worldand there are many meanings or perspectives for any event orconcept. Thus, there is not a correct meaning that we arestriving for” (1991, p. 8).Individuals, as viewed from a constructivist perspective, arenot as lonely and isolated as they might appear at first glance.The process of negotiation between individuals allows them to35come to a common understanding of certain situations (i.e.,social constructions). Although, individuals’ constructions arenot identical, they are close enough for communication and acommon understanding. In fact, the constraints on individualconstructions are largely imposed by the community of whichthe individual is a member (Cognition and Technology Groupat Vanderbilt, 1991).A constructivist perspective has profound implications for thenature of truth and knowledge. It is at odds with the view thatknowledge is an identifiable entity with some truth value.Instead, it is believed that sufficient degrees of freedom existin the structure of the physical and epistemological worlds toallow the construction of alternative personal theories aboutthe environment, and of what it means to “know” (Cognitionand Technology Group at Vanderbilt, 1991). Knowledge,therefore, is not a reduplication of the “real world,” but is arepresentational map or model. Several maps (or models) arepossible, but each one is not equally valid, as some maps willnecessarily fit more closely. Candy (1991), in a review ofconstructivism, reports that the various constructivistdisciplines “have all emphasized how people invent, organizeand impose structures on their experiences, and have arguedthat knowledge is thus a social artifact” (p. 253).36LearningTo adopt a constructivist perspective, one must accept thatknowledge cannot be taught or transferred intact. The learnermust actively construct a system of personal meanings withwhich to construe further events or ideas. It is only throughthe dualistic acts of constructing and construing that theindividual comes to “know” (and understand). It follows thateach system of personal constructs must necessarily beidiosyncratic. “Thus, constructivism in education is concernedwith two things: how learners construe (or interpret) eventsand ideas, and how they construct (build or assemble)structures of meaning. The constant dialectical interplaybetween construing and constructing is at the heart of aconstructivist approach to education, whether it be listening toa lecture, undertaking a laboratory session, attending aworkshop, reading a text, or any other learning activity”(Candy, 1991).Ramsden (1988a), in his book, ImproviugLearning: NewPerspectives, expresses discontent that even the brighteststudents are unable to demonstrate that they understandwhat they have learned, despite the fact that they are able torecall large amounts of factual information on demand, haveamassed huge quantities of detailed knowledge, and can pass37exams successfully. He argues that these students have in factNOT learned at all. He maintains that if we are to improvelearning (and teaching), we must come to a differentunderstanding of what it means to learn.Learning “means a movement towards being able tosolve unfamiliar problems, . ..recognizing the power andelegance of concepts in a subject area, and ...being ableto apply what has been learned in class to problemsoutside class. It means a realization that ‘academic’learning is useful for interpreting the world we live in. Itmeans having changed one’s understanding” (p. 15).Ramsden’s view is in keeping with the constructivistperspective that learning represents a qualitative change inthe learner. Marton and Ramsden (1988) advance thefundamental principle that “learning should be seen as aqualitative change in a person’s way of seeing, experiencing,understanding, conceptualizing, something in the real world -rather than as a quantitative change in the amount ofknowledge someone possesses” (italics mine)(p 271).Perhaps an easier way to depict the qualitative change thatleads to a new way of understanding, is to conceive of learning38as a change from “thinking like a” lay person to “thinking likea...”. To draw an example relevant to this dissertation, let usconsider teacher education. Rather than seeing the process ofteacher education as one of the acquisition (or accumulation)of knowledge, skills, and attitude (i.e., quantitative change),constructivist would argue for having the learner think like ateacher (i.e., qualitative change). In the latter, learninginvolves the construction of a personal map (or model) forthinking like a teacher. At first, this map will necessarily beimperfect (in fact, it can never be perfect), but with experienceand interaction (i.e., negotiation) with “coaches,” studentteachers can refine the “fit” of their map. In the process, theyincreasingly come to think like a teacher; they start to sharecommon meaning for events (i.e., social constructions of the“society” of teachers). This common meaning (i.e.,construction) does not deny that all maps are still personal oridiosyncratic. It simply indicates that teachers, as a group,have maps with a close enough fit to each others, to come tosome common understanding of situations. Saljo (1988) talksabout learning as acquiring “provinces of meaning.”Implicit in this qualitative change in the learner, is anappreciation for the starting point of the learner (i.e., currentconcepts or models). In a sense, the student is “remapping”their knowledge base. Old ideas and concepts are not39abandoned. New connections between old concepts occurs(and new knowledge); misconceptions must be confronted;alternative and more useful, concepts must be constructed.According to White and Gunstone (1992) “the person’sunderstanding develops as new elements are acquired andlinked with the existing pattern of associations betweenelements of knowledge. Addition of new elements will oftenstimulate reorganization of the pattern as the person reflectson the new knowledge and sees how it puts the olderknowledge in a different light” (italics mine) (p. 13). Recallinga constructivist’s view of reality, it follows that “whatever the‘objective’ reality, learners respond to events ‘as though’ theywere true.” This means that learning often proceeds from aseries of personal propositions which, if not disproved, areassimilated into explanatory schema ‘as though’ they weredemonstrably true. After a while, they become so thoroughlyinternalized that, to all intents and purposes, they are true forthe individual” (Candy, 1987, p. 312-313).Except for a brief mention of teacher education, the abovediscussion of constructivism has yet to mention the contentand context of learning. This is by no means to describeconstructivism simply as a process or to imply that the processof constructivism can be played out devoid of content orcontext. On the contrary, the idea of content (the “what”) and40process (the “how”) as interlinked and inseparable parts oflearning is central to a constructivist epistemology (Marton &Ramsden, 1988). Learning, obviously, cannot occur withoutcontent (i.e., something to learn), and learning cannot occurwithout an act of learning (i.e., process). Marton and Ramsden(1988) advocate that “learning and thinking skills are notseparate entities that have a life of their own.... We shouldteach specific knowledge domains in such a way that astudent’s general capacity is developed at the same time; weshould not teach ‘metacognitive skills’ but should encouragestudents to reflect on learning in specific content domains”(italics mine) (p. 274). The importance of content, and morespecifically context, will be addressed in greater detail with thediscussion of a subsection of constructivism, situated learning,later in this chapter.ThachingA shift in assumptions about what it means to “know” and to“learn” necessitates an analogous shift in the meaning ofteaching. From a constructivist perspective “teaching willfocus on what can be changed in the learner’s understanding”(Ramsden, 1988b, p. 21). Contrary to conventional wisdom,teaching is not the transmission of knowledge intact to41learners, but involves the negotiation of meaning allowing thestudent to construct a system of personally relevant meanings.The word “negotiation” in this context is apt to cause someconfusion and deserves elaboration. Negotiation does notmean “meeting the student half way,” nor does it meannecessarily accepting students’ preconceptions (ormisconceptions) as valid. Negotiation describes a process ofchecks and balances involving exchange and dialogue betweenthe student and teacher, at the end of which the teacher issatisfied that the student’s conception is appropriate - i.e., thatunderstanding has occurred. Therefore, teaching becomes avery intersubjective process. This is in directcontradistinction to the more common practice of teaching inwhich students are the object of teachers’ instruction (i.e.,subject-object process). Therefore, from a constructivistperspective, good teaching is primarily concerned withlearning.In his book, Iniproving Learning: New Perspectives, Ramsden(1988a) proposes a relational view of teaching, several aspectsof which are elaborated by himself and other authorsthroughout the book and include: (1) learning is aboutchange in conception, (2) learning always has content as wellas a process, (3) improving learning is about relations betweenlearners and subject matter, not teaching methods and student42characteristics, (4) improving learning is about understandingthe student’s perspective, and (5) educational research andteaching are more closely related than people sometimesbelieve.A brief overview of “phenomenography” (Marton, 1981, citedin Saijo 1988) may clarify the five aspects of the relationalview of teaching as proposed by Ramsden. Phenomenographyis a qualitative research method that explicitly deals withdiscovering and analyzing peoples constructions in aneducational setting. Participant observation, interviews, andthe analysis of written documents are typically used togenerate data. Analysis of the data allows the “mapping” ofindividuals’ constructions and conceptions. Althoughconstructions are idiosyncratic, they tend to cluster in tocategories. Researchers attempt to generate a “picture” of thevariations in conceptions (i.e., constructions) held by a groupof individuals. For instance, a researcher may discover thathigh school students’ understanding of gravity fall into acertain number of categories. The researcher may alsodiscover that some of these are based on commonmisconceptions.Understanding students’ conceptions (or misconceptions) isthe best starting point for teaching from a constructivist43perspective. This fittingly demonstrates the relationship ofteaching and educational research. “Teaching is an activitythat assumes an understanding of learning. To teach in a waythat encourages changes in conceptions, instructors mustrecognize how students already think about phenomena - theymust make themselves aware of, and use, the conceptionsstudents already have” (Ramsden, 1988b, p. 13). Therefore,teaching involves two basic steps: probing understanding inorder to map students’ thinking, and helping students developnew (or more appropriate) conceptions. This approach hasimportant implications for students’ wrong answers. Students’wrong answers to teachers’ questions are a window tostudents’ misconceptions. It becomes more important todiscover the faulty reasoning that led to a student’s wronganswer than to replace the wrong answer with the correct one.By investigating wrong answers teachers can map outdeficiencies, inconsistencies, and misconceptions. Similarly, itis important for teachers to probe for supporting evidence ofstudents’ correct answers. Teachers may be surprised howoften students get “the right answer for the wrong reason” orthat students are simply parroting answers with no clearunderstanding. White and Gunstone (1992) indicate thatquestions beginning with “Why...”, “How....” and “What if...”are more likely to probe understanding, whereas, questionsbeginning with “What...”, “Who...”, “Where...” and “When...”44are more likely to test recall.Marton and Ramsden (1988) suggest several teachingstrategies for conceptual change learning: (1) make thelearners’ conceptions explicit to them, (2) focus on a fewcritical issues and show how they relate, (3) highlight theinconsistencies within and the consequences of learners’conceptions, (4) create situations where learners centreattention on relevant aspects, (5) present the learners withnew ways of seeing, (6) integrate the “knowing what” and“knowing how” of a subject, (7) test understanding ofphenomena; use the results for diagnostic assessment andcurriculum design, and (8) use reflective teaching strategies(italics mine).Factors influenciiig LearningThe nature of the teaching and learning process from aconstructivist perspective can be threatening to students.Probing students! understanding and challenging them toconfront misconceptions cannot occur in a rigid authoritarianatmosphere. The learning climate must be conducive to risktaking, otherwise, little learning will occur.45Providing a safe atmosphere is only the first step towardshelping students build alternative conceptions. Experience isalso key to the process. Teachers should arrange situationsthat allow students to confront their misconceptions and leadthem to more appropriate (and desirable) ways ofunderstanding phenomena. “Students need experiences thatallow them to see that their conception is inappropriate, whichis far more powerful than telling them it is wrong” (Marton &Ramsden, 1988, p. 271). Constructivists emphasize theinseparability of content, process and context; they alsoacknowledge the importance of experience in helping studentsdevelop new constructs. Nevertheless, context and experience(i.e., situations) do not play a central role from a constructivistperspective. The important roles of context and experiencewill be reviewed in more detail in the discussion of the social /situated perspective of adult education later in this chapter.Experience in a safe atmosphere is unlikely to promotelearning if it occurs at a hurried, breathless pace. There is atendency in contemporary educational practice to “cover”more material when students are unfamiliar with a subjectarea. “Paradoxically, providing a structure built on a solidfoundation of a few main issues, at the expense of coveringdetail, leads to students remembering more details in the end”(Marton and Ramsden, p. 277, 1988). If teachers want their46students to understand more, they will have to cover less.Time, therefore, is another important factor in learning.Students need time to engage in discussion with the teacherand other students. They need time to think and reflect.Constructivists emphasize the important role of students’ priorknowledge in the teaching-learning moment. Ramsden (1988)reminds us that “students rarely have no knowledge about atopic, or no strategy when they tackle a problem” (p. 22).Prior knowledge serves as an advanced organizer, or as a wayof construing new phenomena. Some teachers take greatadvantage (often unknowingly) of students’ prior knowledgethrough the use of analogies. Relating abstract concepts toreal world examples is another way of taking advantage ofstudents’ prior knowledge. The quality and quantity of astudents’ prior knowledge offers an explanation to theparadox discussed above: the less students understand abouta subject area, the less they can be expected to learn. The flipside of this argument is that the more students already know,the more advanced organizers they have: i.e., places to“attach” new concepts. Some have argued that priorknowledge is the most important determinant of new learning(Schmidt, De Grave, De Volder, Moust, & Patel, 1989).The above discussion on factors that influence learning has47centred on ways that educators can enhance learning.Although it is beyond the scope of this dissertation to addressthe many potential negative influences on learning, one keyfactor deserves mention: evaluation. Evaluation canfacetiously be likened to the “tail that wags the dog”:evaluation drives the system. Ramsden (1988) argues that“perhaps the most significant single influence on students’learning is their perception of assessment. It is in theassessment process that the greatest opportunity arises forstudents’ perceptions of the educational context and theirunderstanding of concepts to diverge” (p. 24). Throughout acourse, the thought of the evaluation method hangs aroundstudents’ necks. It is important to note that it is theperception of the evaluation method, and not the methoditself, that drives the system. The effect is not only in terms ofeffort expended, but in the choice of study techniques,resource material, etc..The above discussion is by no means an exhaustive review offactors (positive and negative) that influence learning. It ismeant to acknowledge the existence of such factors, and tohighlight a few key players: learning climate, context/situation, time/reflection, prior knowledge, and evaluation.Learning climate was an important factor in the priordiscussion of the andragogical perspective. Context and48situation will be the main focus in the next section: Social/Situated Perspective of Adult Education. Time and reflectionwill be addressed further in the discussion of the role ofreflection in learning.Limitations of a Constructivist PerspectiveIt is beyond the scope of this dissertation to provide anindepth critique of the constructivist perspective of adulteducation. However, criticism grouped into three broadcategories will be considered briefly: high demands of thelearner, subjectivity of the perspective, and the difficulty ofevaluation.Perkins (1992) discusses the high demands constructivismimposes on the learner. First, he discusses the cognitivedemands. He focuses not only on the cognitive demands ofactive participation and construction of new concepts bylearners, but also on the “conflict faced” path of constructivistlearning. By “conflict face,” he is referring to the cognitivedemands imposed by the conflict of continually challengingstudents’ preconceptions and misconceptions in an attempt toreplace them with more appropriate alternative conceptions.Next, he focuses on the cognitive demands of placing students49in the role of “task managers,” in an attempt to have studentsbecome autonomous thinkers. He argues that students maynot be ready to take on task management responsibilities,especially given the already high cognitive demands imposed(see above). Lastly, Perkins worries about students not“buying in” to the constructivist agenda, and thereby, notbecoming fully engaged in the learning process.Another criticism levied against constructivism is its inherentsubjectivity e.g., (Molenda, 1991). What is often neglected isthat constructivism fits along a spectrum of subjectivity. Forthe purpose of this dissertation, a more moderate view ofconstructivism is adopted. As mentioned earlier,constructivists don’t deny the existence of an external reality.Their assumptions are about how individuals come to know(or represent) and interpret reality. Also, an openness toalternative conceptions does not deny that some models aremore appropriate. In fact, the idea behind much ofconstructivist education is having students adopt modelsconsistent with a particular group (e.g., “think like a doctor, orteacher...”).Finally, there is the problem with evaluation from aconstructivist perspective e.g., (Cunningham, 1991). Noattempt will be made to do anything but lift the lid of this50Pandora’s box, as evaluation continues to be one of the mosthotly debated criticisms of constructivism. Issues aroundgoals and objectives, quantity vs. quality, appropriatemethods, and who is best able to judge that learning hasoccurred, only scratch the surface. The issue of evaluation“driving” the system was also discussed briefly above. Theviews of the author with respect to grounding a resident TEPin a constructivist perspective of adult education and theensuing implications for evaluation will unfold throughout theremainder of this dissertation. Evaluation within the contextof the resident TEP was structured with the following featuresin mind: (1) given the voluntary nature of the program andthe perception by the residents that it “didn’t count” towardstheir final evaluation, the method of evaluation should notdrive the system, and (2) the broad goals of the programallows for qualitatively and quantitatively different learningoutcomes for different residents; the main focus is onfacilitating residents achievement of personal goals andobjectives.CQr. cl.usiorisA brief quote from Marton and Ramsden (1988) helpssummarize the main features of a constructivist perspective of51education:From (the) principle of learning as a change in conceptionsflow the themes and injunctions that should by now befamiliar: a view of content and process in learning as parts ofthe same whole, an emphasis on students’ conceptions andperceptions, and learning about students’ thinking as the keythat will unlock the door to better teaching and course design.If we want to change students’ understanding, we have to dealwith their present understanding in a methodical way. Notonly can this kind of learning not be dealt with solely ingeneral terms; it also cannot be value-free. We have to knowwhat view of a particular phenomenon we would like a learnerto develop (p. 272).ReflectionAs mentioned, constructivism is not a single theory, rather it isa group of perspectives grounded on many of the sameassumptions. Given that constructivism may be at the root ofother educational perspectives, it sometimes becomes difficultto tease out specific elements of clear-cut perspectives. Thedesire for order and simplicity may drive some authors (orreaders) to pigeon hole examples into rigid categories.52Perhaps it is more appropriate to think of analyzing examplesfrom a particular perspective rather than trying to label themoutright. Donald A. Schon, in his book, EducatingitheReflective Practitioner (1987) proposes a model for teaching“artistry” in the professions. Both the constructivist andsituated/social perspectives apply. However, Schon’s modelwill be reviewed from a constructivist perspective in the hopesof illustrating not only the practical application ofconstructivism to a resident TEP, but also its value.Before discussing Schon’s (1987) Educating the ReflectivePractitioner, a brief discussion of “reflection” is in order.Given that constructivism locates learning within theindividual, metacognitive skills must play an important role inlearning. “Metacognition refers to the voluntary, conscious,and self-monitoring act of thinking, It is the opposite of reflexthinking. Such words as pondering, deliberating, cogitating,or reflecting describe metacognition” (italics mine) (Barrows& Pickell, 1991, p. 25). “What do we usually imagine when wethink of reflection? From a human view we may imaginequietly, mulling over events in our mind or making sense ofexperiences we have had” (italics mine) (Boud, Keogh, &Walker, 1985c, p. 8). Boud, Keogh, and Walker (1985) remindus that “the activity of reflection is so familiar that, as teachersor trainers, we often overlook it in formal learning settings,53and make assumptions about the fact that not only is itoccurring, but it is occurring effectively” (p. 8). Duley (1981,cited in Boud, Keogh,& Walker, 1985), emphasizes that, “theskill of experiential learning in which people tend to be themost deficient is reflection” (p. 611).In their book (Boud, Keogh, & Walker, 1985b), Reflection:Turniugfxperience into Learning, Boud, Keogh, and Walkeradmonish “the half digested (and half baked) practical workor work experience” that students are subjected to under theguise of professional education (p. 7). They pose (and try toanswer) a number of questions in their book: What is it thatturns experience into learning?; What specifically enableslearners to gain the maximum benefit from the situations theyfind themselves in?; How can they apply their experiences innew contexts?; Why can some learners appear to benefit morethan others? From the authors point of view, the answer is inthe book title, Reflection: Turning Experience into LearningAt first glance, the wording in the above paragraph gives theimpression that Boud, Keogh, and Walker’s book is groundedin a social / situated perspective of adult education (e.g.,“practical work,” “work experience,” “situations,” “apply theirexperience to new contexts”). Upon further reading, onediscovers that there is considerable overlap among54perspectives with a strong emphasis on constructivism. Anandragogical perspective e.g., (Knowles, 1980) is also evidentby the authors’ primary concern for the learner: “Thecharacteristics and aspirations of the learner are the mostimportant factors in the learning process” (p. 21). Theyemphasize the importance of the learners’ past experiencesand diverse backgrounds. They also stress the value of thelearning climate.The major grounding of Boud, Keogh, and Walker’s (1985)book in a social situated perspective is self-evident. Theauthors also discuss in detail the importance of feelings andattitude. Although there are no specific references toBandura’s (1977) work on self-efficacy, the discussions onattitude and feelings are virtually indistinguishable fromBandura’s concept of self-efficacy within his social cognitivetheory (Bandura, 1986). Boud and colleagues, like Bandura,emphasize the importance of “foster(ing) the development ofconfidence and a sense of self-worth that can lead (thelearner) to pursue paths which previously may have beenunavailable to (them)” (1985a, 22). Again, like Bandura,Boud, Keogh, and Walker see perception (or interpretation) ofperformance by the individual as a more important elementthan outside assessment (although neither deny theimportance of validation by external influences). Successful55practice (or “mastery experiences,” (Bandura, 1977) is at thecentre of both models.Multiple perspectives of adult education are compatible withBoud, Keogh, and Walker’s model of reflection. Learning inthis model, however, is situated within the learner, and placesgreat emphasis on the learner’s view. Therefore, one couldargue that constructivism lies at the heart of the model. Theauthors highlight the importance of “experience in order tolead to new understandings and appreciations” (p. 19).According to the authors, reflection “links new knowledge withold” and “integrates learning into his or her existingframework” (p. 21). The authors remind us that reflectionshould apply to the constructions of the learners, not theteachers, because events and concepts are only meaningfulfrom the perspective of the individual construing theirmeaning (italics mine).Boud, Keogh, and Walker (1985) propose a three part modelof experiential learning based on reflection. The three partsinclude (1) experience(s), (2) reflective process, and (3)outcomes. The reflective process itself has three majorelements: returning to the experience, attending to feelings,and re-evaluation. The authors suggest that specific time beallocated for reflection after the experience. The outcomes of56the reflective process include clarification of issues, thedevelopment of new skills, problem resolution, thedevelopment of new cognitive maps, the development of newperspectives, and changes in behaviour.According to Boud and colleagues (1985a), “action ends thereflective process for the time being. Action can obviouslyoccur at any stage of the learning process and it may itselfprecipitate a new phase of reflective activity” (p. 35). To theauthor of this dissertation, this remains one of the majorlimitations of this model. The separation of action andreflection denies the importance of an ability to reflect duringaction. Boud, Keogh, and Walker’s reflection model iscompatible with what Schon (1987) describes as “reflection-on-action.” Schon’s model is more inclusive with the additionof “reflection-in-action” (i.e., reflection during action). Jarvis(1992), in his book, Paradoxes of Learning, informs us that“action is clearly associated with rational thought andreflective learning, for both during the action and after it,actors might begin to reflect on situations and learn from it”(italics mine) (p. 115).According to Schon (1987) “there is a crisis of confidence inthe professions and their schools, (that) is rooted in theprevailing epistemology of practice” (p. 12). He argues that57professional schools are increasingly less able to teach theirstudents what they need to learn most. From Schon’sperspective, this is due to the dominant epistemology ofprofessional practice (i.e., technical rationality) and thehierarchy of knowledge in professional schools: basic science,applied science, and technical skills of day to day practice.Upon graduating, students are ill prepared to deal withproblems of real world practice because most of theseproblems are “not in the book.” Unfortunately, students haveonly learned to apply rigid rules and solutions to “technicalproblems.” Students have not learned what they need most tobe outstanding practitioners: dealing with the “indeterminatezones of practice” - ambiguity, uncertainty, and value conflict.Schon does not deny that outstanding practitioners exist. Hedoes not believe however, that their excellence is borne fromprofessional education. Outstanding practitioners are thoughtto have more “wisdom,” “talent,” “intuition,” or “artistry.”According to Schon, artistry represents a different andimportant kind of knowing that is not inherently mysteriousand can be rigorous in its own way. He is not negating theimportance of applied science and research based knowledge.These are critically important, but they are “bounded onseveral sides by artistry” (p. 13). Schon argues that “thestudent cannot be taught what he needs to know, but (that) hecan be coached: “He has to see on his own behalf and in his58own way the relations between means and methods employedand results achieved”(p. 17). To this end, Schon proposes the“reflective practicum”- learning experiences designed to helpstudents acquire the artistry needed to deal with theindeterminate zones of practice (i.e., ambiguity, uncertainty,and value conflict). He envisions “the gradual passage toconvergence ofmeaning (being) mediated ... by a distinctivedialogue of student and coach...” (italics mine) (p. 20), withreflection playing a central role.Schon begins by describing “knowing-in-action”, a kind of tacitknowing that is independent of the ability for description. Forexample, knowing how to ride a bicycle is embedded in theaction of riding and is difficult to describe. Schon wouldargue that the knowing is in the action. “Whatever languagewe may employ, however, our descriptions of “knowing-inaction” are always constructions. They are always attempts toput into explicit, symbolic form a kind of intelligence thatbegins by being tacit and spontaneous” (Schon’s italics) (p.25). He emphasizes the automatic nature of many of ourcognitive and psychomotor skills. Once learned, “we canexecute smooth sequences of activity, recognition, decision,and adjustment without having...to ‘think about it.’ Ourspontaneous knowing gets us through the day” (p. 26).59When something unexpected interrupts the smooth process ofknowing-in-action, or when a mismatch of an element to anoverall pattern is recognized, “surprise” draws our attention toour knowing-in-action. Attention is drawn to the situation athand. According to Schon, there are two possible courses ofaction. First, we could just “stop and think” - “reflection-on-action” - and then return to the task (which may be later).Alternatively, we could reflect in the midst of action -“reflection-in- action.” The distinction between reflection-on-action and reflection-in-action is somewhat artificial. Forinstance, if one experiences surprise in the midst of action,pauses briefly to think, then returns to the task, is thisreflection-on-action (because of the pause) or reflection-inaction (because the task was ongoing)? The model is, however,more helpful with clear cut examples. For instance, a teacherexperiencing a discipline problem in the classroom maysimply deal with the situation without “thinking about it” (i.e.,knowing-in-action). On her way home that night, she mayreplay the day’s event in her head in an attempt to make senseof it and perhaps devise alternative strategies for dealing withsimilar future situations (i.e., reflection-on-action). Analternative approach would have her specifically attend to thesituation, reflect in the midst of action, and act based on herreflection(s). “What distinguishes reflection-in-action fromother kinds of reflection is its immediate significance for60action. In reflection-in-action, the rethinking of some part ofour knowing-in-action leads to on-the-spot experiment andfurther thinking that affects what we do - in the situation athand and perhaps in others” (p. 29).Some would suggest that reflection-in-action is no more thansimple trial and error. “But the trials are not randomlyrelated to one another; reflection on each trial and its resultssets the stage for the next trial. Such a pattern of inquiry isbetter described as a sequence of “moments” in a process ofreflection-in-action:” (p. 27).What are the implications of Schon’s call for a shift in theepistemology of professional practice? And how will this shiftaddress the indeterminate zones of practice (i.e., artistry) -ambiguity, uncertainty, and value conflict? According toSchon, professionals share a body of knowledge called an “...‘appreciative system’ - the set of values, preferences, andnorms in terms of which they make sense of practicesituations, formulate goals and directions for action, anddetermine what constitutes acceptable professional conduct”(italics mine) (p. 33). Therefore, this ‘appreciative system’ orworld view is a social construct (or map) that professionals useto construe practice situations. Learners, by negotiatingmeaning with established professionals (i.e., coaches), make61the transition from “thinking like a” lay person to “thinkinglike a” professional.“Underlying this view of the practitioner’s reflection-in-actionis a constructionist view of reality with which the practitionerdeals - a view that leads us to see the practitioner asconstructing situations of his practice, not only in the exerciseof professional artistry but also in all other modes ofprofessional competence” (Schon’s italics) (p. 36). Therefore,by selective attention, naming, sensemaking, and boundarysetting, professionals (and “learning professionals”) build andmaintain a world matched to their professional knowledge andknow how.Schon does not deny that learning facts, rules and operations,and applying these to technical (or standard) problems isimportant to the learning professional. His reflection-in-actionmodel is not incompatible with traditional views of learning inthe professions, it simply adds a dimension more suited todealing with “artistry.” “If we see professional knowing interms of “thinking like a” manager, lawyer, or teacher,students will still learn relevant facts and operations but willalso learn the forms of inquiry by which competentpractitioners reason their way, in problematic instances, toclear connections between general knowledge and particular62cases” (p. 39). Therefore, depending on teachers’ views of“thinking like a ...“, they may emphasize the rules of inquiryor the reflection-in-action by which students can develop theirown. Schon goes on to explain how making the coach’s ownreflection-in-action “visible” to students can help studentsdeal with the indeterminate zones of practice and professionalartistry. “If we focus on the kinds of reflection-in-actionthrough which practitioners sometimes make new sense ofuncertain, unique or conflicted situations of practice, then wewill assume neither that existing professional knowledge fitsevery case nor that every problem has a right answer. We willsee students as having to learn a kind of reflection-in-actionthat goes beyond statable rules - not only by devising newmethods of reasoning, as above, but also by constructing andtesting new categories of understanding, strategies of action,and ways of framing problems” (p. 39).Making the coach’s own reflection-in-action “visible” tostudents is also an important feature of the “cognitiveapprenticeship” (Collins, Brown, & Holum, 1991). Althoughdifferent terminology is used, the ideas are similar. The titleof Collins, Brown, and Holum’s (1991) paper, “CognitiveApprenticeship: Making Thinking Visible,” is self explanatory.Collins and colleagues also emphasize the role of reflection inlearning. Cognitive apprenticeship will be discussed in more63detail as part of the social situated perspective below.A recent and intriguing article (Tremmel, 1993) entitled, “Zenand the Art of Reflective Practice in Teacher Education,”“explores the possibility of enriching reflective teaching andteacher education programs by transcending the limitationsimposed by technical and analytic views of reflective practicethrough the incorporation of non-Western notions ofreflection, particularly the Zen Buddhist tradition of‘mindfulness” (p. 434). The author proposes Schon’s conceptof reflection-in-action as a broader approach to reflection, andrelates this concept to Zen teachings. He suggests that relyingon a narrow definition of reflection can lead to the failure ofTEPs, and proposes “preparing the mind” (i.e., learning to payattention) as the first step towards reflective teachereducation.In summary, Schon proposes a new epistemology ofprofessional practice (including teacher education) based on aconstructivist perspective. His reflection-in-action model, hebelieves, will address both the technical and artistrycomponents of what it means to be a professional. “Whenpractitioners respond to the intermediate zones of practice byholding a reflective conversation with the materials of theirsituations, they remake a part of their practice world and64thereby reveal the usually tacit processes of worldmaking thatunderlie all of their practice” (p. 36).Ryond Reflection - Transformative Perspective of AdultEducationThe last sentence of the above paragraph is loaded andmeaningful: “by holding a reflective conversation with thematerials of their situations, they remake a part of theirpractice world and thereby reveal the usually tacit processesof worldmaking that underlie all of their practice” (italicsmine) (Schon, 1987, p. 36). Schon’s reflective model is anatural and appropriate starting point to discuss Mezirow’se.g., (Mezirow, 1978; Mezirow, 1989; Mezirow, 1990a;Mezirow, 1990b; Mezirow, 1991) view of reflection and histransformative perspective of adult education.Schon takes us from “knowing-in-action” to “reflection-onaction” and finally to “reflection-in-action.” Mezirow (1990)challenges us (both educators and students) to move reflectionto a higher level of abstraction: “critical self-reflection.” Toput this in a language similar to Schon’s, Mezirow challengesus to move to “reflection-on-presuppositions.” Critical selfreflection involves an understanding of problem framing (not65unlike that put forth by Schon (1987) and an understandingof perspective taking (i.e., tacit assumptions constituting aframe of reference for construing events and ideas). Mezirowand Schon use the word tacit differently, however, for Schon,tacit is simply a matter of what is unsaid, understood, orimplied. Mezirow takes us one level deeper and would have usquestion the assumptions underlying what is unsaid,understood, or implied. Therefore, Schon would have us makeexplicit our meaning perspective, whereas, Mezirow wouldhave us question the assumptions on which our meaningperspective is founded.But critical self-reflection is also much more that this; it is themeans whereby “transformation” occurs (Mezirow, 1990b).“Perspective transformation is the process of becomingcritically aware of how and why our presuppositions havecome to constrain the way we perceive, understand, and feelabout our world; of reformulating these assumptions to permita more inclusive, discriminating, permeable, and integrativeperspective; and of making decisions or otherwise acting uponthese new understandings” (p. 14).Mezirow (1991) distinguishes between the transformation of“meaning schemes” from the transformation of “meaningperspectives.” Meaning schemes are specific beliefs,66knowledge, value judgements, attitude, and emotionalreactions. Meaning perspectives are more encompassing; theyare “personal paradigms” or maps of the world. Meaningperspectives give rise to meaning schemes. Both meaningschemes and perspectives allow us to construe experiences.According to Mezirow (1991), transformation of meaningschemes through reflection is a common occurrence; it allowsfor the correction of misinterpretation and does notnecessarily involve critical self-reflection. Perspectivetransformation (i.e., transformation of a meaning perspective),on the other hand, is an infrequent occurrence; it involvescritical reflection of distorted presuppositions. The trigger forperspective transformation may be acute in the form of acrisis (i.e., “disorienting dilemma”) or may be more slow goingthrough an accumulation of transformed meaning schemes.Mezirow (1991) reminds us that not all learning istransformative. He identifies “four processes of learning- byextending meaning schemes, creating new ones, transformingold ones, and transforming perspectives” (p. 212). He does,however, see the ultimate role of the adult educator asfacilitating the transformation process. “We professional adulteducators have a commitment to help learners become moreimaginative, intuitive, and critically reflective of assumptions;67to become more rational through effective participation incritical discourse; and to acquire meaning perspectives thatare more inclusive, integrative, discriminating, and open toalternative points of view. By doing this we may help others,and perhaps ourselves, move toward a fuller more dependableunderstanding of the meaning of our mutual experience” (p.224).Before moving on to the next section, the reader is remindedthat the transformative perspective of adult education is alsofirmly grounded in a constructivist epistemology. Mezirow(1978) speaks of “restructuring one’s frame of reference formaking and understanding meaning” (p. 104), and of“restructuring one’s reality” (p. 105). The next section, TheSocial / Situated Perspective of Adult Education is also firmlygrounded in constructivism.Social Situated PerspectiveIntroductionJarvis (1992), in his book, Paradoxes of LearningQnBecoming an Individual in Sodety, points to the self—contradictory nature of research on learning that tries to68separate learners from the social context of learning, insteadof trying to understand the social process of learning. The“Social” (or “Situated”) perspective of adult education focuseson the relationship between learning and the social situationin which it occurs (Lave & Wenger, 1991). Some basic tenetsof the social / situated perspective will be given in an overviewbefore moving on to two specific and practical applications ofthe perspective: cognitive apprenticeship, and self-efficacy.Cognitive apprenticeship e.g., (Collins, et al., 1991) representsan instructional model that allows for the development ofcognitive skills. As an instructional strategy, it is particularlyappropriate for developing some of the teaching skillsaddressed in the resident TEP. Bandura’s (1986) socialcognitive theory represents a theoretical framework forunderstanding motivation, thought, and action. Self-efficacy(Bandura, 1977) represents an important facet of socialcognitive theory in dealing with the interrelationship betweenknowledge and action (i.e., behaviour). Of special interest tothis dissertation is the concept of “teaching self-efficacy” e.g.,(Ashton, 1984) given that a change in teaching self-efficacy isthe major outcomes measure of this research project.The language of constructivism appears throughout this (andother authors’) discussion of the social / situated perspectiveof adult education. In fact, Duffy and Jonassen (1991), in69their essay on the implications of constructivism forinstructional technology, confuse some of the principles ofconstructivism with those of a social / situated perspective.Although grounded in constructivism, the social / situatedperspective’s focus on context is in direct contradistinction toconstructivists who assume that cognitive representation isprior to all else. “A theory of situated cognition suggests thatactivity and perception are importantly and epistemologicallyprior - at a nonconceptual level- to conceptualization and thatit is on them that more attention needs to be focused” (Brown,Collins, & Duguid, 1989, p. 41). Brown, Collins, and Duguid(1989) recommend that we “abandon the notion that(concepts) are abstract, self-contained, entities” (p. 33) anduse the analogy of “tools” to demonstrate how knowledge, liketools, is situated in the context of their use. Both “can only befully understood through use, and using them entails bothchanging the user’s view of the world and adopting the beliefsystem of the culture in which they are used” (p. 33). Laveand Wenger (1991) view situated learning as an intermediarybetween learning as an individual cognitive process andlearning as a characteristic of social practice. In their view,“learning is not merely situated in practice - as if it were someindependently reifiable process that just happened to belocated somewhere; learning is an integral part of generativesocial practice in the lived-in-world” (p. 35). According to70Wilson (1993), cognition exists in its relationship amongindividuals in a cultural setting, and that traditional views ofeducation have focused too heavily on individual internalcognition. Although he credits Schon (see “reflection” above)for providing a framework that comes closest to accounting forthe situated nature of adult cognition, he criticizes him for notspecifically addressing the interpersonal dynamics of practiceor its “tool dependence.” It is for these same reasons thatSchon’s (1987) work is discussed in the above section onconstructivism rather than in the present section.Brown, Collins, and Duguid (1989) maintain that knowledge(and not just learning) is situated. Knowledge is “indexed” bythe context or situation in which it was learned. They drawparallels between the indexed and situated nature ofknowledge with that of language. The evolution of a concept,like that of a word, becomes increasingly “textured” with thesituation of each use. Therefore, concepts, like words, arecontinually under construction and part of their meaningcomes from the context of their use. The situation in which aconcept is learned, thereby, becomes part of its meaning. Theidea of indexicality underscores the importance ofunderstanding the situations in which specific learning takesplace and the difficulty of transferring learning acrosscontexts. This is particularly important in the difficult71transfer from “schooling” to the real world (Duffy andJonassen, 1991). Educators trying to decontextualize concepts(e.g., learning metacognitive skills or problem solving skillsoutside a specific content area) may find the same lack oftransfer. Duffy and Jonassen (1991) contend that experienceis not only important for understanding concepts, but also formaking them available for future use. An everyday example ofthe indexed nature of knowledge comes from recognizingpeople and knowing who they are. For instance, outside theusual context of our workplace, we may recognize coworkers(and even say “hello”) but not be able to “place them” (i.e.,remember who they are out of context). Therefore, studentsshould learn (and apply) concepts under varying circumstance(Spiro, Feltovich, Jacobson, & Coulson, 1991). The idea is notto find some common underlying principles but to understandthe concept from multiple perspectives for eventual use. Theauthors argue that criss-crossing the landscape of contexts iscritical to instruction. Assumptions that knowledge issomething devoid of context leads to teaching methods thatignore the way situations structure cognition. It is essential,therefore, that learning be rooted in authentic activity.Lave and Wenger (1991), in their book, Situated LearningLegitimate Peripheral Participatkn, mould the concept ofsituated activity into a theoretical perspective for72understanding learning. Their perspective emphasizes therelational character of knowledge and learning and thenegotiated character of meaning. They argue that all activityis situated. They also emphasize comprehensiveunderstanding as a “whole person.” Learning is viewed, not asthe acquisition of knowledge transferred by instruction nor asthe imitation of others, but as a form of social coparticipation.They concern themselves more with the types of socialopportunities that provide the optimal context for learningthan with cognitive processes and conceptual structures. “Theindividual learner is not gaining a discrete body of abstractknowledge which (s)he will then transport and reapply in latercontexts. Instead, (s)he acquires the skill to perform byactually engaging in the process, under the attenuatedconditions of legitimate peripheral participation” (on ginalemphasis) (p. 14). Legitimate participation is concerned withactual practice and refers to what other authors have called“authentic activity” e.g., (Collins, et al., 1991). Peripheralparticipation involves limiting learners’ involvement in (andresponsibility for) the end “product” during learning.Learners, therefore, move from the periphery of a practicetowards its centre while developing increasing skills.The authors distinguish between a learning curriculumconsisting of situated opportunities and a teaching curriculum73constructed for instruction. A self contained teachingcurriculum is by its very nature limiting. Learning, therefore,becomes a question of access to legitimate practice as alearning resource rather than providing instruction.Lave and Wenger maintain that learning and the developmentof a sense of identity are inseparable. “Moving towards fullparticipation in practice involves not just greater commitmentof time, intensified effort, more and broader responsibilitieswithin the community, and more difficult and risky tasks, but,more significantly, an increasing sense of identity as a masterpractitioner” (italics mine) (p. 111). This last idea is notunlike the development of increasing self-efficacy through thecultivation of personal mastery experiences (Bandura, 1977).Cogni1ieapprenticeshipCollins, Brown, and Holum (1991) present cognitiveapprenticeship as a learning model based on traditionalapprenticeships while retaining elements of “schooling.” Thekey to their model is making thinking “visible” (viz.,cognitive). During traditional apprenticeships, learners moveincreasingly away from the role of passive observers andincreasingly towards the independent accomplishment of tasks74(i.e., decreasing supervision). Lave and Wenger (1991) centremuch of their discussion of legitimate peripheral participationaround examples of traditional apprenticeship. Collins,Brown, and Holum (1991) delineate four important aspects ofthe traditional apprenticeship: modelling, scaffolding, fading,and coaching. Modelling allows learners to watch masters atwork. Support for learners during actual practice is providedfor in the form of scaffolding. This may involve doing part ofthe work, giving advice, etc.. Fading implies providing lessscaffolding. Coaching includes the first three aspects (i.e.,modelling, scaffolding, and fading), as well as providingevaluation and feedback among other things. In short,coaching indicates supervising students’ learning. Theauthors remind us that providing students with a “conceptualmodel - a picture of the whole - is an important factor inapprenticeship’s success in teaching complex skills” (p. 9). Itprovides learners with advanced organizers and a model forinterpreting the activities of coaching. It will also serve as aninternalized guide for eventual independent practice.The “work” of cognitive skills (e.g., problem solving) is notdirectly observable to students, and students must makeassumptions about the actual process. Students, therefore, donot have a conceptual model of the skill being learned.Collins, Brown, and Holum (1991) translate the salient75features of the traditional apprenticeship into a model ofcognitive apprenticeship. They identify three essentialrequirements: (1) identify the processes of the task and makethem visible to students, (2) situate abstract tasks in authenticcontexts, so that students understand the relevance of thework, and (3) vary the diversity of situations and articulatethe common aspects so that students can transfer what theylearn. The traditional apprenticeship is by definitioncompletely situated in the workplace. It is important to situatethe tasks of the cognitive apprenticeship in authenticactivities. “In traditional apprenticeship, the skills to belearned inhere in the task itself... .The tasks in schooling,however, demand that students be able to transfer what theyhave learned. In cognitive apprenticeship, the challenge is topresent a range of tasks, varying from systematic to diverse,and to encourage students to reflect on and articulate theelements that are common across tasks” (italics mine) (p. 9).The authors propose a framework for designing learningenvironments using the cognitive apprenticeship. Theframework consists of four dimensions: content, method,sequencing, and sociology. The content dimension identifiesthe types of knowledge required for expertise: domainknowledge, heuristic strategies (i.e., “rules of thumb” or“tricks of the trade”), control strategies (i.e., metacognitive76skills), and learning strategies. The methods to promote thedevelopment of expertise include those discussed in thetraditional apprenticeship- modelling, coaching, scaffolding,and fading)- as well as articulation (to make students’thinking visible), reflection, and exploration (to challengestudents). Sequencing of the learning activities is alsoimportant. Students should develop a conceptual model ofthe whole task before performing subtasks (i.e., global skillsbefore local). With increasing experience, tasks shouldbecome increasingly complex and diverse. Sociology refers tothe social characteristics of learning environments. Learningmust be situated in authentic activities. Students should learnby actively using knowledge rather than passively receiving it.Educators should strive to create a community of practice.This “refers to the creation of a learning environment in whichthe participants actively communicate about and engage inthe skills involved in expertise... .Such a community leads to asense of ownership, characterized by personal investment andmutual dependency” (p. 45). Intrinsic motivation for thedevelopment of expertise should be fostered rather than forextrinsic reasons (e.g., grades). The authors also encourageeducators to exploit cooperation by encouraging groupproblem solving.77Self-EfficacyBehaviour is not solely regulated by external outcomes,otherwise “people would behave like weathervanes, constantlyshifting direction to conform to whatever momentary socialinfluence happened to impinge upon them. In actuality,people possess self-reflective and self-reactive capabilitiesthat enable them to exercise some control over their thoughts,feelings, motivation, and actions.... Human functioning is,therefore, regulated by an interplay of self-generated andexternal sources of influence” (italics mine) (Bandura, 1991, p.249). These “self-regulatory” processes are at the core ofpurposeful behaviour. Through forethought, they manifestthemselves as beliefs about capabilities and the likelyconsequences of specific behaviours. They enable goal settingand preparing plans for action. Forethought may also serve tomotivate.Bandura’s (1986) social cognitive theory attempts to explainbehaviour as a function of self-regulative mechanisms. Heidentifies three principle subfunctions of self-regulativemechanisms: (1) self-monitoring of one’s behaviour, itsdeterminants, and its effects, (2) judgment of one’s behaviourin relation to personal standards and environmentalcircumstances, and (3) affective self-reaction. Among the self-78regulatory mechanisms, none is more central or universal aspersonal beliefs about capabilities: self efficacy (Bandura,1977). Self-efficacy “plays a central role in the exercise ofpersonal agency by its strong impact on thought, affect,motivation, and action” (Bandura, 1991, p. 248). It isimportant to distinguish between self-efficacy and socialcognitive theory. Social cognitive theory is a multifacetedtheory involving many determinants of behaviour of whichself-efficacy is only one. Therefore, self-efficacy is only onefactor operating within a more complex causal relationship.Social cognitive theory as applied to adult education, is anexample of the social / situated perspective. Bandura, himself,in a lecture given at the annual meeting of the AmericanEducational Research Association (1992), cites “cognitivemodelling” (cf., cognitive apprenticeship) as an importantmethod for cultivating mastery experiences. He also discussedother important aspects of a social / situated perspective.Social cognitive theory advocates a multifacetedapproach to suit an achievement. Ability is construed asa changeable attribute over which one can exercise somecontrol. Guided mastery serves as the principle vehiclefor the cultivation of competencies. Cognitive modellingand direct tutelage are used to transmit relevant79knowledge and strategies. Guided practice is providedin when and how to use cognitive strategies in thesolution of diverse problems. Activities, incentives andpersonal challenges are structured in ways that ensureself-involving motivation and continual involvement inacademic activities. Growing proficiencies are creditedto expanding personal capabilities. Each of these modelsof influence is structured in ways that strengthenstudents self beliefs that they have what it takes toexercise control over their own self development(Bandura, 1992).The literature on the social / situated perspective of adulteducation demonstrates that knowing “what” does notnecessarily mean knowing “how” (e.g., Lave and Wenger,1991). Bandura’s work on self-efficacy takes this idea one stepfurther. Knowing “how” does not necessarily mean believingone “can” (and consequently “will”). Therefore, situatinglearning in authentic activity is not only important inproviding the learner with knowledge and skills but inproviding successful experiences (i.e., mastery experiences)and thereby, enhancing students’ self-efficacy. Bandura(1992) argues that “efficacy demonstration trials” need to bebuilt into learning experiences. He contends that ifindividuals try their newfound skills at the wrong time or in80the wrong place, the resulting loss of efficacy beliefs maynegate any gains of learning. Therefore, self-efficacy belief isan important antecedent of behaviour but is only partiallydependent on inherent skill. Successful performance,therefore, requires both skills and the efficacy beliefs to usethem.The conception of human ability has undergoneconsiderable change in recent years. Ability is not afixed attribute in one’s behavioural repertoire. Rather, itis a generative capability in which cognitive, social,motivational and behaviour skills must be organized andeffectively organized, orchestrated for diverse purposes.It also involves skill in managing emotional reactionsthat can impair the quality of thinking and of action.There is a marked difference between possessingknowledge and skills and being able to use them wellunder taxing conditions (Bandura, 1992).Bandura (1977) postulates that individuals develop outcomeexpectations based on life experiences, and efficacy beliefsconcerning their ability to cope. That is, outcome and efficacyare separate components of efficacy expectations. First of all,individuals must believe that the specified action will lead tothe desired outcome (i.e., outcome expectation). Secondly,81they must believe themselves capable of the specified action(i.e., self-efficacy belief). The expectations of personal masteryare important for initiating a behaviour, and for perseverancein the face of difficulties. Lack of expectations of personalefficacy play an important role in avoidance behaviour. It isimportant to realize that efficacy expectations are not the soledeterminants of behaviour. Someone may not initiate a task,despite strong self-efficacy, if there is no incentive to do so.The dimensions of efficacy expectations include magnitude,strength, and generality (Bandura, 1977). When rank orderinga task according to difficulty, some individuals’ efficacy beliefsmay be limited to lower levels of difficulty (i.e., lowmagnitude). Efficacy expectations also differ in strength.Individuals with weak expectations are more likely to give upwhen experiencing a set back, whereas, those with a strongsense of self-efficacy are more likely to persist. Some efficacyexpectations may be narrowly specific to the given tasks,whereas, other efficacy beliefs may be generalized beyond thespecific situation. For the most part, efficacy beliefs tend to bespecific and tied to “domains of functioning” (Bandura, 1992).Bandura is critical of what he call “omnibus” tests to measureseveral facets of self-efficacy. Instead, he suggests usingdomain related scales. A more generalized sense of selfefficacy is not necessarily advantageous; some individuals82may have mistaken efficacy beliefs, On occasion, “people canhave profound experiences in which they actually changefundamentally their belief about their cognitive power”(Bandura, 1992) (cf., Mezirow’s perspectives transformation,e.g., Mezirow, 1991). Thereafter, they apply their efficacybeliefs across a wider domain of behaviours.Efficacy expectations come from four sources: (1) performanceaccomplishments, (2) vicarious experience, (3) verbalpersuasion, and (4) emotional arousal (Bandura, 1986).Performance accomplishments “provide the most influentialsource of efficacy information because it is based on authenticmastery experiences” (italics mine) (Bandura, Adams, andBeyer, 1977, cited in Bandura, 1986, p. 399). Successes lead toan enhanced sense of self-efficacy, whereas, failures tend toextinguish it.Self-efficacy judgments have several functions and effects(Bandura, 1986). Choice behaviour is in part determined byefficacy beliefs. Avoidance behaviour is associated with aweak sense of self-efficacy. The stronger the perceivedefficacy, the higher the goal challenges people set forthemselves. When faced with difficulties, self-efficacy plays aconsiderable role in determining effort expenditure andperseverance. Thought patterns and emotional reactions83under aversive conditions are also influenced by efficacybeliefs. People who view themselves as inefficacious dwell oninadequacies and “blow” difficult situations out of perspective,whereas, those with strong efficacy beliefs focus theircognitive energy and attention on the difficult situation andmobilize greater effort to the task at hand. “Research showsthat people who regard themselves as highly efficacious, act,think, and feel differently from those who perceive themselvesas inefficacious. They produce their own future, rather thansimply foretell it” (Bandura, 1986, p. 395).Efficacy beliefs also play a key role in motivation. Asdiscussed, they determine the goals people set for themselves,how much effort they expend, and how much they perseverein the face of difficulties. In contrast, most theories ofmotivation are founded upon a negative feedback system(Bandura, 1992). In this view, discrepancy between one’sperceived performance and an adopted standard motivatesaction to reduce the disparity. Motivation by negativediscrepancy tells only half the story, and not necessarily themore interesting half according to Bandura.Self efficacy, like constructivism, aspires to move beyondbehaviourism by highlighting the importance of cognitiveprocesses and the development of beliefs as guides for action.84The cognitive processing of efficacy information is moreimportant than the “objective” information. Successes must beviewed as resulting from skill rather than chance ormonumental effort. How individuals construe ability ismeaningful for cognitive processing of efficacy information.Mary Bandura (1983) found that children who construe abilityas acquirable, seek challenges that provide opportunities toexpand their knowledge and competencies. Errors are seen asa natural part of learning by these children. They judge theircapabilities more in terms of personal improvement than bycomparison against the achievement of others. Other childrenconstrue ability as an inherent capacity. They viewperformance as diagnostic of their inherent intellectualcapabilities (or lack thereof). Therefore, they prefer tasks thatminimize errors and reveal their proficiency at the expense ofexpanding their knowledge and their competencies. Having toexert high effort is also threatening to these children becauseit presumably reveals that one is “not smart.” The successesof others belittle their own perceived ability. Along the samelines as how individuals construe ability, people’s beliefs aboutthe extent to which their environment is controllable plays arole in the cognitive processing of efficacy information.Since most activities do not provide objective standards forassessing capabilities, people must, therefore, assess their85capabilities in relation to the attainments of others (Bandura,1992). In an educational setting, this often takes the form offeedback. Feedback that focuses on achieved progress (i.e.,positive feedback) underscores personal capabilities, whereas,negative feedback highlights personal deficiencies. Accordingto Bandura, highlighting gains magnifies perceived efficacy,aspirations, efficient analytic thinking, and self satisfaction inperformance accomplishments.Teaching EfficacyAlthough the concept of self-efficacy was initially proposed asa means of intervention for psychotherapy, parallels can beextended to the field of education. Bandura, Jeffery, andGajdos (1975, cited in Bandura 1977) report that the “resultsof recent studies support the thesis that generalized, lastingchanges in self-efficacy and behaviour can best be achieved byparticipant methods...initially to develop capabilities, thenremoving external aids to verify personal efficacy, then finallyusing self directed mastery to strengthen and generalizeexpectations of personal efficacy” (p. 202). Although drawnfrom the psychotherapeutic literature, the wording of theabove comment is strikingly consistent with that used indescriptions of cognitive apprenticeship (e.g., Collins, Brown,86and Holum, 1991). Enochs and Riggs (1990) also suggest thatself-efficacy can be used in teacher training programs throughmicroteaching and field experiences.Patricia Ashton (1984) reviews the concept of teacher efficacyas a motivational paradigm for effective teacher education.She defines a teachers’ sense of efficacy as “the extent towhich teachers believe that they have the capacity to affectstudent performance” (p. 28). She credits two RandCorporation studies (Armor, Conry-Osequera, Pascal, Pauly, &Zellman, 1976; Berman, McLaughlin, Bass, Pauly, & Zellman,1977, cited in Ashton, 1984) for introducing the construct ofself-efficacy into the educational literature. She goes on tooutline the four essential components of a motivationprogram: (1) conceptualization of the attitude, (2) self studyin relation to the attitude, (3) planning and goal setting, and(4) group support. She goes on to describe how each of thesecomponents could serve as the basis for a teacher educationprogram founded on the construct of self-efficacy. First of all,a clear concept of efficacy beliefs and how these beliefstranslate into behaviours should promote the relationshipbetween efficacy beliefs and behaviours. Efficacy beliefs mustalso be reconciled with the individuals’ other beliefs.Accordingly, Ashton identifies eight dimensions of teacherefficacy: (1) a sense of personal accomplishment, (2) positive87expectations for student behaviours and achievement, (3)personal responsibility for student learning, (4) strategies forachieving objectives, (5) positive affect, (6) sense of control,(7) sense of common teacher-student goals, and (8)democratic decision making. In terms of goal setting, Ashtoncomments that teachers are “surprisingly unreflective abouttheir work” (p. 31), and that this should be a specific goal ofteacher education programs. Both Schon’s (1987) andMezirow’s (1991) models seem particularly well suited for thisrole. Finally, Ashton promotes the use of group support tomaintain motivation in TEPs devoted to increasing teacherefficacy.Gibson and Dembo (1984) undertook a study to provideconstruct validation support for teacher efficacy. They factoranalyzed a 30 item 6 point Likert scale and identified twodimensions that corresponded to Bandura efficacyexpectations (see above). A belief in “teaching efficacy” (i.e.,that teachers can make a difference) corresponded withBandura’s “outcome expectancy”, whereas, a belief in“personal teaching efficacy” (i.e., that they personally caneffect change as teachers) corresponded with Bandura’s “selfefficacy.” The results were also compatible with Ashton andWebb (1986) two dimensional model of self-efficacy. Internalconsistency reliability was evident using Cronbach’s alpha88coefficients (r=0.79 for 16 of the 30 items). The authors wenton to use the multitrait-multimethod analysis to demonstrateconvergent and divergent validity from data on three traits(i.e., self-efficacy, verbal ability, and flexibility) using twomethods. Finally, classroom observations were used to identifydifferences in the behaviour of low vs. high efficacy teachers.A positive relationship between teachers’ perceived self-efficacy and effective teaching behaviours was demonstrated.Teachers with a sense of instructional efficacy devoted moreclassroom time to academic learning and provided studentsexperiencing difficulties with the help they needed to succeedand then praised them for their accomplishments. In contrast,teachers with a low sense of instructional efficacy spent moretime on nonacademic pastimes, readily gave up on students ifthey did not get quick results, and criticized them for theirfailures. Thus, teachers who believe strongly in their teachingefficacy create mastery experience for students and thosebesieged by self doubts create classroom environments thatundermine students’ sense of efficacy and cognitivedevelopment. Therefore, teachers with a low sense of teachingefficacy may “pass down” their lack of efficacy beliefs to theirstudents.Enochs and Riggs (1990) developed a two dimensional scale tomeasure elementary science teaching efficacy. They used89Gibson and Dembo’s instrument as a model. Reliabilityanalysis, using Cronbach’s alpha, produced a coefficient of0.90 for all 13 items of the “Personal Science Teaching EfficacyScale,” and a coefficient of 0.76 for the “Science TeachingOutcome Expectancy Scale.”Ashton and Webb (1986), in their book, M.king a DifferenceTeachers’ Sense of Efficacy and Student Achievement, neatlysummarize teaching self-efficacy:The construct of teachers’ sense of efficacy refers toteachers’ situation-specific expectations that they canhelp students learn... .Teachers’ efficacy expectationsinfluence their thoughts and feelings, their choice ofactivities, the amount of effort they expend, and theextent of their persistence in the face of obstacles(Bandura, 1981). For example, teachers with a low senseof efficacy doubt their ability to influence studentlearning; consequently, they tend to avoid activities theybelieve to be beyond their capabilities. They reducetheir efforts or give up entirely when confronted withdifficulties. They are preoccupied with thoughts of theirown inadequacies and believe their difficulties are moreserious than they actually are. Their preoccupation withtheir own limitations raises their level of stress and90reduces their teaching effectiveness by diverting theirattention from the demands of instruction to worriesabout their personal competence. In contrast, teacherswith a strong sense of efficacy believe that they arecapable of having a positive effect on studentperformance. They choose challenging activities and aremotivated to try harder when obstacles confront them.They become engrossed in the teaching situation itself,are not easily diverted, and experience pride in theiraccomplishments when the work is done (p. 3).Ashton and Webb also divided teaching efficacy into twodimensions: sense of teaching efficacy, and sense of personalteaching efficacy. They propose an “ecological framework,”for studying teaching efficacy, based on four assumptions: (1)The study of teachers’ sense of efficacy requires anexploration of the subjective perceptions of teachers; (2)Teachers’ sense of efficacy is context-specific. It varies withspecific characteristics of the teaching situation; (3) Teachers’sense of efficacy is affected by direct and indirect influences;direct influences include the students in the classroom and theprincipal. Indirect influences include the students’ families,the school organization, the community, an the culture; (4)Teachers’ sense of efficacy is reciprocally determined; itaffects teachers’ behaviour and is, in turn, influenced by the91teachers’ perceptions of the consequences of that behaviour(p. 13).Guided by their ecological framework, the specific objective oftheir study was to investigate the following: (1) the nature ofteachers’ efficacy attitude, (2) factors that facilitate andinhibit development of a sense of efficacy, (3) teacherbehaviours associated with teachers’ sense of efficacy, and (4)the relationship between teachers’ sense of efficacy andstudent achievement (p. 25). They used both qualitative andquantitative methods of data collection and analysis.Although the results of the study are too numerous to reportin detail, several merit mentioning. First, they describe theattitude of teachers with a high and low sense of self-efficacyin relation to their beliefs and behaviours: “Low efficacyattitude was related to a distrust of low-achieving students;discomfort in low-achieving classrooms; a control orientationin discipline matters; a reliance on positional authority; theuse of embarrassment and excommunication as behaviourmanagement devices; the sorting and classifying of studentsby ability; a willingness to ignore the lowest achievers in theroom and to send them from the class; a de-emphasis oninstruction and the importance of learning; an inability toignite student interest in academic work; and an unwillingness92to push students and to closely monitor their academicprogress. High efficacy attitude was related to a belief that allstudents can learn and want to do so; efforts to establish warmand encouraging relationships with students; the convictionthat students will behave well if treated fairly, firmly, and withconsistency; a reliance on personal authority; the use of direct,nonemotional management techniques; a reluctance toembarrass students; an effort to treat all students as capableand trustworthy; an emphasis on instruction and theimportance of learning; an effort to keep students on task,interested, and aware of their individual accomplishments; awillingness to teach all students in the class, to push them, andmonitor their work; and the determination not to acceptstudent failure (p. 86-87).Second, they report on the major cultural themesdistinguishing schools. Specifically, they looked at teachers!conception of teaching as either an exalted or burdenedprofession, whether teachers perceived their role as one ofstudent development or academic instruction, and someorganization features of school and teachers’ sense of efficacy.Their findings lead them to conclude that school organization,leadership, and ethos play a role in establishing andmaintaining teachers’ sense of efficacy. Finally, a relationshipbetween teachers’ sense of efficacy and student achievement93was demonstrated. This relationship was found to be situationspecific and there was not necessarily transfer across contentareas (e.g., math vs. reading). Similarly, efficacy beliefs werespecific to the context of teaching (e.g., lecture vs. small groupdiscussion). Ashton and Webb review a number of studies allconsistent with their significant correlations between teachingbehaviours and student achievement. They caution, however,making an inferences about a causal relationship given thecorrelational nature of these (and their own) studies. Theyalso point to the reciprocal relationship between teachingefficacy and student achievement outlined in their theoreticalframework (see above). They conclude by arguing that “thepromotion of a high sense of efficacy in teachers and studentsmust become an educational aim as important as academicachievement” (p. 176).Empirical Perspectives Pertinent to Resident TepsThe focus will now move away from theory to practice. Thissection of chapter two begins with a look at ways to improveteaching. Next, the existing literature on residents as teacherswill be reviewed. Finally, a detailed review and analysis of theliterature on resident TEPs will be undertaken.94IniprovingfeachingCantrell (1973) describes the defeatist attitude adopted bymany medical teachers and speculates that this attitude isbased on the belief “that teachers are born, not made. Thishypothesis underlies an almost fatalistic acceptance of‘teaching skill’ as a set of indefinable qualities that are innate,perhaps genetically determined, and incapable of change” (p.724). Whitman (1982) uses a similar analogy in his book,There is No Gene For Good Teaching: A Handbook onLecturing for Medical Teachers. Rippey (1980), in his book,The Evaluation of Teaching in Medical School, also arguesagainst the fact that the traits of a good clinical teacher areindefinable and innate. The three major points in his book arethat: (1) teaching makes a difference; (2) teacher behaviourcan be improved; and (3) evaluation of teaching is possible.He stresses, however, that the evaluation of teaching does notin and of itself necessarily lead to an improvement ininstruction. That the evaluation of teaching can lead toimprovements in teaching, however, has been investigated byRous, and colleagues (1972). They believed that helpingclinical teachers to establish their strengths and weaknessescould bring about an improvement in the quality of medicalinstruction, and this was suggested by the results of theirstudy. They did caution, however, that the voluntary nature95of the evaluation, and the fact that the process was regardedas threatening by many faculty members, resulted in targetingonly the least threatened and best instructors. Those thatneeded improvement most were, therefore, excluded.Acknowledging that insight (i.e., the results of evaluation) is anecessary but not sufficient condition for change (i.e.,improvement of teaching), many prominent medical educatorsbelieve that the evaluation process, along with teachingseminars / workshops, should be seen as part of facultydevelopment. The literature is replete with the beneficialresults of clinical teacher training programs (e.g., Adams, etal., 1974; Bazuin & Yonke, 1978; Cassie, et al., 1977; Patridge,et al., 1980; Sheets & Henry, 1984; Skeff, et al., 1984). Similarsuccess has been noted with resident TEPs (e.g., Greenberg,Goldberg, & Jewett, 1984; Irby, Vontver, & Stenchever, 1982;Lawson & Harvill, 1980; Lazerson, 1973; Pristach, Donoghue,Sarkin, Wargula, Doerr, Opila, et al., 1991). More recently, ithas been suggested that preparation for the teaching roleshould begin at the undergraduate level, and some schoolsnow offer such an elective to their medical students (Craig &Page, 1987; Sobral, 1989).That some clinical educators have a “natural” ability is evidentby their superior skills without any formal education training.However, these skills are innate and unchangeable. Maxwell,96Cohen, & Reinhard (1983) argue that “attendings who aremost respected as teachers vary greatly in their teachingtechniques. However, improvements within each of thesetechniques are clearly possible for most teaching attendings”(p. 194). How best, then, can these changes be brought about?Skeff, Berman and Stratos (1988) review the various methodsto improve clinical teaching. Feedback from students, alone,was not consistently effective (Rotem & Glassman, 1979; Rous,et a!., 1972; Skeff, 1983; Stillman, 1983). However, whencombined with self-assessment, consultation by a professionaleducator, or programmed feedback booklets, student feedbackbecame effective (Aleamoni & Hexner, 1980; Centra, 1973;Cohen & Herr, 1982; McKeachie, 1979; Pambookian, 1976).Interestingly, despite the fact that educators rarely watch theircolleagues teach, peer review proved to be somewhat effective(Adams, et al., 1974; Centra, 1975; Sell, 1986; Skeff, 1981).Skeff, Berman and Stratos (1988) suggest that peer evaluationmay be more useful for residents than faculty. Consultationwith professional educators, either as participant observers orin reviewing videotapes of teaching, proved to be an effective,albeit time intensive and cost-ineffective approach forimproving clinical teaching (Foley, 1976; Irby, DeMers, Scher,& Matthews, 1976; Patridge, et al., 1980; Wergin, Mason, &Munson, 1976). Several studies have established theeffectiveness of videotape review of teaching, either alone or97with other (including professional educators) (e.g., Jewett,Greenberg, & Goldberg, 1982; Mahier & Benor, 1984; Sheets &Henry, 1984; Skeff, 1983; Skeff, et al., 1984). Skeff andcolleagues (1988) caution, however, the potential for anegative impact of this method. Reviewing one’s teaching onvideotape can be a stressful experience; some teachers maychoose not to participate. “If videotape review leads theviewers to perceive their performance as deficient, they mayhave lowered their self confidence in their ability to teach.This negative effect may not only decrease teachers’motivation to change their teaching, but may even decreasetheir desire to teach at all” (italics mine) (p. 100-101).Therefore, precautions must be taken to provide apsychologically safe environment in order that self-efficacynot be impaired. The value of self-evaluation for improvingteaching remains inconclusive (Carroll, 1983; Seldin, 1980).Concept based training is aimed at enhancing clinical teachers’understanding of the theoretical and conceptual basis ofteaching. The two programs reviewed (i.e., Gliessman & Pugh,1978; Skeff, Stratos, Campbell, Cooke, & Jones, 1986) wereboth effective. Finally, Skeff and colleagues (1988) reviewseventeen multicomponent methods: workshops and seminars(e.g., Camp & Hoban, 1988; Medio, Wilkerson, Lesky, &Borkan, 1988; Pristach, et al., 1991; Sobral, 1989). Theycomment that although single component methods for98improving teaching have not been shown to be consistentlyeffective, that the most convincing evidence for effectivenesscomes from multicomponent methods. The relativecontribution of each component, however, has not beenidentified.Residents as TeachersSteward and Feltovich (1988) address why residents shouldteach and discuss the parallel processes of teaching andlearning. One of the obvious benefits is the acquisition ofteaching skills that can be used for patient education or inpreparation for academic careers. They argue that byconstantly reviewing, reorganizing, and using information,residents increase their knowledge base. Residents arefrequently challenged by students’ questions and the need toprovide explanations. The authors contend that teachingduring residency may promote ongoing self improvement andhelp residents develop the skills required to maintain lifelongprofessional competency. The personal benefits of teachingwere recognized by more than two thirds of residents in onestudy (Apter, Metzger, & Glassroth, 1988), and 90% in another(Barrow, 1966). Stritter, Shahady, and Mattern (1988)propose a model for the professional development of residents99and maintain that teaching plays an important role in thedevelopment of professional competence. Schiffman (1986)remarks that teaching not only benefits residents and theirstudents, but patients as well. By having patients’ casesdiscussed by team members during the teaching process,residents’ thoughts and actions are examined and questionedby other team members who can also make suggestions aboutdiagnostic and therapeutic plans.Medical students frequently consider residents to be theirmost important teachers and look forward to a teaching roleduring residency (Barrow, 1966). Another study, conductedmore than twenty five years later, confirms these findings(Bing-You & Sproul, 1992). Brown (1970), in a study ofhousestaff attitude towards teaching, found that residentsprovide the majority of clinical instruction. According to hisfindings, no one is more available to students and juniorhousestaff through all aspects of medical care, even throughthe night. He argues that without residents, clinical facultywould need to be available 24 hours a day. He found that allresidents consider themselves to be teachers, and spend 20-25% of their time supervising, evaluating, or teaching others.Residents also attribute 40-50% of their own teaching to otherhousestaff. These findings are in keeping with more recentstudies. Undergraduate surgery students credited housestaff100for providing almost one third of the knowledge acquiredduring their rotation (Lowry, 1976). In another study (BingYou & Harvey, 1991), students estimated that one third oftheir knowledge could be attributed to housestaff teaching.Steward and Feltovich (1988) argue that “for teaching medicalstudents, no one is more available or better qualified than aresident” (p. 4). Residents occupy an intermediate positionbetween faculty and students in terms of knowledge,authority, experience, and are less intimidating to students.Their proximity, in terms of level of training, enables them tobetter understand the practical needs and problems ofstudents. Tremonti and Biddle (1982) stress that residents’roles as teachers are complimentary, and not redundant, withthat of faculty. Residents concentrate on daily patient careissues on a large number of patients and spend more time onthe ward and at the bedside. Faculty, on the other hand,stress in depth discussion, psychosocial issues, and problemsolving skills on a small number of patients. Camp and Hoban(1988) identified the teaching settings encountered byresidents: (1) Case presentations; (2) Teaching on workrounds; (3) Teaching clinical skills course to undergraduatemedical students; (4) Large group presentations / lectures; (5)Small group presentations / seminars. Although residents areoccasionally called upon to lecture and do presentations, most101of their teaching occurs in small groups using a dynamictutorial style. Apter, Metzger, and Glassroth (1988) quantifiedthe most frequent teaching settings among residents: patients’bedside (45.5%); one-to-one supervision of junior teammembers (25.5%); “sit-down” ward rounds (23.6%).That residents spend more time with students and are “closer”to their level does not necessarily make them effectiveteachers. Irby (1978) found that although students ratedresidents as being more involved in their clinical teaching,residents were thought to be less effective than faculty. Only10% of students in another study (Brown, 1971) “felt thathousestaff teaching was particularly effective when it wasdone at all” (p. 93). Wilkerson, Lesky, and Medio, (1986)studied the teaching skills of residents during work rounds.“The results.., indicated that during work rounds the residentsexhibited few of the teaching behaviours that can enhancelearning in a patient care setting..., that students and internswere often passive members of the work team, with themajority of clinical decisions being made byresidents Clinical reasoning, problem solving and superviseddecision making were not recognized as learning goals thatmight be pursued while charts were being reviewed andpatients were being visited... .The resident appeared toconceptualize teaching as a classroom activity and equate it to102lecturing” (p. 827). Lewis and Kappelman (1984) noted thatresidents most frequently use an authoritarian lecture style inteaching. Ironically, this was residents’ least favouriteapproach as learners. Medio, Wilkerson, Lesky, and Borkan(1988) observed residents during work rounds.Residents did not often intentionally use daily patientencounters for teaching. When they did intend to teachduring work rounds, they usually provided brieflectures. Not only did the study show the limitedrepertoire of teaching skills used by most residents, butit also delineated the many teaching opportunities thatwere being overlooked. For most residents, teaching hadbecome synonymous with prepared lectures and was,therefore, incompatible with the unpredictable demandsof patient care (p. 215).Although 69% residents in this study modelled empathicbehaviour (towards patient), they rarely discussed theseinteractions with students. Patient visits were often used toverify history and physical findings (63%), but in most casesan opportunity to demonstrate clinical skills was missed.“Mini-lectures” occurred in 40% of interactions. Four teachingbehaviours were used infrequently in the observed patient /resident interaction: (1) directing students to pertinent103literature (3%); (2) commenting on their performance (11%);(3) demonstrating a technique or skill (17%); (4) askingproblem solving questions (22%). Two common non-facilitating teaching behaviours were noted: (1) silentattention to patient charts; (2) decision making withoutinvolvement of the team (>50%). Meleca and Pearsol (1988)urge that residents be made aware of and take advantage oftheir responsibilities and “teachable moments” (i.e., teachingopportunities). One study (Bergen, Stratos, Berman, & Skeff,1993) compared the clinical teaching abilities of residents andattending physicians in the inpatient and lecture settings.Overall, residents and attendings received similar ratings.Where there was a difference, faculty were rated higher thanresidents. Of note, ratings for both groups were generally lowin each category suggesting the need for participation in TEPsby both groups.Residents generally have a positive “attitude” towards theirrole as teachers. The vast majority of residents enjoy teaching(89% of 68 respondents) (Apter, et al., 1988). In this study,enjoyment of teaching was positively associated with increasedpreparation time and perception of positive results ofteaching. Bing-You and Harvey (1991) are the first to addresswhether an association between a positive attitude towardsteaching and perceptions towards teaching are associated with104better student evaluations of teaching. Twenty one (of 24)residents completed a questionnaire in order to survey theirattitude towards teaching. They were subsequently evaluatedby third year medical students over a one year period.Residents’ desire to teach was most strongly correlated (0.77)with active involvement of students and was the only“attitude” correlating with overall teaching effectiveness(0.54). Unfortunately, no correlation was found betweenstudent ratings of residents as teachers and residents’ self-assessment of teaching effectiveness, Of note, residentshaving participated in a TEP were more confident as teachers,were rated more highly in actively involving students and inproviding direction and feedback, and were also moreconfident as teachers.Although residents have major teaching responsibilities,evidence exists that they may not receive enough support orpreparation for this role and that barriers hinder optimalteaching. A US national survey of general surgical residencyprogram directors (Anderson, Anderson, & Scholten, 1990)posed three questions: (1) To what extent do surgicalresidents teach and evaluate medical students? (2) How aresurgical residents prepared for and evaluated on theirteaching responsibilities? (3) What are the surgical programdirectors opinions about residents as teachers? Virtually all105(98%) surgical residents had teaching responsibilities.However, only 36% of programs provided residents withwritten evaluations of their teaching, and 60% of programdirectors did not believe it was important for residents toreceive formal training in teaching skills. Only 14% ofresidents in this study had attended workshops on teaching.Two other studies (Callen & Roberts, 1980, Brown, 1971)report similar findings. Thirteen percent of 136 psychiatryresidents, and 15% of 28 surgery residents had prior teachertraining. A more favourable proportion (i.e., 38% of 21residents) is cited in one study (Bing-You & Harvey, 1991).This likely reflects the author’s prominent role in promotingand developing resident teaching skills at his institution.Schiffman (1986) asks: “How then do house officers learn howto teach? The obvious answer is that the house officer has hadtwenty years of observation of his or her own teachers uponwhich to model his or her style” (p. 55). This remainsinadequate.If most residents do not have prior teacher education, do theyat least receive useful feedback on the teaching that they do?In 1978, the American Association of Medical Colleges (AAMC)surveyed departments of internal medicine, pediatrics,psychiatry, surgery, and family medicine (Tonesk, 1979).Only 87 of 319 (2 7%) programs included teaching106performance as part of residents’ evaluations, and those thatdid usually only required a global assessment of teachingability. The data on supervision of teaching is equally bleak.Apter, Metzger, and Glassroth (1988) report that only 13% (of68) residents felt that faculty supervision of their teaching wasoptimal, and 58% indicated that they had never beensupervised. This lack of support may account for theunfavourable attitude that some residents have towardsteaching. In one study (Callen & Roberts, 1980), 78% (of 136)psychiatry residents thought that “the main reason residentsare required to teach medical students is to free up time, timefor faculty to do research and other things.” On average,these residents estimated that they spent 9 hours per week inteaching activities. Despite this large teaching commitment,only 32% of residents thought that they should be required toattend TEPs. When the question of attending a resident TEP isposed differently, 53% (Apter, et al., 1988) to 66% (Brown,1970) of residents stated they would be interested inattending a workshop if it were offered.In addition to less than satisfactory support for their teachingrole, residents face other impediments. Time and conflictingdemands seem to be most important. Eighty seven percent ofresidents cited either their own or their students’ timeconsuming ward duties as the greatest obstacle to teaching107(Apter, et al., 1988). Post call exhaustion was also animportant factor (49%) making teaching difficult.Kates and Lesser (1985) identify what they consider to bemajor problems faced by residents when teaching. They quotethe AAMC report cited above (Tonesk, 1979) and admonishpost graduate programs for the lack of emphasis placed onresidents’ teaching role. Beyond this, residents’ may beunclear about what their actual role is in terms of supervising- teaching junior housestaff, and as mentioned, they areusually unprepared for their teaching function. Residents areusually unfamiliar with the learning objectives of the juniorsthey supervise and teach. Despite this, they are usually calledupon to help evaluate them. The residents’ own supervisorsoften provide inadequate supervision and support forresidents. This, in itself, may downplay the importance ofteaching for the resident. Finally, few programs make anyspecific efforts to coordinate teaching opportunities forresidents with a special interest in education.Acknowledging the many problems faced by residents whenteaching, and their less than optimal preparation for theirteaching role, not much is known regarding the needs ofresidents in terms of designing a TEP. Boulé and Chamberland(in press) addressed this issue from a residents’ perspective by108asking them “What kind of training do you need to teach moreeffectively?” Eighty residents responded. Two thirds of theiranswers corresponded with needs usually addressed by TEP5,while one third were concerned with medical competency andtime management. Nine key words were most frequently citedin their responses (in order of priority): (1) division of work/ teaching time, (2) teaching methods, (3) medicalknowledge, (4) objectives, (5) synthesis skills, (6) feedback,(7) motivation, (8) psychology applied to teaching, and (9)student problems. More research needs to be done in the areaof the teacher education needs of residents. Otherperspectives and other sources of information shouldcompliment that of residents.Empirical Research on Resident TEPsAn extensive review of the medical education literature wasundertaken to identify existing studies of resident TEPs.Twenty-six references were identified between 1963 and 1991.Of the 26 reports, one study was described in three differentpublications (Greenberg, et al., 1984; Greenberg, Jewett, &Goldberg, 1988; Jewett, et al., 1982), and two studies werereported twice (Camp & Hoban, 1988; Camp, Hoban, & Katz,1985) and (Lazerson, 1972; Lazerson, 1973). Furthermore,109chapter nine (Edwards, Kissling, Paluche, & Marier, 1988b) ofEdwards and Marier’s (1988) book, Clinical TeachinglorMedical Residents: Roles, Techniques,andPragrains, outlinesa resident TEP used for two studies (“Phase I” and “Phase II)that were reported elsewhere (Edwards, Kissling, Brannan,Plauche, & Marier, 1988a; Edwards, Kissling, Plauché, &Marier, 1988). This program was also used for a third study(Edwards, Kissling, Plauche, & Marier, 1986). Therefore, atotal of 21 different studies and 19 different resident TEPswere identified. Of the 19 resident TEPs, two actually depictundergraduate medical school electives: one offered as a thirdyear elective (Craig & Page, 1987), the other as a fourth yearelective (Sobral, 1989). Another program (Lazerson, 1972;Lazerson, 1973) can be more accurately described as ateaching experience under supervision rather than a residentTEP. This study describes the experience of psychiatryresidents given the opportunity to teach undergraduatepsychology at a community college. Although these residentsreceived feedback on their teaching skills, no formal teachertraining was undertaken. Consequently, only 18 studiesdescribed 16 programs in which residents underwent acurriculum with a specific goal of developing teaching skills.A database was created extracting information from all studiesfor easy comparison. The information was organized into the110following fields: (1) Participation (voluntary or mandatory);(2) n (i.e., number); (3) Specialty (of residents); (4) level (i.e.,postgraduate year (PGY) of training of resident); (5) Goals &Objectives (of TEP); (6) Methodology (i.e., study design); (7)Program Format; (8) Instructor(s) (i.e., professional educatorsor physicians); (9) Consultation(s) (i.e., whether or notprofessional educators were involved in program developmentor implementation); (10) Timeline (i.e., number of hours overwhat time frame); (11) Content (of TEP); (12) ProgramEvaluation (results); (13) Study Results; (14) Problems(identified); (15) Recommendations (practical).The first resident TEP reported (Husted & Hawkins, 1963)dates back to 1963. This case study was initiated as a pilotproject. The investigators asked department chairmen toinvite two residents each to participate in the program. Giventhe voluntary nature of the course, residents could decline theinvitation. A total of seven residents participated in the six“lecture-discussion” sessions. No attempt was made to assessoutcome measures. Even the program itself was not assessedwith any rigor. The authors conclude that “participants werecertain enough that the pilot venture was of sufficient benefitto them to lead to the suggestion that the orientation berepeated and the invitations expanded...” (p. 115). Theteaching role of residents has become increasingly more111prominent over the years, with 17 of the 26 references beingpublished since 1985, and the recent publication of books onthe subject (Edwards & Marier, 1988; Schwenk & Whitman,1984; Weinholtz & Edwards, 1992). A summary of the medicaleducation literature on this subject will be the focus of theremainder of chapter two.ParticipationParticipation in the TEP was “voluntary” in 9 studies,“mandatory” in 6, and not stated in the remaining 7. Variousarguments can be made for and against both strategies, but noconclusions can be drawn from these studies. Allowingresidents to “opt-out” of TEPs, however, may result inneglecting those residents who need it most.SpecialtyGeneral internal medicine is the most represented of allspecialties among the studies reviewed. Internal medicineresidents were involved in 11 of the 22 programs. Thosestudies (e.g., Edwards, et al., 1988) looking for distinctionsbetween specialties generally found no significant differences.112LevelNo consensus exists as to when is the best time to introduce aresident TEP. A quick glance at the target audience (i.e., postgraduate year of training) of the various TEPs outlined makesthis clear. Five programs were geared to PGY 1 residents andfour programs were geared to all levels of residency. Twoprograms were undergraduate medical school electives. Otherlevels were the target in five programs and no information wasavailable for the remaining six. Only one study (Bing-You,1990) addressed program outcomes in relation to level oftraining. Further studies are needed to define the best time toimplement TEPs. “Readiness” to learn, level of professionalcompetence, competing demands / availability, and costeffectiveness (e.g., final year residents only have a shortteaching career remaining) are only a few of the factors to beconsidered.Goals and ObjectivesGoals and Objectives varied considerably between programs.Although none of the programs formally stated the theoreticalunderpinnings from which the goals and objectives emanated,the language used to describe them is revealing. The desire to113“transfer” information is prominent. Programs alternativelywanted to “acquaint residents with” (Husted & Hawkins,1963), “provide information” (Brown, 1971), “introduceconcepts” (Lewis & Kappleman, 1984), or have residents “gainknowledge / become familiar with” (Camp & Hoban, 1988;Camp, et al., 1985). Standard behavioural objectives were alsocommon. For example, one program (Husted & Hawkins,1963) expected participating residents to be able to “(a) selectthe appropriate (teaching) technique and (b) begin to developskill in self-appraisal of their ability to effectively function intheir teaching role” (p. 111), while another (Edwards, et al.,1988b) expected residents to “give feedback to learners” (p.159). The wording in two further studies alludes toconstructivism: (1) “The workshop’s aim is not to teach“teaching skills,” such as lecturing or running a tutorial, but toexplore the organizational aspects of supervising a studentsuch as the relationship between the resident and their ownsupervisor, and their understanding of the objectives of theclerk’s rotation” (italics mine) (Kates & Lesser, 1985, p. 418),and (2) “to expand the residents’ concept of teaching” (italicsmine) (Medio, et al., 1988, p. 214). Finally, one study(Edwards, et al., 1988b) had increased self-confidence inteaching (cf., teaching self-efficacy) as a program goal.114MethodoiQgyIt is beyond the scope of this dissertation to discuss themethodologic flaws of the studies reviewed. The patient-centred pace of hospital practice and postgraduate medicaltraining make it difficult to run educational experiments inthis context. The authors of the reviewed studies should becommended for their efforts and innovative attempts to poseand answer questions. Of the 22 database entries, 19 are casestudies. Two of these make an attempt at an experimentaldesign: “quasi-experimental” (Snell, 1989), and “case-control,pre- and post- observation” (Medio, et a!., 1988). Both ofthese studies used residents who did not attend the TEP as acomparison (i.e., control) group. The mere fact that they didnot choose to attend makes them different; any differencesfound between the two groups may just as likely be attributedto the characteristics of the individuals in the respectivegroups as to the intervention (i.e., TEP). Conclusion fromthese studies should be interpreted with caution. One of thedatabase references is a simple program description withstudy results reported elsewhere. The remaining two studies(one of which is reported three times) (Edwards, et a!., 1988a;Greenberg, et a!., 1984; Greenberg, et a!., 1988; Jewett, et a!.,1982) have a randomized case control design. Both have arelatively small total number of study subjects, 22 and11553 respectively.formatOverall, an attempt was made to use instructional methodsthat actively involve residents. For the most part, however,this simply meant having residents take part in groupdiscussions (cf., authentic activities e.g., Collins, et al., 1991).Lave and Wenger (1991), in their discussion of discourse andpractice, stress the important differences “between talkingabout a practice from outside and talking within it” (p. 107).They argue “that for newcomers then the purpose is not tolearn from talk as a substitute for legitimate peripheralparticipation; it is to learn to talk as a key to legitimateperipheral participation” (original emphasis) (p. 109). Asdiscussed in an earlier section of this chapter, Lave andWenger (1991) distinguish between a learning curriculumconsisting of situated opportunities and a teachingcurriculum constructed for instruction. From theirperspective, then, learning becomes a question of access tolegitimate practice as a learning resource rather thanproviding instruction. Most of the programs described, itseems, have little grounding in a social / situated perspectiveof adult education. A few studies, however, did attempt to116emphasize the important role of experience as part of the TEP:microteaching, with and without video playback (Lawson &Harvill, 1980; Medio, et al., 1988; Pristach, et al., 1991; Snell,1989), and role playing (Edwards, et al., 1988b; Sobral, 1989).TimelineIn Jarvis’ (1992) discussion of learning in the workplace, hereminds us “that there are two basic forms of experience:primary and secondary experience. The former involves theactual experience people have in a given situation; this type ofexperience moulds their self-identity to a great extent. Thelatter involves experiences in which interaction or teachingoccurs over and above the primary experience” (p. 108-181).Although microteaching and role playing may be (or comeclose to being) authentic activities, they would still beclassified as secondary experiences from Jarvis’ point of view.It must be remembered that whether or not residencyprograms decide to develop and implement TEPs, residentswill still have major teaching obligations (and opportunities).Most programs did not take specific advantage of residents’current teaching assignments as a learning resource. Oneprogram (Snell, 1989) did mention that residents had “anopportunity to practice the (newly learned teaching) skills on117the wards during the weeks between sessions” (italics mine)(p. 125). Another program, consisting of two three-hourworkshops, separated both workshops by 5 months so that“the experimental group had an opportunity to apply these(teaching) skills in their daily activities” (italics mine) (p.361). Unfortunately, without structure and follow-up, students(including residents) do not always take advantage ofopportunities. None of the programs specifically structuredand included such learning activities.The first decision when deciding on a timeline for a program isdeciding whether to offer a “one-shot” or a longitudinalexperience. A second decision also involves timing: shouldresidents take part in a TEP only while they have teachingresponsibilities? A program based on a longitudinalexperience while residents have teaching responsibilities cantake advantage of Jarvis’ so-called primary experiences. Theprogram developed as part of this dissertation was specificallydesigned with these ideas in mind and included a “Task forthe Week” between sessions (see chapter three). A teaching“task” was assigned at the end of the each seminar based onthat seminar’s content. A lab-coat pocket sized reminder cardwas handed out to residents. The task became the focus of areflection (and review) exercise at the beginning of the nextweekly session.118Of interest, none of the studies were specifically designed tomeasure the impact of a teaching responsibility itself onoutcomes measures. This is one of the research questionsaddressed by this dissertation.In those studies commenting on timeline, about half provideda longitudinal experience while the other half offered a “oneshot” exposure (e.g., 7 hour “Teachathon” (Maxmen, 1980)).ContentProgram content, where provided, variably included thefollowing topics: (1) theories / models of teaching, (2)theories / models of learning, (3) large group teaching /lecturing, (4) small group teaching / discussion, (5) one-onone teaching, (6) bedside teaching, and (7) evaluation /feedback.Pmgram EvaluationAll programs were rated favourably; there was a high degreeof satisfaction with both instruction and content. Residentsconsidered the experience valuable and useful.119Study ResultsImpact of resident TEPs.All but one of the studies designed to investigate the impact ofresident TEP demonstrated a positive effect. Brown (1971)used a pre- and post- 50 item multiple choice test to assesschanges in residents’ knowledge of teaching and learning. Nosignificant difference was found at the 0.05 level (i.e., mean24.0 vs. 24.7). On the other hand, Edwards, Kissling, Plauche,& Marier (1986) report that after one year, 67% of residentscould still recall specific points presented, and 61% reportedusing ideas from the course in their teaching. Overall,knowledge was not an important outcomes measure in thestudies reviewed.Improvements in teaching behaviours have been the mainfocus of most studies assessing outcomes. Sources ofperceptions have included residents (i.e., self), students, peers(i.e., other residents and faculty), as well as professionaleducators. Improvements in self-concept and self-reportedbehaviours were demonstrated in four studies (Bing-You &Greenberg, 1990; Edwards, et al., 1986; Edwards, et al., 1988;Snell, 1989). Student ratings of residents who attended ateaching skills workshop were significantly higher (p.<0.05) ii120four of nine dimensions including “overall teachingeffectiveness” (Edwards, et al., 1988). In another study(Edwards, et al., 1986) an attempt was made to study theeffect of a resident TEP on student ratings of resident teaching;unfortunately, the data was too “scanty” to be interpretedvalidly.Improvements in resident teaching behaviours have also beenstudied by observation methods. One study (Camp & Hoban,1988; Camp, et al., 1985) used direct informal observation ofresident teaching by educators to assess change. Facultyobservers “believed that the participants showed that they hadput into practice many of the skills that had been discussedand demonstrated in the course on teaching...” (p. 212). Moreformal attempts to observe and measure changes in residentteaching behaviours, using observation instruments, exist. Acase-control pre- and post- observation study (Medio, et al.,1988) demonstrated an improvement in the “treatment”group as compared to “controls.” Each resident (6 treatmentand 6 controls) was observed during one work round whilereviewing an average of ten patients. Unfortunately, the smallsample size, and the fact that “controls” consisted of residentsnot participating in the program (i.e., non-random) makeinterpretation of the results difficult. Snell (1989), using asimilar experimental design with 9 subjects and 5 controls121showed that post-intervention scores increased in all threeareas measured (i.e., lecture, tutorial, and discussion (p <0.05)). Observation studies using videotaped residentteaching also demonstrated a positive impact of TEP5 onteaching behaviours (Bing-You, 1990; Edwards, et al., 1988a;Greenberg, et al., 1984; Greenberg, et al., 1988; Jewett, et a!.,1982; Lawson & Harvill, 1980).Need for reinforcement / long term effect.How long are improvements in teaching skills maintained aftera TEP? One group of investigators (Edwards, et a!., 1988a)noted that improvement in residents’ skills (videotapedteaching) had declined when measures were repeated sixmonths later; ratings were, however, still higher than preinstruction. The authors suggest that residents may needperiodic short “refresher” courses to reinforce teaching skillsthroughout their residency. Of interest, another study(Edwards, et a!., 1986) using the same TEP found that postcourse improvements in self-rated teaching skills “enduredwithout decay for at least a year and a half” (p. 970).Furthermore, “residents could still recall and explain majorteaching points and reported that they had used theseteaching points 18 months after the course” (p. 970).Similarly, Snell (1989) found that increased ratings of122teaching behaviours (based on observations) were maintainedfor eight months after a TEP. Overall, little is known about therate of “decay” of residents’ teaching skills after a TEP. Aninteresting, and unanswered, question is whether or notfocusing on “attitude” and “self-efficacy” (cf., specific teachingbehaviours) has any effect on the rate of decay.“Confidence” / self-efficacy.Although the construct of self-efficacy has not specificallybeen used as an outcomes measure, self-reported “self-confidence” has. Interestingly, those studies assessing changesin self-confidence did not seek to demonstrate an associationwith changes in teaching behaviours. Further, the impact of ateaching assignment itself (i.e., experience) on self-confidencehas not been explicitly addressed. All three of these issues arespecifically addressed in the study described in thisdissertation.Snell (1989) measured self-confidence pre- and post-course byself assessment questionnaire. Significant increases in“confidence in teaching” were found in the treatment group (p<0.05). Snell goes on to comment that “eight months afterthe course, the residents all thought that they were more123confident in their teaching” (p. 126). Unfortunately, the datais not presented nor is the analysis. Also, no mention of“control” group comparison is made.Bing-You and Greenberg (1990) assessed residents’ confidenceas teachers and perceptions toward teaching using a preworkshop questionnaire. However, no post-workshopquestionnaire was given; therefore, no comment on theimpact of the TEP on self-confidence can be made. At thebeginning of the program, 25% of residents felt confident orvery confident as teachers (68% somewhat confident, and 7%not confident). Perceived feedback of their teaching wassimilar to confidence levels, with 32% reporting positive orvery positive feedback.Bing-You (1990) used a pre- and post-workshop questionnaireto assess residents’ “attitude towards teaching.” In addition,trained raters assessed videotapes of resident teaching at theend of the workshop and again at a mean of 6.3 months later(2-11 months). However, no inferences can be maderegarding the relationship between teaching attitude andteaching behaviours given the two different study designs foreach outcomes measure (i.e., pre-post vs. immediate anddelayed post). After the workshop, both residents and internsrated themselves as more effective (p <0.05) as teachers in124the area of knowledge (using references) but only the internsfelt more effective in their technical skills (p <0.01). Withoutdirect access to the questionnaire items, it is difficult todetermine whether “use of references” and “technical skills”represent attitude or self-reported behaviours.The most interesting and best designed of the studies lookingat self-confidence has been reported three times (Greenberg,et al., 1984; Greenberg, et al., 1988; Jewett, et al., 1982). Theinvestigators used a pre-test / post-test control design to studythe impact of the workshops: random assignment of 27 in theexperimental group attended workshop and consultationsessions; 26 in the control group had no intervention. Threeoutcomes measures were assessed: (1) self-assessment: pre& post-questionnaires assessing residents’ teaching attitudeand perceptions of teaching, (2) peer, student, and facultyevaluation of resident teaching, and (3) videotaped sessionsof resident teaching were analyzed by nonphysicians using aninstrument deigned to categorize residents’ behaviour every 3seconds.Forty-nine of the 53 residents completed both self-assessmentquestionnaires: 18% of residents were “confident” or “veryconfident” as teachers at beginning of study. After the course,42% of the experimental group and 22% of the control group125(p <0.05) were “confident” or “very confident” as teachers.Also, 87% of experimental group felt their teaching skills wereimproving (vs. 52% control).After the course, faculty, students, and peers rated 52% ofexperimental residents as “effective” (vs. 27% of controls;approaching statistical significance). No attempt was made todemonstrate an association of change in attitude with achange in behaviour.The authors report that “a number of significant correlationswere found between the confidence of residents in bothgroups (experimental and control) as teachers and theirperceptions of teaching as a responsibility” (p. 362).Perception of teaching as a responsibility was divided into 4categories: (1) attitude towards teaching, (2) their role as ateacher, (3) teaching methods, and (4) improving clinicalteaching. The range of reported correlation coefficients(absolute value) was 0.26-0.58. If “confidence as a teacher” isaccepted as a measure of teaching self-efficacy, it can beassumed that this one item measure of degree of “confidenceas a teacher” using a Likert scale is neither as valid nor asreliable as a multi-item scale assessing the same construct.Therefore, one can postulate that the “confidence as ateacher” item in this study is a generic or global (albeit126imperfect) measure of teaching self-efficacy. Of interest, manyof the items in Greenberg, Goldberg, and Jewett’s (1984)instrument assessing residents’ perception of teachingresponsibility could arguably be said to assess the variousdimensions of teaching self efficacy as described by Ashton(1984). For instance, “Teaching medical students is one of theprimary responsibilities of the resident” (p. 362) correspondswith the dimension of “Personal Responsibility for StudentLearning” (p. 29) of Ashton’s eight dimensions of teachingself-efficacy. It is not surprising, therefore, to find so many(and statistically significant) correlations between “confidenceas a teacher” and perceptions of teaching as a responsibility.Most of the items in the perceptions of teaching as aresponsibility simply tap the various dimensions of teachingself-efficacy. Further support for this argument will unfold inthe methods and results chapters of this dissertation, as manyof the items from Greenberg, Goldberg, and Jewett’s (1984)instrument assessing residents’ perception of teachingresponsibility were incorporated into the dissertation’s studyinstrument where good internal consistency reliability wasfound.127Importance of attitude.Lawson and Harvill (1980) comment that most residents haveno prior training in teaching skills, and that many areunconvinced of the benefits of taking part in a resident TEP.They argue that, “changing such negative attitude should be aprimary goal of a teaching skills program” (p. 1004). Using anend of program questionnaire, the authors assessed residents’“attitude toward participating in a teaching skills program” (p.1002). Residents were asked to rate their attitude (verynegative, negative, indifferent, positive, very positive) post-program and pre-program (retrospectively) at the same time.Residents’ initial attitude (as assessed retrospectively) towardsparticipating in a TEP were distributed as follows (n=14): 2very(-); 4 (-); 5 indifferent; 3 (+); 0 very(+). Attitudeimproved after taking part in the TEP: 0 very(-); 2 (-); 0indifferent; 7 (+); 5 very(+). Therefore, three maintained thesame attitude while 11 became more positive (p <0.001).128129CHAPTER THREE: METHODSOverview / IntroductionThis research study reports the development, implementation,and evaluation of a Teacher Education Program (TEP), andexamines its impact on internal medicine residents, morespecifically, on residents’ (1) sense of teaching self-efficacy,(2) self-reported teaching behaviours, (3) beliefs aboutteaching, and (4) interest in teaching.A quasi-experimental design was used and assignment ofsubjects (i.e., residents) was based on the existing ClinicalTeaching Unit (CTU) rotation schedule. A needs assessmentwas carried out on the control group (n=8) over the course oftwo rotations, the results of which are reported elsewhere(Arseneau, 1993). The content of the TEP was developed tomeet residents’ needs as determined by the needs assessment,as well as a review of the literature. Theoretical guidelines forprogram development were based on several perspectives ofadult education, and psychology (see chapter two). Mostimportantly, teaching self-efficacy was used as a motivationalparadigm (Ashton, 1984), and was the main outcomesmeasure. The treatment group (n= 11) attended weekly one130hour seminars longitudinally over the course of their CTUrotation (for a total of five or six sessions). The program wasrun a total of three times over the course of three rotations.Using the same categories used to describe and analyze thereports of resident TEPs in the literature (see chapter two), abrief program description is provided.Workshop participants:-CTU residents (PGY 2 or PGY 3)-two groups of 4 and one group of 3 (total 11)Participation:-voluntaryGoals:1. Attitude (major emphasis)-enhance residents’ perception of teaching self-efficacy-enhance residents’ perception of teaching responsibility-assist residents in conceptualizing their role as teachers-enable residents to set teaching goals-facilitate the application of residents’ teaching goals2. Reflection-on-action / reflection-in-action (major emphasis)-promote resident reflection on teaching131-promote resident reflection while teaching3. Knowledge & Skills (minor emphasis)-help residents develop the knowledge and skills to becomemore effective teachersInstructor: Ric Arseneau, MD, FRCPCTime line: 1 hour per week for 6 of 8 weeksFormat:-multicomponent workshop format-up to 4 residents at one time-appeal to adult learner-minimize technical jargon-practical-no reading assignmentsMajor breakdown of each session:1. at the end of each session, one or more “tasks” is assignedto the residents (e.g., a formal feedback session with students)2. the subsequent session began by reviewing the assignedtask(s) with a reflection exercise3. this was followed by presentation / discussion of newmaterial and microteaching / role playing / practice132opportunities for residents, with instructor and peer feedbackon performance4. based on the new material, tasks were assigned to bereviewed the following weekContentSession 1 - Introduction: Teaching & LearningSession 2 - Work Rounds & One Minute Teaching SkillsSession 3 - Feedback & EvaluationSession 4 - Questioning & Non-Facilitating TeachingBehavioursSession 5 - Cognitive Learning Prinicples & Problem SolvingSession 6 - Small Group TeachingHandouts:-although there were no reading assignment, a one page tnfold pamphlet (that fits easily into residents’ lab coat pockets)was provided for each session-the front cover listed the tasks for the week-the body copy contained a synopsis of the sessionProgram evaluation:program satisfaction questionnaire133Rationale for Study DesignBefore outlining the rationale for the study design, the readeris reminded of the research questions:1. What attitude do general internal medicine residents havetowards teaching (i.e., self-efficacy, beliefs about teaching, andinterest in teaching)?2. What is the effect of a CTU rotation and associated teachingresponsibilities on residents’ sense of teaching self-efficacy,self-reported teaching behaviours, beliefs about teaching, andinterest in teaching?3. What is the impact of a TEP on residents’ sense of teachingself-efficacy, self-reported teaching behaviours, beliefs aboutteaching, and interest in teaching?4. Is a change in self-efficacy (i.e., attitude subconstruct)associated with a change in self-reported teaching behaviours?The four research questions were addressed in the followingway:134Question 1:The instrument was administered to all residents (i.e., controland treatment groups) at baseline; information about teachingself-efficacy, beliefs about teaching, and interest in teachingwas collected.Question 2:The research instrument was administered at the beginningand again at the end of the CTU rotation, while residents hadmajor teaching responsibilities (i.e., control group). Data onteaching self-efficacy, self-reported teaching behaviours,beliefs about teaching, and interest in teaching was collected.A pre- / post- difference was sought.Question 3:The same instrument was administered pre- and post- the TEP(i.e., treatment group). Again, a pre- / post- difference wassought.Question 4:Data from questions 2 and 3 was further analyzed looking foran association between self-efficacy and self-reportedbehaviour.The study used an experimental research design. It cannot,135however, be described as a “true” experimental design sincesubjects were not randomly assigned to the control andtreatment group. The quasi-experimental design approximatesa true experiment. Convenience sampling was used and basedon the existing CTU rotation schedule. Residents assigned todo CTU in Sept-Oct 1992, and Nov-Dec 1992 made up thecontrol group (n=8); residents assigned to do CTU in Jan-Feb1993, Mar-Apr 1993, and Jul-Aug 1993 made up the treatmentgroup (n=1 1). Although assignment to control and treatmentgroups was not random, this study design approximatesprobabilistic sampling in that residents are randomly assignedto the CTU schedule.Control groupconvenience sampling based on CTU rotation schedulesenior resident (i.e., PGY 2 or 3)participation voluntary (100% participation)4 residents, Sept-Oct 19924 residents, Nov-Dec 1992total n=8pre- and post- CTU instrument administrationno intervention (i.e., did not participate in resident TEP)Treatment groupconvenience sampling based on CTU rotation schedule136senior resident (i.e., PGY 2 or 3)participation voluntary (100% participation, although oneresident attended only 3 of 6 sessions)4 residents, Jan-Feb 19934 residents, Mar-Apr 19933 residents, Jul-Aug 1993 (one resident had alreadyparticipated earlier)total n=11intervention: resident TEP consisting of 5 or 6 weekly onehour sessionspre- and post- TEP instrument administrationInstrumentRationaleThis section discusses the development of the instrument tomeasure the impact of the TEP. It is a self-report, pencil andpaper, instrument intended to measure residents’ attitudetowards teaching, and self-reported teaching behaviours. Theword “attitude” will be used broadly to describe all objectivesthat have to do with affect, feelings, values, and beliefs(Henerson, Morris, & Fitz-Gibbon, 1987). Henerson, Morris,and Fitz-Gibbon (1987) comment on the problems unique to137measuring attitude and remark that “attempting todemonstrate attitude change . . . is probably the most difficult ofall evaluation tasks” (original emphasis) (p. 11). First of all,attitude is an abstract concept (i.e., a construct) and not a“real” thing that lends itself easily to measurement. Gould(1981), in his book, The Mismeasure of Man, warns of thepotential detrimental consequences of reification (andmeasurement) of abstract concepts. Attitude is not somethingthat can be measured like someone’s height. We can onlyinfer people’s attitude by what they say and do. In fact,attitude is usually defined in terms of behaviour. Gagne(1978), in his discussion of attitude as learning outcomes,describes attitude as “internal states that influence theindividual’s choices of action “(original emphasis) (p. 231).He cautions, however, that attitude does not determinebehaviours, but only makes them more likely. Anotherproblem is that people don’t always say what they trulybelieve for fear of looking bad. However, unless there isreason to believe that the truth will be concealed, what peoplesay probably most accurately reflects their attitude.According to Henerson, Morris, and Fitz-Gibbon (1987), “selfreport procedures represent the most direct type of attitudeassessment and should probably be employed unless you havereason to believe that the people whose attitude you areinvestigating are unable or unwilling to provide the necessary138information” (p. 20).Another problem with measuring attitude, is that they oftenrepresent complex multidimension concepts. Ghiselli,Campbell, and Zedeck (1981) discuss the problems inmeasuring multidimension constructs and the content validityof the instrument used to measure them. On one hand, itemhomogeneity (i.e., high positive correlations between items)suggests that the items are tapping the same trait. However,this may lead to an instrument that does not cover all aspectsof the construct being measured. Teaching attitude (orattitude towards teaching) is a very complex construct. Thereader is reminded that teaching self-efficacy, asubcomponent of the construct, was found to have eightdimensions itself (Ashton, 1984). Therefore, for the purposeof this study, no attempt was made to assess teaching attitudecomprehensively. Only those aspects of immediate interest tothe study were included in the instrument: residents’ sense ofteaching self-efficacy, beliefs about teaching, and interest inteaching.The final instrument used for the study (see Appendix A)included three sections on attitude and one section on selfreported teaching behaviours.139I. Teaching Scale (self-efficacy)II. Residents as Teachers - Opinion (beliefs about teaching)III. Teaching Skills (self-reported behaviours)IV. Interest in TeachingThe word “attitude” has been used as a catch all in studies ofresident teaching. One study (Skeff, Campbell, Stratos, Jones,& Cooke, 1984) defined it as: a desire to evaluate and improveteaching; satisfaction with teaching, enthusiasm for teaching,awareness of teaching strengths, and awareness of teachingproblems. Bing-You and Harvey (1991) studied therelationship between residents attitude (as measured by aquestionnaire) and student ratings of the residents’ teachingskills. The authors comment that they have included twoquestions “to measure a teacher’s sense of self-efficacy definedby Ashton (1984)” (p.96). Interestingly, several other itemsfrom their questionnaire could be interpreted as measuringself-efficacy. No attempt was made to group these items into a“self-efficacy scale.” Like other investigators, the attitude itemsof the questionnaire included a mixture of perception, selfreported behaviour, interest, and enjoyment. Another study(Greenberg, Goldberg, & Jewett, 1984) defined teachingattitude more broadly. Part of the study looked forcorrelations between “confidence as a teacher” andperceptions of teaching as a responsibility (i.e., attitude). The140authors report that “a number of significant correlations werefound between the confidence of residents in both groups(experimental and control) as teachers and their perceptionsof teaching as a responsibility” (p. 362). Perception ofteaching as a responsibility was divided into 4 categories: (1)attitude towards teaching, (2) their role as a teacher, (3)teaching methods, and (4) improving clinical teaching. Therange of reported correlation coefficients (absolute value) was0.26-0.58. If the response to the item “confidence as ateacher” is accepted as a measure of teaching self-efficacy, itcan be assumed that this one item measure of degree of“confidence as a teacher” using a Likert scale is neither asvalid nor as reliable as a multi-item scale assessing the sameconstruct. Therefore, one can postulate that the “confidenceas a teacher” item in this study is a generic or global (albeitimperfect) measure of teaching self-efficacy. Of interest, manyof the items in Greenberg, Goldberg, and Jewett’s (1984)instrument assessing residents’ perception of teachingresponsibility could arguably be said to assess the variousdimensions of teaching self efficacy as described by Ashton(1984). For instance, “Teaching medical students is one of theprimary responsibilities of the resident” (p. 362) correspondswith the dimension of “Personal Responsibility for StudentLearning” (p. 29) in Ashton’s eight dimensions of teachingself-efficacy. It is not surprising, therefore, to find so many141(and statistically significant) correlations between “confidenceas a teacher” and perceptions of teaching as a responsibility.Most of the items from “perceptions of teaching as aresponsibility” simply tap the various dimensions of teachingself-efficacy. Further support for this argument will unfold inthis section and chapter five (results) of this dissertation, asmany of the items from Greenberg, Goldberg, and Jewett’s(1984) instrument assessing residents’ perception of teachingresponsibility were incorporated into the teaching efficacyscale of the instrument being described in this section.Instrument DevelopmentThe final instrument (Appendix A) used to measure theoutcomes of the TEP for Medical Residents consists of foursections: I. Teaching Scale (self-efficacy), II. Residents asTeachers - Opinion (beliefs about teaching), III. TeachingSkills (self-reported behaviours), and IV. Interest in Teaching.Only the first and third sections (i.e., teaching efficacy andself-reported behaviours) are scales, the development of whichis described in detail below. The last two sections (i.e., beliefsabout teaching and interest in teaching) are used fordescriptive purposes only, and the reader is referred toAppendix A.142IeacfflngEfficacyAlthough no specific instrument exists for the specific needs ofthe program described below, several items were “borrowed”from the education and medical education literature. The scalewas divided into two subscales based on the model of teachingefficacy: A) Teaching efficacy, and B) Personal teachingefficacy (Ashton & Webb, 1986; Bandura, 1977). A matrix wasdeveloped, using Ashton’s (1984) eight dimensions of self-efficacy, for each subscale. Both positively and negativelyworded items were written (or borrowed) for each dimension(and each subscale) using the matrix as a template.The initial item pool consisted of 8 items on subscale A(teaching efficacy), and 48 items on subscale B (personalteaching efficacy). The items were reviewed with Sue Brigden,M.A. (Ph.D. student, U.B.C.) for clarity and ambiguity. Severalitems were rewritten. Five new items were written for subscaleA (new total = 13) and 22 items were dropped from subscale B(new total = 26).The items were removed from the matrix, but kept as twosubscales, and presented as a forced choice 5 point Likertagreement scale (1=strongly agree; 5=strongly disagree). Thisinitial draft of the instrument was sent to two well know143medical educators: D. Irby, Ph.D., University of Washington,and M. Bergen, Ph.D., Stanford University. Both reviewers haveconsiderable experience with medical education, as well asfaculty development. Their suggestions were taken intoconsideration, and several of the items were reworked. Oneitem was dropped from subscale B. In addition, the Likert scalewas reversed (i.e., 1=strongly disagree; 5=strongly agree).The instrument was then piloted at the Veterans’Administration Hospital, Seattle, Washington. The pilot groupconsisted of interns, residents, and faculty (n=22).Reliability for the two subscales was established using Lertapsoftware, and the Hoyt method of internal consistency. Itemswith poor loading were removed from each subscale. The finalinstrument consisted of 6 items from subscale A (teachingefficacy); one item was negatively worded. Subscale Bconsisted of 12 items (teaching self-efficacy); two items werenegatively worded. Items from both subscales were mixed intoone section of the final instrument.Factor analysis was not carried out given the small number ofitems and the small number of respondents.Considerable evidence exists for the construct validity of self-144efficacy and was reviewed in chapter two. In order todemonstrate the validity of the instrument used in this study.The same questionnaire was sent to 30 members of thedepartment of medicine, St. Paul’s Hospital. Thequestionnaires were sent, received, and the data coded andtranscribed by the individual in charge of faculty evaluation(i.e., the author of the dissertation was blinded in all regardsto provide confidentiality). Information about student ratingsof faculty teaching (i.e., the global assessment item: “Overallis an effective teacher”) over the past two years was alsoprovided. Both the teaching efficacy and teaching self-efficacysubscale scores were correlated with scores on self-reportedbehaviours and student teaching evaluations for evidence ofinstrument validity.Self-Reported TeachingBehavioursThe self-reported teaching behaviours scale initially consistedof 17 items based on the content of the resident TEP and wasdeveloped, reviewed, and piloted as part of the samequestionnaire as teaching efficacy (see above for details).Upon review 2 questions were thought to be opinions onteaching and were moved to section II of the final instrument.145Reliability for the scale was established using Lertap software,and the Hoyt method of internal consistency. No items hadpoor loading, and all were kept in the final instrument.Data Collection and AnalysisThe study (i.e., quasi-experimental study of TEP) collectedquantitative data using the instrument described above. Theinstrument collected data in four categories: (1) teachingself-efficacy, (2) self-reported teaching behaviours, (3) beliefsabout teaching, and (4) interest in teaching.The self-efficacy data consisted of 6 items on the teachingefficacy subscale and 12 items on the teaching self-efficacysubscale. The results are reported as a score on each subscale.Data was collected at the beginning and at the end of the CTUrotation for all groups (i.e., 2 control groups (n=8), and 3treatment groups of (n=1 1). Pre- and post- differences wereanalyzed using a paired t-test. Between group differences (i.e.,control vs. treatment) were analyzed by MANOVA.The self-reported teaching behaviour data consisted of 16items added into a total score (i.e., a scale). Data was collectedat the beginning and again at the end of the CTU rotation.146The end data for the treatment group consisted of two sets ofthe same 16 items. The first set was the standard pre- andpost- items. The second set of the same items formed a “retro”scale, that is a retrospective assessment of self-reportedteaching behaviours. The retro-scale allowed residents toreassess their behaviours at the start of the rotation giventheir more sophisticated understanding of the teaching andlearning process. For example, item 3 of this scale asksresidents to rate the following statement (1 =strongly disagreeto 5=strongly agree): I routinely use feedback in studentteaching. Beginning residents may rate themselves relativelyhigher on this scale given their unsophisticated understandingof feedback. After participating in the TEP, which includesinstruction-discussion, role-play, and a feedback “Task of theWeek,” residents may retrospectively give themselves a lowerrating for their feedback efforts at the start of the rotation.Therefore, a retro- / post- comparison may give a moreaccurate assessment of gains made by participating in the TEP.Both a pre- / post- comparison and a retro- / post- comparisonwere done. The pre- / post- difference and the retro- / postdifference were analyzed using a paired t-test. Between groupdifferences (i.e., control vs. treatment) were analyzed byMANOVA.An “intention to treat” analysis was carried out for both of the147above scales. Given that one resident attended only half ofthe TEP sessions, a decision of whether or not to include theresident in the data analysis needed to be made, as both preand post- instrument data was available for this subject. It islikely that this resident differed from the others in somecharacteristic(s) (e.g., interest in teaching), and therefore, hisquestionnaire responses were compared to the rest of thegroup. Interestingly, this is the resident that had a secondCTU rotation during the course of the study; therefore, thisresident had a second chance to participate in the TEP andmake up for the missed sessions but chose not to do so. Thedata from this resident was included in the analysis as part ofthe intention to treat analysis (i.e., what are the results when“all corners” are considered?). A second analysis was carriedout for the ten residents who participated in all (or most ofthe study). An arbitrary decision was made at the beginningof the study to consider any resident who had attended morethan half of the sessions as having undergone theintervention; residents having attended half, or less than half,of the sessions would not be considered to have undergone theintervention. A few of the residents missed one session;attendance data is available as part of the program evaluationdata (see Appendix B). The second analysis was thought togive a better idea of the TEP effect on those who completed theprogram.148Correlations between changes (i.e., the pre- / post- difference)in the teaching self-efficacy subscale and the self-reportedteaching behaviour scale were computed using Pearson’scorrelation coefficient to see if changes in teaching self-efficacy were associated with changes in self-reported teachingbehaviours.Beliefs about teaching consisted of 15 items and interest inteaching consisted of 5 items. Neither of these were added tomake a scale. Each item was analyzed using descriptivestatistics. Pre- / post- differences for both groups wereanalyzed using a paired t-test. Results for the control groupand the treatment group were presented side by side forcomparison.Program DescriptionIdentification of Goals and ObjectivesA literature survey of the current status of clinical teachingwas undertaken, and a number of medical schools (includingour own) having resident or faculty TEPs were contacted andmaterials were requested (i.e., Harvard Medical School,University of Washington , University of British Columbia149Medical School, Stanford University Medical Centre, MaineMedical Centre, and St. Louis University Medical Centre).Important sources included those references discussed inchapter two, as well as the following: Resident TeachingAManual to Make it Successful (Johnson & First, 1990), TheRole of The Senior Resident: Team Manager, Leader,andTeacher (Wipf, 1992), TIPS: Teachinginiprovement ProjectSystems for Health Care Educators, Ward Attending: The FortyDay Month (Osborn & Whitman, 1991), Successful FacultyinAcademic Medicine- Essential Skills and How to Acquire Them(Bland, Schmitz, Stritter, Henry, & Aluise, 1990), ClinicalTeaching for Medical Residents: Rolesjechniqiie, andPmgraans (Edwards & Marier, 1988a), A Practical Guide toClinical Teaching in Medicine (Douglas, Hosokawa, & Lawler,1988), Creative Medical Teaching (Whitman, 1990), Residentsas Teachers: A Guide to Educational Practice (Schwenk &Whitman, 1984), Preceptors as Teachers (Whitman & Schwenk,1984), A Handbook for Group Discussion Leaders:Alternatives to Lecturing Medical Students to Death (Whitman& Schwenk, 1983), “Feedback in Clinical Medical Education”(Ende, 1983), “Six Common Non-Facilitating TeachingBehaviours” (Napell, 1976). A more important considerationfor developing the goals and objectives of the resident TEP wasthe results of the needs assessment (i.e., participant150observation and structured interviews) conducted on thecontrol and the results of which are reported elsewhere(Arseneau, 1993).Most of the references in chapter two and those cited abovefocused more heavily on behavioural objectives and coursecontent. Many ideas and most of the content for the residentTEP were adapted from these sources. However, what mostclearly distinguishes the resident TEP discussed below is theprocess used (cf., content) and the emphasis on non-behavioural objectives. The resident TEP is firmly grounded infour important theoretical concepts discussed in chapter two(i.e., constructivism, situated learning, reflection, and selfefficacy). The rationale for employing these concepts iselaborated in chapter two and will not be repeated here.Resident TEP: GoalsThe goals of the resident TEP were presented in theIntroduction / Overview at the beginning of this chapter.151DesiguoLProgram and Selection and Development of Content,Pxoces&, and MaterialsChapter two introduced four important concepts that runthroughout this dissertation: constructivism, situatedlearning, reflection, and self-efficacy. The resident TEP isfirmly grounded in the marriage of these theoreticalperspectives. Although one could argue that the overlapbetween these concepts is what makes for a good marriage.The author of this dissertation contends, that instead, it is thepotential synergy between them that underlies the making of asolid foundation for the development of a resident TEP; thetotal is more than the sum of the individual parts. This willbecome evident in the detailed discussion of the rationale forthe development of two process components of the residentTEP: (1) case studies, and (2) “Task of the Week” (seebelow). While it is beyond the scope of this dissertation to givea detailed account of the rationale underlying the choice andimplementation of all the content and process decisions madefor the resident TEP, a detailed account of the case methodand a brief account of the “Task of the Week” should providethe reader with a better appreciation of how the author’schoice and understanding of the concepts underlying thegrounded theory were translated into practice. Beforeelaborating on process, however, an overview of the time line,152program format and content will be presented. This sectionwill then close with details of the implementation andevaluation of the program.Time lineTime line decisions for the program described were deliberateand well thought out, and focused on two important decisions:(1) using a longitudinal program (cf., “one-shot”), and (2)offering the program while residents had a major teachingassignment. The CTU (Clinical Teaching Unit) rotationprovides the core program for general internal medicine. Thisis supplemented by both required and elective rotations insubspecialty medicine (e.g., cardiology). The two month CTUrotations (during PGY 2 and PGY 3) include supervisory andteaching responsibilities with the resident leading a teamconsisting of one intern (PGY 1) and two MSIs (MedicalStudent Interns, i.e., final year undergraduate medicalstudents). The resident TEP was, therefore, offered over thecourse of the CTU rotation.From an educational perspective (cf., practical or resource)offering the resident TEP during the CTU rotation has severaladvantages. Given the residents’ supervisory and teachingresponsibilities, the content of the program is immediately153relevant, and residents are motivated to participate. Thismakes good sense from an andragogical perspective (Knowles,1980). More importantly, it situates learning in legitimateperipheral participation (Lave & Wenger, 1991). From thisperspective, it also takes advantage of what Jarvis (1992)describes as “primary experiences” (see Chapter two:Empirical Research on Resident TEPs: Time line). Finally, alongitudinal program offered during a major teachingresponsibility allows residents to cultivate the necessary“mastery experiences” that enhance self-efficacy (Bandura,1977).In consultation with the Department of Medicine and theResidency Committee, the six sessions of the program wereoffered on Thursdays from 12:00 to 13:00 (except the lastThursday of each month which is reserved for Morbidity andMortality Rounds) over the course of each two month rotationfor a total of six hours of instruction per group.ProgramformatBased on a review of effective program formats (Skeff, Berman,& Stratos, 1988), a “multicomponent” workshop format wasused. Given that there are four CTUs, it was anticipated that154up to four residents would take part in the program at onetime. The interest generated by word of mouth, however, leadto a request by residents in subspecialty rotations toparticipate in the program. One or two residents (per courseoffering) were thus allowed to take part but were notconsidered study subjects (except in filling out programevaluation forms).The program was designed to appeal to adult learners(Knowles, 1980), and the use of technical jargon was kept to aminimum. It was important that residents perceive theprogram as practical, as well as interesting. Given the multipleand competing demands on residents’ time, there were noreading assignments. The author served as instructor for allsessions.The breakdown of each session followed a similar formatconsisting of: (1) reviewing and reflecting on the “Task of theWeek” assigned in the prior session (except during firstsession), (2) presentation / discussion of new material, (3)microteaching / role playing / practice opportunities forresidents, with instructor and peer feedback on performance,and (4) assignment of the “Tasks for the Week” to bereviewed at the following session155ContentThe course content was selected based on an extensive reviewof the literature including several monographs (see Goals andObjectives above). The results of the needs assessment helpednarrow the scope of the course content. Given that St. Paul’sHospital already had programs designed to help residentsdevelop lecturing and bedside teaching skills (unfortunately,both of which have since been abandoned), these two areaswere not addressed in the resident TEP curriculum. For themost part, the program was directed towards the developmentof teaching skills applicable during residents’ CTU rotation. Adetailed outline of each session is provided in Appendix C.The content of each session is briefly outlined below.Session 1: introduction: teaching & learning.IntroductionGoals and Objectives for the ProgramCourse ContentTeaching and LearningWhat Makes a Good Teacher?Residents as TeachersLearning Environment / ClimateClinical Teaching Techniques for ResidentsTasks for the Week156Session 2: work rounds & one minute teaching skills.Review of Last Week’s TasksModels for Work RoundsTips for Running Efficient Work RoundsDelegating WorkOne Minute Teaching Skills During Work RoundsMicroskills Role Play: One Minute Teaching SkillsTasks for the WeekSession 3: feedback & evaluation.Review of Last Week’s TasksFeedback vs. EvaluationFeedback: The Psychological MeaningContent of Effective FeedbackRole Play: Evaluation & FeedbackManaging MistakesTasks for the WeekSession 4: questioning & non-facilitating teachingbehaviours.Review of Last Week’s TasksIntroductionLevels of Questioning- “KAP”: Knowledge, Application, &Psychomotor SkillsQuestioning Techniques157Microteaching: QuestioningSix Common Non-Facilitating Teaching BehavioursReflection Exercise: Non-Facilitating Teaching BehavioursTasks for the WeekSession 5: cognitive learning prinicples & problemsolving.Review of Last Week’s TasksCognitive Learning PrinicplesDiscovery Learning ExercisesReflection ExerciseProblem Solving StrategiesTasks for the WeekSession 6: small group teaching.Review of Last Week’s TasksIntroduction / Setting ObjectivesTeacher & Session CharacteristicsGroup Discussion Teaching TechniquesManaging Group DynamicsPreparing A Small Group DiscussionResident TEP Evaluation158PracesThe discussion that follows, of the rationale for thedevelopment of two process components (i.e., case studies,and “Task of the Week”), will provide the reader with someinsight into how the author translated the importanttheoretical concepts underlying the resident TEP (i.e.,constructivism, situated learning, reflection, and self-efficacy)into practice. The author shares Mezirow’s (1991) concern forthe “disturbing fault line” that separates adult learningtheories from practice, and agrees that more effort is neededin synthesizing different theories for use by adult educators;the program described herein is one such effort. Mezirowwarns against the misguided use of “theory-in-practice” basedon common experience. He contends that “experience hasoften been predicated upon behaviourist assumptions simplybecause the behaviourist approach has so many featuresamenable to bureaucratic control, such as accountability,measurability, and focus on anticipated behaviouraloutcomes” (p. xi). He criticizes adult educators for ignoringthe pre-eminence of meaning “-how it is constructed,validated, and reformulated - and the social conditions thatinfluence the ways in which adults make meaning of theirexperience “(italics mine) (p. xii). He argues “that it is not somuch what happens to people but how they interpret and159explain what happens to them that determines their actions,their hopes, their contentment and emotional well being, andtheir performance” (p. xiii).Meaning and constructivism are the foundation on which theresident TEP (and this dissertation) is built. Constructivism isthe theme that is woven through the three other importantconcepts: situated learning, reflection, and self-efficacy. Thereader is reminded that residents, in taking part in the TEP,are in fact learners; however, they are learning how to teach,or more importantly, they are learning to facilitate others’learning. It would be paradoxical, if not ridiculous, to useconstructivist principles in the process of educating residentsabout teaching, without expecting residents to in turn usethese same principles in their own teaching. First of all, byusing constructivist principles and actively involving residentsin the learning process, the author is modelling what heconsiders to be effective teaching. Secondly, the principles ofconstructivism are referred to throughout the program, andthen formally addressed in Session 5: Cognitive LearningPrinciples & Problem Solving. Residents “discover” sixprinciples of constructivism by taking part in discoverylearning exercises or games. Thereafter, they are asked toreflect on their undergraduate and graduate medicaleducation, and consider two questions: (1) What160circumstances in medical education work for or againsteffective learning? (2) How can we facilitate effectivelearning? The content of this session is presented in detail inAppendix C, Session 5. Although the literature on residentTEP warns against presenting anything but practical skillsbecause of poor reception of theoretical material by residents,the author did not heed this advice. In fact, this sessionproved to be one of the most popular for residents. Theycommented that it provided “insight into learning” and theyrecommended that this session should definitely be kept inthe program. The authors’ views and approach are consistentwith those expressed by Bowden (1988). Bowden proposesthat achieving change in teaching requires changing teachers’conceptions of themselves as teachers, of the role of students,and of what it means to learn. He draws a distinction betweenteachers’ “espoused theory” and “theory-in-use” of teaching(p. 256). He contends that “the problem lies in a mismatchbetween espoused theory and the way students are actuallytaught and assessed” (p. 258). He warns that it is possible toteach (and assess) students in ways which unintentionallypromote simple recall rather than higher level aims. As onesolution to this problem, he proposes helping bridge the gapbetween teachers’ espoused theories and their theories-inaction. To this end, he proposes helping teachers change theirconception of teaching. Teachers’ focus should be probing161students’ understanding of material and helping them modifyunsophisticated concepts (or misconceptions). He emphasizesthat “there is no point in merely informing teachers of generalprinciples they should adopt, principles that would be largelycontent-free and meant to apply to all context” (p. 259). Heargues that “we need, therefore, to create an opportunity forteachers to develop an understanding of what those processesinvolve and for them to discover actively the ways in whichthey might apply to their own disciplines” (italics mine) (p.259).Although the constructivist perspective underlies the whole ofthe resident TEP, the case studies and the “Tasks for the Week”illustrate the so-called marriage of constructivism withsituated learning, reflection, and self-efficacy. These will nowbe considered in turn.Case method.Judith Shulman (1992a), in her book, Case Methods inTeacher Education, expresses concern about the gap that existsbetween the complexity of real world teaching and the“theoretical principles taught as quasi-prescriptions” in TEPs(p. xiii). She proposes using case studies in an attempt to162bridge the gap between theory and practice. She sees cases ascontrollable reality offering a more vivid context thantextbook discussions, and yet being more manageable (andless threatening) than real world experience to newcomers.Shulman cites the recommendations of the landmark report bythe Carnegie Task Force on Teaching as a Profession (1986)that “teaching ‘cases’ illustrating a great variety of teachingproblems should be developed as a major focus of instruction”(p. xiv). She contends that cases offer a means of providingsituated knowledge (see discussion in chapter two) and anopportunity to analyze ill-structured problems (cf., Schon’s“swamp”, 1987) where there is no one right answer. Finally,she comments on the use of cases as a stimulus for reflection.Cases “stimulate teachers’ individual reflection on their ownteaching, as well as providing a basis for dialogue andinteraction among teachers themselves” (p. xv). The reader isalso reminded of the four sources of efficacy expectations asdiscussed in chapter two: (1) performance accomplishments,(2) vicarious experience, (3) verbal persuasion, and (4)emotional arousal (Bandura, 1986). Case discussions byresidents may enhance perceived teaching self-efficacythrough vicarious experience and verbal persuasion. Kleinfeld(1992) also supports the notion that “cases...give the student agreat deal of vicarious experience” (p. 34). It is her positionthat the major role of TEPs is to teach students “how to ‘think163like a teacher,’ that is, learn how to formulate educationalproblems, design strategies that fit specific (situations), andreflect on the ethical and policy issues as well on thepedagogical issues embedded in everyday instructionaldecisions” (p. 34). She uses a case to illustrate how the casemethod can provide: (1) Vicarious experience with the kindsof problematic situations characteristic of teaching; (2) Amodel of how an expert teacher goes about framing andconstructing educational problems; (3) A model of how asophisticated teacher inquires about and reflects on suchproblems; (4) A stock of educational strategies for use inanalogous problem situations; and (5) A sense that teaching isan inherently ambiguous activity requiring continuousreflection (italics mine) (p. 34-35). Case studies, therefore,establish a means of “marrying” the four important conceptsunderlying the grounded theory of the resident TEP:constructivism, situated learning, reflection, and self-efficacy.Lee Shulman (1992b) discusses five situations in which casesand case methods are particularly appropriate: (1)theoretical principles (i.e., offering theoretical explanations forcourses of action); (2) precedents for practice (i.e.,prototypical cases may be guides for future actions); (3)moral or ethical principles (i.e., provide clear models ofworthy attitude and behaviours); (4) strategies, dispositions,164reflection, and habits of mind (i.e., provide opportunities fornewcomers to “think like a teacher”); and (5) visions orimages of the possible. Furthermore, cases may motivate andstimulate interest. Shulman reports “the growing feelingamong teacher educators that while the average teacher couldhardly be characterized as reflective, the image of reflectivepractice corresponds to the most desirable vision of properpedagogy” (p. 8). She argues that “cases provide occasions forprofessionals to gather together for retelling, reflection, andanalysis” (p. 10), and cites case conferences in medicine asone prototype. The author of this dissertation is more thanfamiliar with this “prototype,” and would argue, in fact, that itis not one prototype. Several different approaches to caseconferences exist. The reader is also cautioned not to equatecase methods with discussion or reflection, as this author isfamiliar with many examples of the case conference inmedicine where an opportunity for neither is provided.Schwab (1964, cited in Shulman, 1992b) suggests that casediscussion should occur on two distinct layers. The first layerdeals with the content of the case itself and a discussion ofalternative interpretations. The second layer is reflexive;students reflect on their own understanding and analysis.These two layers are not necessarily dealt with in succession,as the movement between the first layer (i.e., cognition) andthe second layer (i.e., metacognition) is usually iterative.165The narratives of the cases used in the resident TEP aresituated in real stories collected by the author of thisdissertation; they reflect the social and cultural context withinwhich residents are expected to teach. This may reduce theproblem of transfer from the seminar room to actual teachingon the wards by residents, as residents “may find it far easierto remember and use ideas that are located in the narrativeform of cases” (Shulman, 1992b, p. 24). The cases used forthe resident TEP can be found in the outlines of sessioncontent (Appendix C). One example is provided, here, for thereader:RF is an R2 in medicine. She is scheduled for a CTUrotation at St. Paul’s Hospital. She looks forward to hernew role as team leader and teacher. In fact, she spendsmany hours preparing small “talks” for the juniorsbefore starting the rotation.Her intern and MSI are particularly strong academically.During the first week she gives one of her mini lectures -nephrotic syndrome - with well prepared overheads. Shesenses that the juniors are not very interested. Sheconcludes that the juniors are not motivated and decidesnot to give any more talks.166As the rotation proceeds a power struggle developsbetween RF and the juniors. She tries to maintain controlof the team, and to teach by imparting information andher opinions on patient management. The juniors seeher as controlling and overbearing.What went wrong?During the discussion, residents are first asked to frame theproblem, and offer possible solutions. Next, they are forced toreflect on the assumptions underlying their frames ofreference and solutions. Considerable emphasis is placed onseeing alternate frames and solutions.“Tasks for the Week.”“Tasks for the Week” were assigned at the end of each of thefirst five sessions (i.e., briefing); they provided a brief reviewof and closure for each session. Residents received a one pagetn-fold pamphlet containing a review of the session (seeAppendix D). The front flap of the pamphlet listed the tasksand provided the residents with a “reminder.” Residents wereexpected to perform the tasks during the week until the nextsession. The beginning of the next session began by167debriefing residents on their performance of the tasks; thisprovided a review of the material and an opportunity forreflection. Residents gave brief accounts of performing thetask. They were prompted to provide their “reflection-inaction” at the time. The ensuing group discussion provided anopportunity for “reflection-on-reflection-in-action” (sic).Greater emphasis was placed on the positive aspect ofaccounts in order to promote perceived self-efficacy. Whenaccounts were mostly negative, residents were asked to comeup with more useful alternatives.Pearson (1985) discusses the central role of debriefing inexperience-based learning. He states that “through eachexperience we may gain new understandings and skill, and ourbeliefs about ourselves, others and the world are challenged,changed or reinforced” (p. 69). He cautions, however, that“simply to experience.., is not enough. Often we are so deeplyinvolved in the experience itself that we are unable, or do nothave the opportunity, to step back from it and reflect uponwhat we are doing in any critical way” (p. 69). He traces thehistorical roots of debriefing to the military where participantsof campaigns and war games were asked to account for theiractions, and to develop new strategies as a result of theexperience. He suggest three questions (i.e., steps) in thedebriefing process: (1) What happened? (2) How did the168participant feel? (3) What does it mean? He argues that“reflection lies at the core of experience-based learning.Without it, experiences may remain as experiences and the fullpotential for learning by the participant may not be realized”(p. 83). He outlines “rules” for effective debriefing: (1) apositive commitment to debriefing, (2) the deliberateplanning of debriefing, (3) briefing (i.e., establishing clearobjectives, and purposes for the activities), and (4) a positivedebriefing “environment.”A review of the “Tasks for the Week” is available from theresident TEP handouts (Appendix D).The main reason for developing the “Tasks for the Week” wasto allow residents to cultivate mastery experience and thereby,enhance their sense of teaching self-efficacy (i.e., the majoroutcomes measure of this study). Beyond this, the situatednature of these exercises in authentic activity providedresidents with primary experiences (Jarvis, 1992) tocomplement the secondary experiences provided by the TEP.These tasks can be seen to occupy the centre of what Wengerand Lave (1991) describe as legitimate peripheralparticipation, as the residents have moved to “legitimateparticipation.”169The above discussion provides yet another example of thehappy marriage of constructivism, situated learning,reflection, and self-efficacy.Other.Several other processes are used throughout the resident TEP(e.g., brainstorming, microteaching, role-playing). Otherswere specifically designed for use in the program described. Adetailed account of all of these can be gleaned by reviewingthe content of each session provided in Appendix C (seeTASK). It is beyond the scope of this dissertation to give adetailed account of the rationale for choosing or designingeach and every one of these; this would be tedious andredundant as the discussion of the case method and the “Taskfor the Week” were designed with the same ideas in mind.MaterialsAlthough no readings were assigned, one photocopiedreference was provided: “Clinical Teaching Techniques forResidents” (Edwards & Marier, 1988b). Also, a one page tnfold pamphlet (that fit easily into residents’ lab coat pockets),was provided for each session. The front cover of thepamphlet listed the tasks for the week; the body copy170contained a synopsis of the session. The only other materialsincluded the Department of Medicine resident teachingevaluation form (i.e., student rating form of resident teaching)and a “12 Steps of Effective Feedback” checklist (all of theabove materials are available in Appendix D).ImplementationBeginning in January 1993, the resident TEP was offered toCTU residents at St. Paul’s Hospital, University of BritishColumbia. The program was offered a total of three times (todate): January-February 1993, March-April 1993, and July-August 1993. The May-June 1993 CTU rotation was skippedbecause MSIs are absent for three weeks during the month ofMay. All four CTU residents participated in the first twoofferings. During the third offering, one resident whoparticipated in the program previously (4 months earlier) didnot take part again. Therefore, a total of 11 CTU residentsparticipated in the resident TEP in three groups over an eightmonth period. The interest generated by word of mouth,however, lead to a request by residents in subspecialtyrotations to participate in the program. One or two residents(per course offering) were thus allowed to take part but werenot considered study subjects (except in filling out program171evaluation forms). The author of the dissertation conductedall the sessions.Pmgram EvaluationA program satisfaction questionnaire with both quantitativeand qualitative questions was completed by participatingresidents at the end of the TEP. The quality of the program,the quality of the teaching, and the relevance of each sessionwere assessed. A copy of the program evaluation instrumentis provided in Appendix B.—I173CHAPTER FOUR: RESULTSIntroductionThis chapter reviews the results of the study. The results ofinstrument piloting will be reviewed first. This will befollowed by the data analysis of the four parts of theinstrument:I. Teaching Scale (self-efficacy and teaching self-efficacy)II. Residents as Teachers - Opinion (beliefs aboutteaching)III. Teaching Skills (self-reported teaching behaviours)lV. Interest in TeachingFinally, the results of the program evaluation will be reported.Before moving on, however, the reader is reminded of theresearch questions for this study.Research Questions1. What attitude do general internal medicine residents havetowards teaching (i.e., self-efficacy, beliefs about teaching, and174interest in teaching)?2. What is the effect of a CTU rotation and associated teachingresponsibilities on residents’ sense of teaching self-efficacy,self-reported teaching behaviours, beliefs about teaching, andinterest in teaching?3. What is the impact of a TEP on residents’ sense of teachingself-efficacy, self-reported teaching behaviours, beliefs aboutteaching, and interest in teaching?4. Is a change in self-efficacy (i.e., attitude subconstruct)associated with a change in self-reported teaching behaviours?Instrument PilotingThe design and development of the study instrument wasdiscussed in detail in chapter three and will not be repeatedhere.A copy of the pilot instrument is available in Appendix A. Theitems with the best “loading” and providing the best internalconsistency reliability were kept in the final instrument (seeAppendix A).175Item statistics (i.e., “loading”; r) for items used in the finalinstrument are available in Appendix E.Below is the final number of items in, and the internalconsistency reliability for each scale.INTERNAL CONSISTENCY RELIABILITY OF PILOT INSTRUMENTTE TSE SRBItems (n) 6 12 16Hoyt (r) 0.61 0.87 0.81TE = Teaching EfficacyTSE = Teaching Self-EfficacySRB = Self-Reported Teaching BehavioursInstrument ValidationConsiderable evidence exists for the construct validity of selfefficacy and was reviewed in chapter two. It is beyond thescope of this dissertation to provide extensive construct176validation or instrument validation. However, some evidenceof instrument validity was sought by examining therelationship between department of medicine faculty scoreson the two teaching efficacy subscales (i.e., teaching efficacyand teaching self-efficacy) and the self-reported teachingbehaviour scale. In addition, scores on the two teachingefficacy subscales were correlated with student evaluations offaculty teaching. A global assessment of faculty teaching wasprovided by using the mean rating on a 5 point Likert scale tothe item “Overall is an effective teacher” over a two yearperiod.The instrument was sent to 30 faculty members of St. Paul’sHospital Department of Medicine. Twenty-five questionnaireswere returned for a response rate of 83%. The individualresponsible for collecting, analysing, and reporting studentevaluations of faculty teaching, provided a mean rating ofstudents’ reponses to “Overall is an effective teacher.” Datafrom at least 5 students over a two year period was providedfor each faculty member. Student rating data andquestionnaire responses were blinded in terms of facultyidentity to the author of this dissertation. Teaching efficacyand teaching self-efficacy were correlated to self-reportedteaching behaviours (SRB) and student ratings using Pearson’scorrelation177Pearson’s rTE TSESRB 0.14 0.57Student Ratings -0.17 0.30TE = Teaching EfficacyTSE Teaching Self -EfficacySRB = Self-Reported Teaching BehavioursThe results show little or no correlation between teachingefficacy and self-reported teaching behaviours or studentratings. However, a much stronger correlation was foundbetween teaching self-efficacy and self-reported teachingbehaviours or student ratings. This is consistent with the twodimensional model of self-efficacy.Sections I & III: Self-Efficacy and Self-Reported BehaviourScalesThis section reports the results of the control (n=8) andtreatment (n= 11) groups on the self-efficacy and self-reported178behaviour scales. Both scales are 5 point Likert agreementscales: 1=strongly disagree, 2=disagree, 3=neutral, 4=agree,and 5=strongly agree. The self-efficacy scale is divided intotwo subscales. The “teaching efficacy” subscale is composedof 6 items for a possible maximum score of 30. The “teachingself-efficacy” subscale is composed of 12 items for a possiblescore of 60. The self-reported teaching behaviour scale iscomposed of 16 items for a possible maximum score of 80.Pre- and post-measurements were made for each scale. Inaddition, a self-reported behaviour “retro-” measurement wasmade for the treatment group. Therefore, post-intervention,residents were asked to assess themselves on several teachingbehaviours (e.g., “I routinely use feedback in studentteaching”). A retro-measurement allowed residents to reassesstheir behaviour at the beginning of the rotation (cf., pre-) inlight of their new understanding of teaching behavioursthrough participation in the TEP. For example, at thebeginning of the program (i.e., pre-), residents may ratethemselves highly on the feedback question in the exampleabove. However, through participation in the TEP they maydiscover that they hold a limited conception of what it meansto give feedback and change their behaviour accordingly. Atthe end of the program, they may then again rate themselveshighly on the feedback question. Adding a retro-question mayhelp control for this phenomenon and allow a better179assessment of improvement.The data analysis is further complicated by the fact that onetreatment group participant only attended 3 of the 6 sessions.A decision was made at the onset of the program to consideranyone having completed more than half the program ashaving undergone the intervention. Therefore, two analyseswere carried out for this section, as self-efficacy and self-reported teaching behaviours were the major outcomesmeasures. An “intention to treat” analysis was carried outusing data from all 11 subjects (i.e., all those that agreed toparticipate). A second analysis was carried out with datafrom subject #14 removed (i.e., n=10) to assess the outcomefor those individuals that completed at least 50% of theprogram.Raw data of total scores on the two self-efficacy subscales andthe self-reported behaviour scale is available in Appendix F.Student t-TestsTo begin with a paired sample student t-test was done preand post- for each scale (the term “scale” will be used to referto both self-efficacy subscales and the self-reported behaviour180scale). The mean difference refers to the total possible scoreon the scale (i.e., teaching efficacy=6; teaching selfefficacy= 12; self-reported teaching behaviour= 16). Forinstance, the mean difference for teaching efficacy (pre- vs.post-) in the control group is 0.62 5 out of a possible 6. Thisrepresents a difference of approximately 0.1 on a 5 pointLikert scale (i.e., 0.625/60. 1). This very small difference didnot achieve statistical significance (p=0.472). Given that eachscale had a different total number of items, differences will bereported as a difference on a 5 point Likert scale.For each scale, a non-paired student t-test was done,comparing the pre- results of both the control and treatmentgroups, to demonstrate whether the groups were the same atbaseline. Groups are considered significantly different atbaseline if P <0.05.Statistical results for each scale appear on the following pages,the last of which looks at the “retro-” vs. post- self-reportedbehaviour scale. Results appear twice, both with and withoutcase #14. The results of pre- vs. post- are placed alongside foreasy comparison.181Teaching Efficacy (TE)PAIRED SAMPLES T-TEST 8 CASESTeaching Efficacy Control Pre- vs. Post-MEAN DIFFERENCE = 0.625 i.e., 0.1 on a 5 point scaleSD DIFFERENCE = 2.326P= 0.472PAIRED SAMPLES T-TEST 11 CASESTeaching Efficacy Treatment Pre- vs. Post-MEAN DIFFERENCE = 0.273 i.e., 0.05 on a 5 point scaleSD DIFFERENCE = 3.5800.806PAIRED SAMPLES T-TEST 10 CASES (without 14)Teaching Efficacy Treatment Pre- vs. PostMEAN DIFFERENCE = 0.200 i.e., 0.03 on a 5 point scaleSD DIFFERENCE = 3.7650.870NON-PAIRED SAMPLES T-TEST 18 CASESTeaching Efficacy Control Pre- vs. Treatment PreP= 0.540182Teaching Self-Efficacy (TSE)PAIRED SAMPLES T-TEST 8 CASESTeaching Self-Efficacy Control Pre- vs. Post-MEAN DIFFERENCE = 2.625 i.e., 0.2 on a 5 point scaleSD DIFFERENCE = 2.72 2P= 0.029PAIRED SAMPLES T-TEST 11 CASESTeaching Self-Efficacy Treatment Pre- vs. Post-MEAN DIFFERENCE = 5.000 i.e., 0.4 on a 5 point scaleSD DIFFERENCE = 5.422P= 0.012PAIRED SAMPLES T-TEST 10 CASES (without 14)Teaching Self-Efficacy Treatment Pre- vs. PostMEAN DIFFERENCE = 4.900 i.e., 0.4 on a 5 point scaleSD DIFFERENCE = 5.7050.024NON-PAIRED SAMPLES T-TEST 18 CASESTeaching Self-Efficacy Control Pre- vs. Treatment PreP= 0.547183Self-Reported Teaching Behaviours (SRB)PAIRED SAMPLES T-TEST 8 CASESSelf-Reported Behaviours Control Pre- vs. Post-MEAN DIFFERENCE = 2.750 i.e., 0.2 on a 5 point scaleSD DIFFERENCE = 3.808P= 0.080PAIRED SAMPLES T-TEST 11 CASESSelf-Reported Behaviours Treatment Pre- vs. Post-MEAN DIFFERENCE = 10.818 i.e., 0.7 on a 5 point scaleSD DIFFERENCE = 8.6580.002PAIRED SAMPLES T-TEST 10 CASES (without 14)Self-Reported Behaviours Treatment Pre- vs. PostMEAN DIFFERENCE = 11.900 i.e., 0.7 on a 5 point scaleSD DIFFERENCE = 8.306P= 0.001NON-PAIRED SAMPLES T-TEST 18 CASESSelf-Reported Behaviours Control Pre- vs. Treatment PreP= 0.866184“Retro-”: Self-Reported Teaching Behaviours (SRB)PAIRED SAMPLES T-TEST 11 CASESSelf-Reported Behaviours Treatment Retro- vs. Post-MEAN DIFFERENCE = 15.182 i.e., 0.9 on a 5 point scaleSD DIFFERENCE = 10.078P= 0.001Self-Reported Behaviours Treatment Pre- vs. Post-MEAN DIFFERENCE = 10.818 i.e., 0.7 on a 5 point scaleSD DIFFERENCE = 8.658P= 0.002PAIRED SAMPLES T-TEST 10 CASES (without 14)Self-Reported Behaviours Treatment Retro- vs. Post-MEAN DIFFERENCE = 17.200 i.e., 1.1 on a 5 point scaleSD DIFFERENCE = 7.94145P= 0.00007Self-Reported Behaviours Treatment Pre- vs. PostMEAN DIFFERENCE = 11.900 i.e., 0.7 on a 5 point scaleSD DIFFERENCE = 8.3060.001185TeachingJfficacyOnly a small pre- post-difference was demonstrated for teachingefficacy in both the control and treatment groups (0.1 and 0.05respectively). These differences did not achieve statisticalsignificance (0.472 and 0.870 respectively). Also, there was nosignificant difference between groups at baseline (p=0.54).Therefore, teaching efficacy remained stable throughout theprogram. No effect could be demonstrated by participation in aresident TEP or having a CTU teaching assignment.Teaching Self-EfficacyThe control group had an increase of 0.2 (out of 5) that wasstatistically significant (p=0.029). The treatment groupimprovement was twice that of the control group at 0.4 (out of5)(p=0.0l2). No significant differences were noted with theremoval of case #14. Also, both groups were comparable atbaseline (p=0.547). Both a teaching assignment and the residentTEP had a positive impact on residents’ sense of teaching selfefficacy, with the TEP effect being twice that of a teachingassignment alone.186Self-Reported Teaching BehavioursThe control group had a small increase of 0.2 (out of 5) thatdid not achieve statistical significance (p=0.080). In contrast,the treatment group increased by 0.7 (out of 5) and wassignificant at the 0.002 level. Results were similar with andwithout case #14. Also, the results indicate that the twogroups were the same at baseline (p=0.866). Therefore, theCTU teaching assignment had no significant effect on self-reported teaching behaviours in the control group, whereas,the addition of a resident TEP was related to an improvementof 0.7 (on a 5 point scale) in the treatment group.A retro- assessment of behaviours at the beginning of therotation, in light of new insights provided by participating inthe TEP, reveal that the improvements in self-reportedbehaviours for the treatment group may be an underestimate.Using a retro- vs. post- design, the improvements in selfreported teaching behaviours improved from 0.7 to 0.9 (for allcases; n=11; p=0.OOl) and from 0.7 to 1.1 (case #14 removed;n=10; p=0.00007).187Internal Consistency Reliability of ScalesThere was good internal consistency reliability for the scalesuse with all but one result falling into the 0.74- 0.87 range.Only the Teaching efficacy: Control post- was outside thisrange at 0.45.All of the r values appear below.INTERNAL CONSISTENCY RELIABILITY OF INSTRUMENT SCALESTE TSE SRB SRB-retroControlPre- 0.87 0.80 0.87Post- 0.45 0.82 0.81TreatmentPre- 0.84 0.73 0.84Post- 0.82 0.83 0.74 0.86TE = Teaching EfficacyTSE = Teaching Self-EfficacySRB = Self-Reported Teaching Behaviours188MANOVAData analysis was repeated using MANOVA to perform amultivariate analysis of variance. Specifically, the followingdifferences were sought: (1) Between Group Difference atBaseline, (2) Pre- vs. Post- Difference, and (3) Treatment vs.Control Difference. Differences were considered significant atthe 0.05 level.Data for each scale is presented in the following pages andincludes: Mean (score) pre- and post-, SD (standard deviation)pre- and post-, p values for “Between Group Difference atBaseline”, “Pre- vs. Post- Difference,” and “Treatment vs.Control Difference.” A graphic representation is also included.Analysis of VarianceMANOVATEACHING EFFICACYMean SDn11189Between Group Difference at BaselinePre- vs. Post- Difference p = 0.545Treatment vs. Control Difference p= 0.811p= 0.422P reTeaching EfficacyPostPre Post- Pre- Post-23.2Treatment 22.9 3.3 3.7Control 23.8 24.4 3.0 1.6 824.524.023.5D 23.022.50C-,C,,Treatment D ControlAnalysis of VarianceMANOVA190TEACHING SELF -EFFICACYMean SDTreatmentPre- Post-40.3 45.3Pre- Post-5.2 5.1n11Between Group Difference at BaselinePre- vs. Post- Difference p = 0.002p= 0.895Treatment vs. Control Difference p = 0.2 736 46.045.0o 44.04-,D 43.00‘—‘ 42.0iP reTeaching Self-EfficacyPostControl 41.8 44.4 5.5 4.9 80 Treatment ControlAnalysis of VarianceMANOVASELF-REPORTED BEHAVIOURMean SD191Pre- Post-Between Group Difference at BaselinePre- Post-p= 0.092Pre- vs. Post- Difference p = 0.00 160.055.050.0PostTreatmentControl52.2 63.0 7.0 4.751.6 54.4 7.7 7.0 8n11Treatment vs. Control Difference p = 0.025Self-Reported Behavior8 65.004-a0V0Cl,P rep Treatment ControlAnalysis of Variance- Subject 14 RemovedMANOVA192TEACHING EFFICACYMean SDPre- Post- Pre- Post- n23.8 24.4 8Between Group Difference at BaselinePre- vs. Post- Difference p = 0.596000i)I0C.)J)p= 0.681TreatmentControl23.5 23.7 2.8 3.53.0 1.610Treatment vs. Control Difference p = 0.784Teach Efficacy (-#1 4)24.524.0,23.523.022.5P re Post0 Treatment ControlAnalysis of Variance - Subject 14 RemovedMANOVA193TEACHING SELF -EFFICACYMean SDPre- Post- Pre- Post- nTreatmentControl41.0 45.941.8 44.44.9 4.95.5 4.9108Between Group Difference at BaselinePre- vs. Post- Difference p = 0.004C0.1-ID0II)0Up= 0.857Treatment vs. Control Difference p = 0.3 17Teach SeIf-Eff (-#1 4)46.045.044.043.042.041.040.0P re Post0 Treatment ControlMANOVASELF-REPORTED BEHAVIOURMean SD194Pre- Post- Pre- Post-TreatmentControl51.5 63.451.6 54.46.9 4.77.7 7.0108Between Group Difference at Baselinep<p= 0.118Treatment vs. Control Difference p =6’ 65.0OD00a)0C.)C.,)P re60.055.050.00.11Self-Rep Behav (-#1 4)PostAnalysis of Variance- Subject 14 RemovednPre- vs. Post- Difference 0.001Treatrnent Control195Teaching EfficacyNo difference was demonstrated between groups at baseline,no pre- vs. post- difference, and no treatment vs. controldifference. Therefore, both groups were similar at baselineand no change in teaching efficacy could be demonstrated ineither group.Teaching Self-EfficacyBoth groups were the same at baseline (p=0.895). Asignificant pre- vs. post- difference was demonstrated(p=0.002). The treatment vs. control difference approached,but did not achieve, statistical significance (p=0.273).Self-Reported Teachingi3ehavioiirNo between group difference was demonstrated at baseline(p=O.92). Pre- vs. post-, and treatment vs. control differenceswere statistically significant (p=0.001 and p=0.025respectively). With case #14 removed p values were <0.001and 0.11 respectively.196Correlation of Self-Efficacy with Self-Reported EehavioursOne of the questions that this study proposes to answer is, “Isa change in self-efficacy (i.e., attitude subconstruct) associatedwith a change in self-reported teaching behaviours?”Therefore, the change in both teaching efficacy (TE) andteaching self-efficacy (TSE) (i.e., change = post - pre) wascorrelated with the change in self-reported teachingbehaviours (SRB) (i.e., change = post - pre). Data from allsubjects (i.e., treatment and control) was used to calculate aPearson’s correlation coefficient.Pearson’s rChange in TE Change in TSEChange in SRB 0.21 0.66TE = Teaching EfficacyTSE = Teaching Self-EfficacySRB = Self-Reported Teaching BehavioursTherefore, a change in teaching efficacy beliefs was197moderately correlated with a change in self-reported teachingbehaviours. However, a more impressive correlation wasfound between a change in teaching self-efficacy beliefs and achange in self-reported teaching behaviours.Sections II: Beliefs About TeachingThe results of this part of the questionnaire are reported inthe following pages. Data from both the control (n=8) andtreatment (n=1 1) groups for each of the 15 questions arepresented on a separate page (i.e., one question per page).The mean and standard deviation (SD) are reported pre- andpost- for both groups. The means represent the averageagreement to the question statement on a 5 point Likert scale:1=strongly disagree, 2=disagree, 3=neutral, 4=agree, and5=strongly agree. The mean difference (Mean diff.) pre- andpost- (i.e., mean post - mean pre) and the level of significance(i.e., p; two-tailed paired student t-test) for this difference isalso reported. The mean difference represents the amount ofchange from pre- to post- on a 5 point scale. For instance, a0.5 difference represents an increase of one half scale point inagreement to the statement question.In order to demonstrate that both groups were similar at198baseline, a non-paired, two-tailed student t-test was performedon the means of both groups at the outset (i.e., control-pre vs.treatment-pre) - see “All Pre-.” The mean difference (Meandiff) between groups is also reported. The two means (i.e.,control-pre and treatment-pre) are also taken to represent thebeliefs of general internal medicine residents at baseline.199#1. Teaching Is A Primary Responsibility Of ResidentsControl (n=8) Treatment (n=11)Pre- Post- Pre- Post-Mean 3.38 3.89 3.45 3.73SD 1.30 0.99 0.82 1.19Mean diff. 0.50 0.27p= 0.17 0.19All PrePre- PreControl TreatmentMean 3.38 3.45SD 1.30 0.82Mean diff. 0.08p= 0.87200#2. Residents Play An Important Role In Teaching StudentsControl (n=8) Treatment (n=1 1)Pre- Post- Pre- Post-Mean 4.25 4.38 4.18 4.73SD 0.46 0.52 0.87 0.47Mean diff. 0.13 0.55p= 0.35 0.025All PrePre- PreControl TreatmentMean 4.25 4.18SD 0.46 0.87Mean diff. -0.07p= 0.83201#3. Teaching Students Helps Me Be A Better ClinicianControl (n=8) Treatment (n=11)Pre- Post- Pre- Post-Mean 4.25 4.25 4.27 4.45SD 0.71 0.71 0.65 0.52Mean diff. 0.00 0.180.00 0.17All PrePre- PreControl TreatmentMean 4.25 4.27SD 0.71 0.65Mean diff. 0.020.94202#4. Lectures Are The Best Way To Teach Clinical MedicineControl (nz=8) Treatment (n= 11)Pre- Post- Pre- Post-Mean 2.13 1.88 2.00 1.64SD 0.84 0.64 0.45 0.67Mean diff. -0.25 -0.36p= 0.17 0.10All PrePre- PreControl TreatmentMean 2.13 2.00SD 0.83 0.45Mean diff. -0.13p= 0.65203#5. Providing Students With Information On My ExperienceAnd My Readings Is The Most Effective Way To TeachControl (n=8) Treatment (n=11)Pre- Post- Pre- Post-Mean 3.50 3.00 3.55 2.91SD 0.54 0.93 0.82 1.22Mean diff. -0.50 -0.64p= 0.10 0.026All PrePre- PreControl TreatmentMean 3.50 3.55SD 0.53 0.82Mean diff. 0.05p= 0.89204#6. There Is Enough Time In The Day To Effectively TeachStudentsControl (n=8) Treatment (n=1 1)Pre- Post- Pre- Post-Mean 2.00 2.38 3.00 2.64SD 0.76 1.06 1.26 1.12Mean diff. 0.38 -0.36p= 0.28 0.44All PrePre- PreControl TreatmentMean 2.00 3.00SD 0.76 1.26Mean diff. 1.00p= 0.052205#7. It Is Important That My Students Enjoy Themselves WhileWorking With MeControl (n=8) Treatment (n=11)Pre- Post- Pre- Post-Mean 4.50 4.50 4.64 4.73SD 0.54 0.54 0.50 0.47Mean diff. 0.00 0.09p= 0.00 0.59All PrePre- PreControl TreatmentMean 4.50 4.64SD 0.53 0.50Mean diff. 0.14p= 0.55206#8. It Is My Role To Keep Students Motivated And InterestedControl (n=8) Treatment (n=11)Pre- Post- Pre- Post-Mean 4.25 3.88 4.09 4.27SD 0.71 0.64 0.54 0.47Mean diff. -0.38 0.18p= 0.079 0.34All PrePre- PreControl TreatmentMean 4.25 4.09SD 0.71 0.54Mean diff. -0.16p 0.58207#9. MSI’s (Clinical Clerks) Are Primarily Physicians AndShould Be Treated As Such (i.e., Given The SameResponsibilities As Physicians)Control (n=8) Treatment (n=1 1)Pre- Post- Pre- Post-Mean 3.75 3.63 3.09 3.91SD 1.17 1.06 1.04 0.70Mean diff. -0.125 0.82p= 0.76 0.020All PrePre- PreControl TreatmentMean 3.75 3.09SD 1.16 1.04Mean diff. -0.660.19208#10. I Feel Frustrated Teaching Students Because I May NotKnow All The FactsControl (n=8) Treatment (n=1 1)Pre- Post- Pre- Post-Mean 3.63 3.13 3.64 2.91SD 0.92 1.13 0.92 0.94Mean diff. -0.50 -0.73p= 0.10 0.054All PrePre- PreControl TreatmentMean 3.63 3.64SD 0.92 0.92Mean diff. 0.01p= 0.98209#11. I Worry That MSI’s Poor Performance Will Reflect On MeControl (n=8) Treatment (n= 11)Pre- Post- Pre- Post-Mean 2.38 2.75 3.00 2.82SD 0.52 0.89 0.89 0.98Mean diff. 0.38 -0.18p= 0.20 0.17All PrePre- PreControl TreatmentMean 2.38 3.00SD 0.52 0.89Mean diff. 0.63p 0.065210#12. Given The Day To Day Demands Of Ward Work, There IsNo Time Left Over To Effectively Teach Medical StudentsControl (n=8) Treatment (n=1 1)Pre- Post- Pre- Post-Mean 3.63 3.00 3.09 2.45SD 0.92 1.20 0.94 1.04Mean diff. -0.625 -0.64p = 0.095 0.089All PrePre- PreControl TreatmentMean 3.63 3.09SD 0.92 0.94Mean diff. -0.53p= 0.20211#13. MSI’s Are Primarily Students And Care Must Be TakenNot To Give Them Too Much ResponsibilityControl (n=8) Treatment (n= 11)Pre- Post- Pre- Post-Mean 2.63 2.13 2.91 2.18SD 0.92 0.35 0.83 0.98Mean diff. -0.50 -0.73p= 0.17 0.012All PrePre- PreControl TreatmentMean 2.63 2.91SD 0.92 0.83Mean diff. 0.28p= 0.48212#14. I Have Difficulty Giving MSI’s Too Many Patient CareResponsibilities Because I Am Ultimately Responsible For TheirMistakesControl (n=8) Treatment (n=11)Pre- Post- Pre- Post-Mean 3.00 2.13 2.82 2.36SD 0.93 0.84 0.87 0.81Mean diff. -0.88 -0.45p= 0.041 0.18All PrePre- PreControl TreatmentMean 3.00 2.82SD 0.93 0.87Mean diff. -0.180.65213#15. Residents Are Important Role Models For MedicalStudentsControl (n=8) Treatment (n=1 1)Pre- Post- Pre- Post-Mean 4.25 4.50 4.18 4.55SD 0.46 0.54 0.40 0.52Mean diff. 0.25 0.36p= 0.17 0.038All PrePre- PreControl TreatmentMean 4.25 4.18SD 0.46 0.40Mean diff. -0.07p= 0.70214No significant differences between groups were demonstratedat baseline (see “All Pre-” for each question). However, abaseline difference approaching statistical significance (at the0.05 level) was demonstrated for 2 of the 15 questions:#6. There Is Enough Time In The Day To Effectively TeachStudents (control pre- mean=2.00, treatment pre- mean=3.00,mean diff.= 1.00, p=0.052), and#11. I Worry That MSI’s Poor Performance Will Reflect On Me(control pre- mean=2.38, treatment pre- mean=3.00, meandiff.=0.63, p=0.065).A significant pre- and post- difference was found for 5 of 15questions for the treatment group:#2. Residents Play An Important Role In Teaching Students(treatment pre- mean=4.18, treatment post- mean=4.73, meandiff.=0.55, p=0.025),#5. Providing Students With Information On My ExperienceAnd My Readings Is The Most Effective Way To Teach(treatment pre- mean=3.55, treatment post- mean=2.91, meandiff.=-0.64, p=O.026),#9. MSI’s (Clinical Clerks) Are Primarily Physicians AndShould Be Treated As Such (i.e., Given The SameResponsibilities As Physicians) (treatment pre- mean=3 .09,treatment post- mean=3.91, mean diff.=0.82, p=0.00),#13. MSI’s Are Primarily Students And Care Must Be Taken215Not To Give Them Too Much Responsibility (treatment premean=2.91, treatment post- mean=2.18, mean diff.=-O.73,p=0.012), and#15. Residents Are Important Role Models For MedicalStudents (treatment pre- mean=4. 18, treatment postmean=4.55, mean diff.=0.36, p=0.038).A difference approaching statistical significance (at the 0.05level) was found for the treatment group for one additionalquestion:#10. I Feel Frustrated Teaching Students Because I May NotKnow All The Facts (treatment pre- mean=3.64, treatmentpost- mean=2.91, mean diff.=-0.73, p=0.054).All of these differences represent “improvements” in beliefsabout teaching. These improvements are significant not onlyat the statistical level, but also on the level of magnitude: onethird to almost one full point on a 5 point Likert scale (i.e.,0.36 - 0.82).In contrast, a significant pre- and post- difference was foundfor only 1 of 15 questions for the control group:#14. I Have Difficulty Giving MSI’s Too Many Patient CareResponsibilities Because I Am Ultimately Responsible For TheirMistakes (control pre- mean=3.0O, control post- mean=2.13,216mean diff.=-O.88, p=O.041).Section IV. Interest in TeachingThe results of this part of the questionnaire are reported inthe following pages. Data from both the control (n=8) andtreatment (n= 11) groups for each of the 5 questions arepresented on a separate page (i.e., one question per page).The mean and standard deviation (SD) are reported pre- andpost- for both groups (except question #3). The meansrepresent the average agreement to the question statement ona 5 point Likert scale: 1=strongly disagree, 2=disagree,3=neutral, 4=agree, and 5=strongly agree. The meandifference (Mean diff.) pre- and post- (i.e., mean post- meanpre) and the level of significance (i.e., p; two-tailed pairedstudent t-test) for this difference is also reported. The meandifference represents the amount of change from pre- to poston a 5 point scale. For instance, a 0.5 difference represents anincrease of one half scale point in agreement to the statementquestion.In order to demonstrate that both groups were similar atbaseline, a non-paired, two-tailed student t-test was performedon the means of both groups at the outset (i.e., control-pre vs.217treatment-pre) - see “All Pre-.” The mean difference (Meandiff) between groups is also reported. The two means (i.e.,control-pre and treatment-pre) are also taken to represent thebeliefs of general internal medicine residents at baseline.218#1. I Routinely Ask Students For Feedback On My TeachingEffectivenessControl (n=8) Treatment (n=11)Pre- Post- Pre- Post-Mean 3.00 3.25 2.73 3.45SD 0.93 1.04 0.79 0.82Mean diff. 0.25 0.73p= 0.52 0.012All PrePre- PreControl TreatmentMean 3.00 2.73SD 0.93 0.79Mean diff. -0.27p= 0.45219#2. Overall, I Put More Effort Into Teaching Than Most Of MyPeersControl (n=8) Treatment (n=1 1)Pre- Post- Pre- Post-Mean 2.88 3.38 2.82 3.45SD 0.64 0.74 0.75 0.82Mean diff. 0.50 0.64p= 0.23 0.002All PrePre- PreControl TreatmentMean 2.88 2.82SD 0.64 0.75Mean diff. -0.06p= 0.86220#3. I Have Had Previous “Teacher Training”Control (n=8) Treatment (n=zl 1)Pre- Post- Pre- Post-Yes 0/8 0/8 0/11 1/11(9%)TIPS CourseNo 8/8 8/8 11/11 10/11(100%) (100%) (100%) (91%)All PrePre- PreControl TreatmentYes 0/8 0/11No 8/8 (100%) 11/11 (100%)221#4. If Time Situations Were Ideal, I Would Prefer To SpendMore Time TeachingControl (n=8) Treatment (n=1 1)Pre- Post- Pre- Post-Mean 4.25 4.25 3.91 4.00SD 0.71 0.71 0.94 1.00Mean diff. 0.00 0.09p 0.00 0.68All PrePre- PreControl TreatmentMean 4.25 3.91SD 0.71 0.94Mean diff. -0.340.36222#5. I Would Be Interested In Attending A Workshop /Seminars On TeachingControl (n=8) Treatment (n=1 1)Pre- Post- Pre- Post-Mean 4.25 4.38 4.18 3.91SD 0.71 0.52 0.98 0.70Mean diff. 0.13 -0.27p= 0.60 0.19All PrePre- PreControl TreatmentMean 4.25 4.18SD 0.71 0.98Mean diff. -0.07p= 0.86223Question #3 revealed that none of the 19 residents had priorteacher education experience at baseline (control n=8 andtreatment n=1 1). Of the four remaining questions, nosignificant differences between groups were demonstrated atbaseline (see “All Pre-” for each question).A significant pre- and post- difference was found for 2 of 4questions for the treatment group:#1. I Routinely Ask Students For Feedback On My TeachingEffectiveness (treatment pre- mean=2.73, treatment postmean=3.45, mean diff.=O.73, p=O.012), and#2. Overall, I Put More Effort Into Teaching Than Most Of MyPeers (treatment pre- mean=2.82, treatment post- mean=3.45,mean diff.=O.64, p=O.002).In contrast, no significant pre- and post- differences werefound for the control group.Program EvaluationA copy of the program evaluation instrument, and detailedresults and analysis of the program evaluation are available inAppendix B.224Attendance was good overall, and was more than 90% for thefirst four sessions. The last two sessions (i.e., #5 CognitiveLearning Principles and Problem Solving Strategies, and #6Small Group Teaching) had attendance rates of 62% and 85%respectively.For each session, residents’ were asked to respond to thefollowing questions on a 5 point Likert agreement scale(1=strongly disagree, and 5=strongly agree): “This topic washelpful to me in my teaching role as a CTU resident.”Responses ranged from 4.25 to 4.67, except for session #6Small Group Teaching were it was 3.73. Upon furtherdiscussion with the residents, this session was dropped for thelast two groups.Overall, residents were satisfied with the course, with itscontent, and with the method of instruction as isdemonstrated by a sample of responses (overall group meanon a 5 point Likert agreement scale).#1 Overall, it was a worthwhile course 4.77#3 I would recommend this course to other residentswho have a teaching assignment 4.62225#11 The instructor was an effective teacher 4.62#7 The course content addressed my needs for myteaching role as a CTU resident 4.23Open ended questions asked residents to consider thefollowing:A. How did this series of seminars change yourapproach to teaching / learning on the CTU andteaching / learning in general?B. What was the most helpful aspect for this course?C. What was the least helpful aspect for this course?D. Suggestions for improvement.Transcribed responses are available as part of Appendix B.226227CHAPTER FIVE: DISCUSSION AND CONCLUSIONSIntroduction“Perhaps the most important single cause ofa person’s success or failure educationallyhas to do with the question of what hebelieves about himself.” Arthur Combsp. 307 (Pajares, 1992)Residents provide the majority of instruction for otherhousestaff (Bing-You & Harvey, 1991; Brown, 1970; Lowry,1976). Some have argued that no one is more available ormore qualified for this task (Steward & Feltovich, 1988), andthat the resident’s role is not redundant with that of faculty(Tremonti and Biddle, 1982). Most residents look forward toteaching responsibilities (Barrow, 1966; Bing-You &Sproul,1992). Unfortunately, that residents spend more time withstudents and are “closer” to their level does not necessarilymake them effective teachers. Residents are rated as lesseffective than faculty (Irby, 1978). Observation studies havefound that residents exhibit “few of the teaching behavioursthat can enhance learning in an inpatient care setting”(Wilkerson, Lesky, & Medio, 1986, p. 827), and that theyfrequently use an authoritarian lecture style in teaching (Lewis& Kappelman, 1984). Daily patient rounds are not often228intentionally used for teaching; when they are, it is usually inthe form of brief lectures (Medio, Wilkerson, Lesky, & Borkan,1988). Residents need to become aware and take advantage of“teachable moments” (Meleca & Pearsol, 1988).Residents generally have a positive attitude towards teaching(Apter, et al., 1988; Bing-You and Harvey, 1991). Despite theirinterest, and the fact that they have major teachingresponsibilities, evidence exists that residents do not receiveenough support or preparation for this role and that barriershinder optimal teaching (Anderson, Anderson, & Scholten,1990). Few programs provide residents with feedback on theirteaching, and 60% of residency program directors did notbelieve it was important for residents to receive formaltraining in teaching skills. Only 14% of residents in the abovestudy had attended workshops on teaching. This finding is inkeeping with the results of other studies (Brown, 1971; BingYou & Harvey, 1991; Callen & Roberts, 1980). Schiffman(1986) asks: “How then do house officers learn how to teach?The obvious answer is that the house officer has had twentyyears of observation of his or her own teachers upon which tomodel his or her style” (p. 55). This remains inadequate.This research study reports the development, implementation,and evaluation of a resident Teacher Education Program229(TEP), and examines its impact on internal medicine residents,more specifically, on residents’ (1) sense of teaching self-efficacy, (2) self reported teaching behaviours, (3) beliefsabout teaching, and (4) interest in teaching.The Resident TEP CurriculumThis dissertation describes, in detail, the content of a residentTEP successful in improving residents’ self-efficacy andteaching behaviours. The content addressed residents’specific needs as teachers on the CTU, as assessed by theresidents themselves. This dissertation should be helpful indefining future resident TEP curricula.According to Pratt (1992) conceptions of teaching are “adynamic and interdependent trilogy of Actions, Intentions,and Beliefs” (original emphasis) (p. 206). The reader hasbeen provided with an extensive review of the relevant adulteducation literature in chapter two. A detailed rationale forthe use of a constructivist paradigm in the development andimplementation of the resident TEP was given. Theimportance of reflection, situated learning, and self-efficacywas reviewed. The hope was to provide the reader with theepistemic beliefs and assumptions, as well as the intentions230that informed the strategies developed and used in theresident TEP.To begin with, the principles of andragogy were kept in mind(Knowles, 1980). These principles provided direction forsome of the practical considerations in organizing the course.By having the TEP coincide with residents’ CTU rotation (i.e.,while they have major teaching responsibilities), the programdealt with residents’ immediate interests and concerns; also,new knowledge was immediately applicable. Concepts andprinciples were stressed, rather than facts, and the programstressed the active participation of residents. Ample feedbackwas provided so that residents could evaluate their progress.Overall, residents were viewed as users rather than recipientsof education.More importantly, however, a constructivist epistemology wasat the root of the whole program. The maj or focus is onhaving residents make the transition to “thinking like ateacher.” The emphasis was on qualitative changes inunderstanding rather than the acquisition of knowledge, skills,and attitude (i.e., quantitative). Implicit in this qualitativechange is an appreciation for the starting point of the learner.This required a shift in assumptions about what it means to“know,” and to “learn,” and an analogous shift it the meaning231of teaching. From a constructivist perspective “teaching(focuses) on what can be changed in the learner’sunderstanding” (Ramsden, 1988b, p. 21). A “relational” viewof teaching was held during the development andimplementation of all aspects of the TEP: (1) learning isabout change in conception, (2) learning always has content aswell as process, (3) improving learning is about relationsbetween learners and subject matter, not teaching methodsand student characteristics, (4) improving learning is aboutunderstanding the student’s perspective, and (5) educationalresearch and teaching are more closely related than peoplesometimes believe (Ramsden, 1988b).Understanding students’ conceptions (and misconceptions) isthe best starting point of teaching from a constructivistperspective. Therefore, teaching involves two basic steps:probing understanding in order to map students’ thinking,and helping students develop new (or more appropriate)conceptions. Marton and Ramsden (1988) suggest severalteaching strategies for conceptual change learning: (1) makethe learners’ conceptions explicit to them, (2) focus on a fewcritical issues and show how they relate, (3) highlight theinconsistencies within and the consequences of learners’conceptions, (4) create situations where learners centreattention on relevant aspects, (5) present the learners with232new ways of seeing, (6) integrate the “knowing what” and“knowing how” of a subject, (7) test understanding ofphenomena; use the results for diagnostic assessment andcurriculum design, and (8) use reflective teaching strategies(italics mine).The absence of specific goals and objectives for the TEP is notan oversight and is in keeping with a constructivistepistemology. The broad goals of the program allowed forqualitatively and quantitatively different learning outcomesfor different residents; the main focus being on facilitatingresidents achievement of personal goals and objectives.Reflection also played an important role in the resident TEP.Duley (1981, cited in Boud, et al., 1985), emphasizes that, “theskill of experiential learning in which people tend to be themost deficient is reflection” (p. 611). Berliner (1987) suggeststhat the old aphorism that experience is the best teachershould be more accurately restated as, “experience that isreflected upon is a very good teacher” (p. 60). He reminds usthat although experience and expertise emanate from thesame root, they do not mean the same thing. Experience is anecessary, but not sufficient, condition leading to expertise.Reflection on experience may help translate practicalexperiences into learning and expertise. This is in keeping233with the idea of “reflection-on-action,” as proposed by Schon(1987). Further, Schon suggests that we should learn toreflect in the midst of action: “reflection-in-action.” Heargues that both these types of reflection, as part of a“reflective practicum,” enable professionals to learn to dealwith the indeterminate zones of practice- ambiguity,uncertainty, and value conflict. Having residents learn toreflect-on-action, and reflect-in-action was a maj or goal of theprogram, and stated as such. The idea was not only to usereflection as a learning tool during the TEP, but to haveresidents learn and adopt reflection as a metacognitive skillfor use in future learning and in all aspects of theirprofessional lives. Therefore, several opportunities werecreated, and the use of reflection was supported during theTEP.The idea of situated learning played an important role in theTEP. From this perspective, learning is viewed, not as theacquisition of knowledge transferred by instruction nor as theimitation of others, but as a form of social coparticipation(Lave and Wenger, 1991). The concern is with the types ofsocial opportunities that provide the optimal context forlearning, rather than with cognitive processes and conceptualstructures. “The individual learner is not gaining a discretebody of abstract knowledge which (s)he will then transport234and reapply in later contexts. Instead, (s)he acquires the skillto perform by actually engaging in the process, under theattenuated conditions of legitimate peripheral participation”(original emphasis) (p. 14). A resident TEP is a perfectopportunity for engaging residents in authentic activity andfacilitating movement from the periphery of practice towardsits centre, as residents develop increasing teaching skills andtake on more teaching responsibilities. Lave and Wenger(1991) maintain that learning and the development of a senseof identity are inseparable. “Moving towards full participationin practice involves not just greater commitment of time,intensified effort, more and broader responsibilities within thecommunity, and more difficult and risky tasks, but, moresignificantly, an increasing sense of identity as a masterpractitioner” (italics mine) (p. 111). This last idea is inkeeping with the development of self-efficacy through thecultivation of personal mastery experiences (Bandura, 1977).Most TEPs reviewed in chapter two did not take specificadvantage of residents’ current teaching assignments as alearning resource. One program (Snell, 1989) did mentionthat residents had “an opportunity to practice the (newlylearned teaching) skills on the wards during the weeksbetween sessions” (italics mine) (p. 125). Another program,consisting of two three-hour workshops, separated bothworkshops by 5 months so that “the experimental group had235an opportunity to apply these (teaching) skills in their dailyactivities” (italics mine) (p. 361). Unfortunately, withoutstructure and follow-up, students (including residents) do notalways take advantage of opportunities. None of the programsspecifically structured and included such learning activities.Although “reflection-on-action” and “reflection-in-action”were the main goals articulated to the residents, enhancedteaching self-efficacy was the major goal from the author’sperspective. The literature on the social / situated perspectiveof adult education demonstrates that knowing “what” does notnecessarily mean knowing “how” (e.g., Lave and Wenger,1991). Bandura’s work on self-efficacy takes this idea one stepfurther. Knowing “how” does not necessarily mean believingone “can” (and consequently “will”). Therefore, situatinglearning in authentic activity is not only important to providethe learner with knowledge and skills but to provide successfulexperiences (i.e., mastery experiences) and thereby, enhancingstudents’ self-efficacy. Self-efficacy “plays a central role in theexercise of personal agency by its strong impact on though,affect, motivation, and action” (Bandura, 1991, p. 248).Bandura (1977) postulates that individuals develop outcomeexpectations based on life experiences, and efficacy beliefsconcerning their ability to cope. Similarly, a two dimensionalmodel of teaching efficacy has been proposed (Ashton, 1984):236teaching efficacy (cf., outcome expectation) and teaching self-efficacy (cf., efficacy beliefs). “Teachers with a low sense ofefficacy doubt their ability to influence student learning;consequently, they tend to avoid activities they believe to bebeyond their capabilities. They reduce their efforts or give upentirely when confronted with difficulties” (Ashton and Webb,1986, p. 3).The resident TEP, therefore, went beyond simply helpingresident reconceptualize their role as teachers. The provisionof numerous exercises (e.g., role play), as well as the timing ofthe TEP while residents had teaching responsibilities, allowedresidents to cultivate the important personal masteryexperiences necessary to enhance perceived teaching self-efficacy.In keeping with Mezirow’s (1991) concern with “the disturbingfault line” that separates adult learning theories from practice,an attempt was made to synthesize the educational conceptsdiscussed above (i.e., constructivism, reflection, situatedlearning, and self-efficacy). The best example of the marriageof these concepts is reflected in the use of the case method,and “Tasks for the Week.”Perhaps what most distinguishes the resident TEP described in237this dissertation, from those reported in the literature, is thestrong theoretical grounding of the process (cf., content) andthe emphasis on non-behavioural objectives.Statement of ResultsInstrumentGiven the context specificity of beliefs (and beliefsubconstructs) an instrument was developed to specificallyaddress the needs of this study, and consisted of the followingfour sections (see appendix A):I. Teaching Scale (self-efficacy),II. Residents as Teachers - Opinion (beliefs about teaching),III. Teaching Skills (self-reported behaviours), andIV. Interest in Teaching.Sections I and III are scales, whereas, sections TI and IV aredescriptive. Both of the scales performed well during pilotingand faculty validating studies, and during subsequent use inthe research project. The results are in keeping with otherteaching efficacy scales reported in the literature (e.g., Gibsonand Dembo, 1984, and Enochs and Riggs,1990).238Chapter two reviewed the literature for construct validity ofself-efficacy and teaching self-efficacy. It was beyond thescope of this dissertation to repeat this work. However, asmall study was carried out to provide evidence of theinstrument’s validity. Faculty members’ scores on the self-efficacy subscales were correlated with scores on the self-reported teaching behaviour scale and data from studentratings of faculty teaching. As predicted by the twodimensional self-efficacy model, both self-reported teachingbehaviours and student ratings showed a far greatercorrelation to teaching self -efficacy than to teaching efficacy(i.e., 0.57 and 0.30, vs. 0.14 and -0.17 respectively). Teacherswith higher scores on the self-efficacy subscale had higherscores of teaching behaviours (as measured by self-report) andwere rated as more effective teachers by their students. Theagreement of student ratings is important given that itprovides an outside perspective on teacher effectiveness. Thehigher correlation seen with self-reported behaviour isconsistent with the fact that both the teaching self-efficacysubscale and the self-reported behaviour scale were of thesame type (i.e., pencil and paper self-reports).239Study Results and DiscussionResearch Questions1. What attitude do general internal medicine residents havetowards teaching(ie,se1ffficacy. beliefs about teaching,andinterest in teachingZClark (1988) noted that teachers’ beliefs “tend to be eclecticaggregations of cause-effect propositions from many sources,rules of thumb, generalizations drawn from personalexperience, beliefs, values, biases, and prejudices” (p. 5).Beliefs cannot be investigated directly but must be inferred.Inferential evidence comes from three main sources: (1)belief statements, (2) intentionality to behave in apredisposed manner, and (3) behaviour related to the belief inquestion (Rokeach, 1968 cited in Pajares, 1992). Theoperational definition of teaching attitude for this dissertationincluded teaching efficacy beliefs, opinions about teaching,and interest in teaching. These are reflected in sections I, II,and TV of the study instrument (i.e., Teaching Scale (selfefficacy), Residents as Teachers - Opinion (beliefs aboutteaching), and Interest in Teaching respectively).The word “attitude” has been used as a catch all in studies of240resident teaching. Attitude items have included a mixture ofperception, self reported behaviour, interest, and enjoyment.Residents, generally, have a positive “attitude” towards theirrole as teachers. The vast majority of residents enjoy teaching(89% of 68 respondents) (Apter, et al., 1988). In this study,enjoyment of teaching was positively associated with increasedpreparation time and perception of positive results ofteaching. Bing-You and Harvey (1991) were the first toaddress whether an association between a positive attitudetowards teaching and student evaluations of teaching exists.Unfortunately, no correlation was found between studentratings of residents as teachers and residents’ self-assessmentof teaching effectiveness. Of note, residents havingparticipated in a TEP were more confident as teachers, wererated more highly in actively involving students and inproviding direction and feedback, and were also moreconfident as teachers.Results (i.e., answer to Question 1)Baseline data (i.e., pre-) for both the control (n=8) andtreatment (n=1 1) groups were used to define the teachingattitude of the general internal medicine residents at ourinstitution.241I. Teaching scale (self-efficacy).General internal medicine residents had a positive outcomeexpectancy for teaching (i.e., they believed teaching makes adifference) as demonstrated by the high scores on theteaching efficacy subscale (4.0 and 3.8). However, theirefficacy beliefs concerning their own abilities as teachers wasnot rated as highly, as demonstrated by the lower scores onthe teaching self-efficacy subscale (3.5 and 3.4).Bandura (1977) postulates that individuals develop outcomeexpectations based on life experiences, and efficacy beliefsconcerning their ability to cope. That is, outcome and efficacyare separate components of efficacy expectations. First,individuals must believe that the specified action will lead tothe desired outcome (i.e., outcome expectation). Second, theymust believe themselves capable of the specified action (i.e.,self-efficacy belief). The expectations of personal mastery areimportant for initiating a behaviour, and for perseverance inthe face of difficulties. Lack of expectations of personalefficacy play an important role in avoidance behaviour.The discrepancy between scores on the teaching efficacy andteaching self-efficacy subscales, as well as the relatively lowscores on the teaching self-efficacy subscale, suggest that self-242efficacy could play an important role as a goal for residentTEPs. The author agrees with Ashton and Webb (1986) that“the promotion of a high sense of efficacy in teachers andstudents must become an educational aim as important asacademic achievement” (p. 176).II. Residents as teachers - opinion (beliefs aboutteaching).Overall, residents had a “positive” attitude towards teaching asdemonstrated by the results in chapter 4. They sawthemselves as playing an important role in teaching students(4.25 & 4.18), and as role models (4.25 & 4.18). They alsoappreciated the function that teaching has for their ownlearning (4.25 & 4.27). It is surprising, therefore, to discovertheir more neutral view of teaching as a responsibility (3.38 &3.45).There was general agreement among residents that lectureswere not an effective means of teaching clinical medicine (2.13& 2.0). Despite this, elements of a transmission model forteaching and learning persists as evidenced by responses toquestion #5: Providing Students With Information On MyExperience And My Readings Is The Most Effective Way To243Teach (3.50 & 3.55). This is also apparent with the frustrationresidents feel regarding the adequacy of their own knowledgebase as teachers (3.63 & 3.64).It is likely that residents create an atmosphere conducive tolearning given their concern for student enjoyment in thelearning process (4.50 & 4.64) and the role they see forthemselves as motivators (4.25 & 4.09).Residents seem to be struggling with their concept of theappropriate role for MSI5. There is no strong agreement as towhether they should be treated as students (2.63 & 2.91) or asphysicians (3.75 & 3.09). This struggle for a clear concept ofan MSI’s role is further evidenced by the ambivalenceresidents feel in delegating responsibilities to MSIs and theresponsibility they feel for MSIs’ mistakes (3.00 & 2.82).Ambivalence also exists in the worry that MSI5’ poorperformance may reflect on them (2.38 & 3.00).Time pressures are prominent in residents’ minds and they donot agree that there is enough time in the day for effectiveteaching given competing demands (2.00 & 3.00; 3.63 &3.09).244IV. Interest in teaching.None of the 19 residents in the study had prior teachereducation experience. However, resident interest in teachingis apparent by their interest in participating in a workshop /seminar (4.25 & 4.18). They would also like to do moreteaching if they had more time (4.25 & 3.91).Despite this ostensible interest in teaching, residents did notfeel that they put more effort into their teaching than theirpeers (2.88 & 2.82), nor did they routinely ask students forfeedback on their teaching (3.00 & 2.73).Overall, it seems that residents are interested in teaching.Competing demands and other factors may frustrate residents’good intentions. Further inquiry into the institutional barriersthat prevent residents from acting on their interest in teachingmay provide avenues outside the usual realm of TEP5 toenhance residents roles as teachers.2. What is the effect of a CTU rotation and associated teachingresponsibilities on residents’ sense of teaching self-efficacy.self-reported teaching behaviours, beliefs about teaching÷andintPrst. in teach ing?245Of interest, none of the studies reported in chapter two werespecifically designed to measure the impact of a teachingresponsibility itself on outcome measures. This is one of theresearch questions addressed by this dissertation. Thisquestion is important for at least two reasons. First, one needsto understand the role of a teaching experience on residents’development as teachers (i.e., attitude and behaviours). Doesthe provision of an opportunity to develop teaching skillsnecessarily lead to this outcome. And if it did, what would therole of resident TEP5 be (if any). Second, given that we do notknow the effects of a teaching experience on residents’attitude and behaviours, it would be difficult to sort out theresult of the treatment (i.e., participation in the TEP) fromsimply having a teaching assignment given that both occurredconcurrently. Therefore, the control group in this study hastwo functions. Participants in the control group have notparticipated in the resident TEP and thus, serve as controls forthose who did (i.e., treatment group). In addition, pre- andpost- measurement of study parameters for the control groupgive insight into the effects of a teaching assignment onresident teaching attitude and behaviours.246Rsu1ts (i.e., answer to Question 2)I. Teaching scale (self-efficacy).The CTU rotation and the associated teaching assignment hadno effect on residents’ outcome expectancy beliefs aboutteaching which were already positive (4.0). That is to say,residents already believe that teaching makes a difference, andthat the CTU / teaching experience had no effect on this belief.The CTU / teaching experience had a modest, but statisticallysignificant, effect on residents’ teaching self-efficacy beliefs. Itis difficult to quantify the increase in teaching self-efficacy.Pre- and post- raw scores tell us little given that they aredependent on the number of questions. The difference of themean on the 5 point Likert scale is likely more meaningful, ifstill an imperfect measure. First, this method is not dependenton the number of questions. Second, the “anchors” (i.e.,1 =strongly disagree, 2 =disagree, 3 =neutral, 4=agree, and5=strongly agree) give meaning to movement on the scale.The mean self-efficacy score increased from 3.5 to 3.7 for anincrease of 0.2 on a 5 point scale (p=0.029).Sources or efficacy expectations come from four sources: (1)247performance accomplishments, (2) vicarious experience, (3)verbal persuasion, and (4) emotional arousal (Bandura, 1986).Performance accomplishments “provide the most influentialsource of efficacy information because it is based on authenticmastery experiences” (italics mine) (Bandura, Adams, andBeyer, 1977, cited in Bandura, 1986, p. 399). Teachingresponsibilities during the CTU rotation provided residentswith authentic experiences. Such successful experiences (i.e.,mastery) may be responsible for the increased self-efficacyreported by residents at the end of the CTU rotation.II. Residents as teachers - opinion (beliefs aboutteaching).As mentioned in the discussion of the first research question,resident’s beliefs about teaching were generally positive. It isnot surprising that a simple CTU / teaching assignment hadlittle effect on residents’ beliefs. A significant pre- and postdifference was found for only 1 of 15 questions. Therefore,residents beliefs, as assessed by section II of the studyinstrument, were essentially unchanged by the teachingassignment associated with the CTU rotation.248III. Teaching skills (self-reported behaviours).The CTU rotation and the associated teaching assignment hadno effect on residents’ teaching behaviours (as assessed byself-report). Therefore, a teaching assignment, in and of itself,is not sufficient to bring about change in residents’ teachingbehaviours. Perhaps this statement could be more correctlyworded by stating that there was no perception of change inresidents’ teaching behaviours as assessed by the residentsthemselves.IV. Interest in teaching.No significant pre- and post- differences were found for the 5items in this section of the instrument. Therefore, the CTU /teaching experience had no effect on residents’ interest inteaching.3. What is the impactof a TEl? on residents’ sense of teachingself-efficacy, self-reported teaching behaviours, beliefs aboutteaching, and interest in teaching?All but one of the studies designed to investigate the impact of249resident TEPs demonstrated a positive effect (i.e., Brown,1971). Knowledge was not an important outcomes measure inthe studies reviewed (Brown (1971), and Edwards, et al.,(1986). Improving teaching behaviours has been the mainfocus of most studies assessing outcomes. Improvements inself-concept and self-reported behaviours were demonstratedin four studies (Bing-You & Greenberg, 1990; Edwards, et al.,1986; Edwards, et al., 1988; Snell, 1989). Although theconstruct of self-efficacy has not specifically been used as anoutcomes measure, self-reported “self-confidence” has (BingYou & Greenberg, 1990; Snell, 1989). Interestingly, thosestudies assessing changes in self-confidence did not seek todemonstrate an association with changes in teachingbehaviours. Further, the impact of a teaching assignmentitself (i.e., experience) on self-confidence has not beenexplicitly addressed. All three of these issues were specificallyaddressed in the study described in this dissertation.The most interesting and best designed of the studies lookingat self-confidence has been reported three times (Greenberg,et al., 1984; Greenberg, et al., 1988; Jewett, et al., 1982). Theinvestigators used a pre-test / post-test control design to studythe impact of the workshops (controls=27; treatment=26).Residents participating in the TEP showed improvedconfidence as compared to controls. Unfortunately, no250attempt was made to demonstrate an association of change inattitude with a change in behaviour (as does this dissertation).The authors report that “a number of significant correlationswere found between the confidence of residents in bothgroups (experimental and control) as teachers and theirperceptions of teaching as a responsibility” (p. 362). Ofinterest, many of the items in Greenberg, Goldberg, andJewett’s (1984) instrument assessing residents’ perception ofteaching responsibility could arguably be said to assess thevarious dimensions of teaching self-efficacy as described byAshton (1984). It is not surprising, therefore, to find so manycorrelations between “confidence as a teacher” andperceptions of teaching as a responsibility. Most of the itemsin the perceptions of teaching as a responsibility simply tapthe various dimensions of teaching self-efficacy. Furthersupport for this argument comes from the fact that many ofthe items from this instrument (Greenberg, et al., 1984) wereincorporated into this dissertation’s self-efficacy subscales,where good internal consistency reliability was found (seechapter 4).Bing-You and Harvey (1991) studied the relationship betweenresidents’ attitude (as measured by a questionnaire) andstudent ratings of the residents’ teaching skills. The authorscomment that they have included two questions “to measure a251teacher’s sense of self-efficacy-defined by Ashton (1984)” (p.96). Interestingly, several other items from their questionnairecould be interpreted as measuring self-efficacy. No attemptwas made to group these items into a “self-efficacy scale.”Lawson and Harvill (1980) comment that most residents haveno prior training in teaching skills, and that many areunconvinced of the benefits of taking part in a resident TEP.They argue that, “changing such negative attitude should be aprimary goal of a teaching skills program” (p. 1004). Using anend of program questionnaire, the authors demonstrated apositive effect on residents’ “attitude toward participating in ateaching skills program” (p. 1002).Results (i.e., answer to Question 3)This was the major research question of this dissertation. Asmentioned previously, there was no difference between thecontrol and treatment groups at baseline. The answer toquestion 2. above provides the results of the control group(i.e., pre- / post- differences at the beginning and end of aCTU rotation with a teaching assignment but WITHOUT thestudy intervention - participation in the resident TEP).252I. Teaching scale (self-efficacy).The resident TEP had no effect on residents’ outcomeexpectancy beliefs about teaching which were already positive(3.8). That is to say, residents already believe that teachingmakes a difference, and that the resident TEP had no effect onthis belief.Residents participating in the TEP had a statistically significantimprovement in teaching self-efficacy scores (from 3.4 to 3.8,for a gain of 0.4 on a 5 point scale; p=0.0l2). This representstwice the improvement experienced by the control group (0.4vs. 0.2).Multivariate analysis found no between group difference atbaseline. The pre- vs. post- difference was significant(p=0.002). However, the treatment vs. control difference didnot achieve statistical significance (p=0.273), although therewas a trend in this direction. It is interesting to note thatthere was no difference between the control and treatmentgroups at baseline as assessed by both t-test and MANOVA.Further, the pre- / post- difference was significant for both thecontrol and treatment group as assessed by t-test. However,the MANOVA did not reveal a control vs. treatment difference.This may be due to the small number of individuals in both253groups (i.e, control=8; treatment=11). A larger sample sizewould be needed to show a difference.II. Residents as teachers - opinion (beliefs aboutteaching).As mentioned in the discussion of the first research question,residents’ beliefs about teaching were generally positive.Further, the CTU / teaching experience itself had little effecton the control group as evidenced by the significant pre- andpost- difference for only 1 of 15 questions. In contrast, asignificant pre- and post- difference was found for 5 of 15questions for the treatment group. These results areremarkable, not only because of the number of items showingimprovement (i.e., one third of total items) or the relativeimprovement vs. the control group (i.e., five-fold difference innumber of items), but because of the significant positive skewat baseline for some of the items.It would seem that residents participating in the TEP seethemselves as playing an even more important role asteachers. The initial ambivalence towards the MSIs’ role seemsto have been resolved. MSIs are now viewed more as juniorphysicians rather than students. There is evidence that254residents are moving away from a transmission model forteaching and learning, and that they have a greaterappreciation for their responsibilities as role models.III. Teaching skills (self-reported behaviours).Residents participating in the TEP had a large and statisticallysignificant improvement in self-reported teaching behavioursscores (from 3.3 to 4.0, for a mean increase of 0.7 on a 5 pointscale; p=0.002). In contrast, no significantpre- / post- difference was found for the control group.Using a “retro” vs. post comparison (see Chapter four forrationale), the magnitude of improvement was even greater(i.e., 0.9; p=0.001).Multivariate analysis found no between group difference atbaseline. Both pre- vs. post-, and control vs. treatmentdifferences achieved statistical significance (i.e., p = 0.001 and0.025 respectively).255N. Interest in teaching.A significant pre- and post- difference was found for 2 of 4questions for the treatment group. In contrast, no significantpre- and post- differences were found for the control group.Therefore, residents participating in the TEP showed evidenceof increased interest in teaching despite the already positiveskew of baseline results. Their interest in teaching is manifestby an increased request for student feedback of their teachingand the belief that they put more effort into teaching thantheir peers.4. Is. a change in self-efficacyLe, attitude subconstruct)associated with a change in self-reported teaching behaviours?The changes in teaching efficacy and teaching self-efficacy(i.e., change = post - pre-) were correlated with the change inself-reported teaching behaviours. Data from all subjects (i.e.,treatment and control) was used to calculate a Pearson’scorrelation coefficient.A correlation coefficient of 0.21 was found for the associatedchanges between teaching efficacy and self-reported teachingbehaviours. A correlation coefficient of 0.66 was found for the256associated changes between teaching self-efficacy and self-reported teaching behaviours. Therefore, a change in teachingefficacy beliefs was moderately correlated with a change inself-reported teaching behaviours. However, a moreimpressive correlation was found between a change inteaching self -efficacy beliefs and a change in self-reportedteaching behaviours. Interestingly, these numbers are similarto those found during the instrument validation study withfaculty (i.e., 0.14 and 0.57 respectively).The results are in keeping with the two dimensional model ofteaching efficacy. Positive outcome expectations (i.e., teachingefficacy) are a necessary but not sufficient prerequisite;residents must believe that teaching makes a difference instudent outcome. But more importantly, they must believethat they themselves are able to bring about this change (i.e.,teaching self -efficacy).Teaching self-efficacy is, therefore, an important marker foreffective teaching behaviours. If Bandura (1977) is correct,and efficacy beliefs are prior to and causal for behaviours,teaching self-efficacy should be considered an important partof any TEP. According to Bandura (Bandura, 1986, cited inPaj ares, 1992) “people regulate their level and distribution ofeffort in accordance with the effects they expect their actions257to have. As a result, their behaviour is better predicted fromtheir beliefs than from the actual consequences of theiractions” (p. 324).Pmgram EvaluationAttendance was over 90% for the first four sessions anddropped to 62% and 85% for the last two sessions. Residentsthought that the topics were helpful for their teaching role (>4.0) except for session #6, Small Group Teaching, where it was3.73. Upon further discussion with the residents, this sectionof the course was dropped for the last two groups. Overall,residents were satisfied with the course as a whole, with itscontent, and with the method of instruction; mean scores onall satisfaction items were above 4.0 on a 5 point Likert scale(or below 2 for negatively worded items). Responses to openended questions were also encouraging. A copy of theprogram evaluation instrument, and detailed results andanalysis of the program evaluation are available inAppendix B.258Limitations of the StudyLike many other educational research studies, the studyreported is limited by a number of practical considerationsthat make “true” experimentation difficult. It would havebeen impossible to use a randomized controlled design,therefore, a quasi-experimental design was used; assignmentto each group was based on the preexisting CTU rotationschedule. No significant differences were found between thecontrol and treatment groups at baseline for any of theoutcome measures. The study is further limited by the smallsample size for each group (i.e., control=8, treatment=11).Despite this, many of the results achieved statisticalsignificance. The larger size of the treatment group mayaccount for the higher number of significant results in thisgroup.Although the possibility that the positive results for thecontrol group may be due to the “Hawthorne effect” (i.e., anon-specific effect of the intervention due to attention paid tothe participants) exists, this effect was, at least partly,controlled by the involvement of the control group. Thecontrol subjects responded to the same pre- and postquestionnaire that the treatment group did. Further, the“control” subjects were part of another study used to259determine the appropriate content for a resident TEP (i.e.,needs assessment)- the results of which are reportedelsewhere (Arseneau, 1993). The control subjects werefollowed by the investigator during work rounds as part of aparticipant observation study. Afterwards, they wereinterviewed regarding their beliefs about teaching on theCTUs.The results of the reported study are very context specific andclaims of result generalizability should be made with caution.The residents at our institution may not be representative ofthose found at other institutions in terms of interest inteaching, beliefs, or prior experience. Further, their beliefsmay be part of the wider “culture” found at our hospital.Recommendations for Further ResearchThe findings of this dissertation are consistent with those ofother investigators in that beliefs about teaching were stronglyassociated with teaching behaviours (see Pajares, 1992 forreview). What remains to be shown, however, is a strong linkbetween beliefs about teaching and student learning andachievement. As it stands, teaching beliefs are, at best, anincomplete and inconsistent set of predictors for teaching260behaviours. And teaching behaviours remain “surrogatemarkers” for the real objects of interest: student learning andachievement.The tendency to use easy to measure belief subconstructs sucha self-efficacy in educational research necessarily gives anincomplete picture of teachers’ “belief systems.” It negates theimportant relationships and interactions among beliefsubconstructs. It is unlikely that quantitative methods bythemselves can provide all (or even most) of the answers. Notall belief subconstructs lend themselves well to measurementand scaling, as is demonstrated by this dissertation.Furthermore, there are finite limits to quantitative findingsabout beliefs; it is impossible for teachers to define their beliefsystem with any degree of accuracy within the confines ofspecific research questions and questionnaire items.Qualitative methods will be needed to complementquantitative research if new insights are to be gained.The timing of the post measurement used for this study (i.e.,immediately at the end of the CTU rotation) leaves thequestion of the long term impact of the resident TEPunanswered. Although the results of this study demonstratethe success of a resident TEP based on “attitudinal” objectives,no comment can be made regarding the relative merits of a261program based on behavioural objectives, or whether acombination of attitudinal and behavioural objectives wouldbe optimal. 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Salt Lake City: University ofUtah School of Medicine.Wilkerson, L., Lesky, L., & Medio, F. J. (1986). The Resident AsTeacher During Work Rounds. Journal of MedicalEducation, ftl, 823-829.Wilson, A. L. (1993). The Promise of Situated Cognition. In S. B.Merriam (Ed.), An Update on Adult Learning Theory (pp.7 1-80). San Francisco: Jossey-Bass Publishers.286Wipf, J. E. (1992). The Role of The Senior Resident: TeamManager, Leader, and Teacher. Unpublished manuscript,University of Washington, Seattle, WA.287APPENDIX ASTUDY INSTRUMENTSPilot Instrument 289Study Instrument 295Study Instrument- “Retro 301Note: All instruments have been printed at 75% theoriginal size to allow binding.288289Resident Teaching Instrument - Pilot TestingThank you for helping us pilot this instrument to measure resident teaching attitudes.Many of the questions may appear to be asking the same thing. This is because we haveincluded similar items for piloting the instrument so that we can assess which items giveus the most information. Try and answer the questions without looking back at previousresponses.Thanks for your helpDemographic data:1. Level of training Ri (intern)R2R3R4FacultyOther (specify)2. Specialty290Resident Teaching Instrument - Piiot TestingI A. Teaching Scale Strongly Disagree Neutral Agree StronglyDisagree Agree1. If teachers have adequate skifis they can get1 2 3 4 5through to even the most difficult students2. Teachers contribute significantly to student 1 2 3 4 5learning3. The amount that a student can learn is primarily i 2 3 4 5related to their degree of intelligence4. A student’s poor previous academic performance 1 2 3 4 5can be overcome by good teaching5. Even a teacher with excellent teaching skills cannot 1 2 3 4 5reach all students6. The work teachers do with students is important 1 2 3 4and meaningful7. When a student gets a better grade than usual, it is 1 2 3 4 5because the teacher found a better way of teaching thatstudent8. When a student does poorly it can usually be 1 2 3 4 5explained in terms of their academic abifity, motivation,or attitude9. When a “borderline” student makes significant 1 2 3 4 5achievement, it is because the teacher had a chance togive them extra attention10. If a student masters a new medical concept 1 2 3 4 5quickly, it is because the teacher knew the steps inteaching that concept11. When all factors are considered, teachers are not 1 2 3 4 5an important influence on student achievement12. The amount of time teachers spend with students 1 2 3 4has little influence on student achievement whencompared to their previous medical education13. Students learn because of the experience they get 1 2 3 4 son the wards rather than the specific teaching skills ofpage 1291Strongly Disagree Neutral Agree StronglyDisagree AgreeI B. Personal Teaching Scale1. I feel confident as a teacher 1 2 3 4 52. I look forward to rotations with teaching 1 2 3 4 5responsibilities3. When a student does better than usual, it is 1 2 3 4 5because I exerted a little extra effort4. When compared with their previous medicaleducation, the amount of time I spend teaching 1 2 3 4 5students has little influence on their achievement5. When I really try I can get through to the most 1 2 3 4 5difficult student6. I do not feel responsible if a student fails 1 2 3 4 57. I have the skifis to be an effective teacher 1 2 3 4 58. I significantly contribute to student learning 1 2 3 4 59. I am sometimes anxious anticipating questionsstudents ask, for fear of a lack of knowledge on my 1 2 3 4 5part10. Students learn because of the experience they get 1 2 3 4 5on the wards rather than my specific teaching skills11. I expect my students to do better than average, 1 2 3 4 5and they do12. If a student masters a new medical conceptquickly, it is because I knew the necessary steps in 1 2 3 4 5teaching that concept13. Teaching students is good for my self esteem 1 2 3 4 514. My students do no better than their peers 1 2 3 4 515. It is my responsibifity to see that students learnwhile they are working with me 1 2 3 4 516. If a student isn’t doing well, I examine my 1 2 3 4 5methods to see how I can improve things17. When a student gets a better grade than usual, it is 1 2 3 4 5page 2292Strongly Disagree Neutral Agree StronglyDisagree Agree18. If a student forgot something that I taught them 1 2 3 4 5before, I would attempt a different strategy to improveretention-19. If a student is having difficulty with a patient 1 2 3 4 5problem, I can assess if the patient problem is at thecorrect level for the student20. Medical students know what I expect of them 1 2 3 4 521. My teaching is well organized 1 2 3 4 522. I often think of new ways of presenting material 1 2 3 4 523. When teaching on the wards, I don’t use any 1 2 3 4 Sspecific strategies24. I enjoy working with students and teaching 1 2 3 4 525. Given the choice I would prefer not working with 1 2 3 4 5studentsII. Residents as Teachers - Opinion1. Teaching is a primary responsibifity of residents 1 2 3 4 52. Residents play an important role in teaching 1 2 3 4 5students3. Teaching students helps me be a better clinician 1 2 3 4 s4. Lectures are the best way to teach clinical medicine1 2 3 45. Providing students with information on myexperience and my readings is the most effective way 1 2 3 4 5to teach6. There is enough time in the day to effectively teach 1 2 3 4 5students7. It is important that my students enjoy themselves 1 2 3 4 5while working with me8. It is my role to keep students motivated and 1 2 3 4 5interestedpage 3293Strongly Disagree Neutral Agree StronglyDisagree Agree9. MSI’s (clinical clerks) are primarily physicians andshould be treated as such (i.e., given the same 1 2 3 4 5responsibffities as physicians)10. I feel frustrated teaching students because I may 1 2 3 4 5not know ail the facts11. I worry that MSI’s poor performance wifi reflect on 1 2 3 4me12. Given the day to day demands of ward work, there 1 2 3 4is no time left over to effectively teach medical students13. MSI’s are primarily students and care must be1 2 3 4 5taken not to give them too much responsibifity14. I have difficulty giving MSI’s too many patient careresponsibifities because I am ultimately responsible for 1 2 3 4 5their mistakesIII. Teaching Skills1. Residents are important role models for medical 1 2 3 4 5students2. I set specific learning goals for my students 1 2 3 4 53. I know the difference between feedback and 1 2 3 4 5evaluation4. I routinely use feedback in student teaching 1 2 3 4 55. I routinely use evaluate students as part of my 1 2 3 4 5teaching6. I have an organized approach to teaching problem i 2 3 4 5solving strategies7. I am aware of which behaviors can inhibit student 1 2 3 4 5learning and take specific steps to avoid them8. I foster self directed learning about patients in my 1 2 3 4 5students9. I understand the principles of small group i 2 3 4 5dynamics during teaching10. I apply the principles of small group dynamics 1 2 3 4 5when teaching small groups of studentspage 4294Strongly Disagree Neutral Agree StronglyDisagree Agree11. I am familiar with the principles of “one-on-one”1 2 3 4teaching and use these principles when working withindividual students12. I know how to use questioning to bring about 1 2 3 4 5effective student learning13. I routinely confirm and review medical students 1 2 3 4 5physical findings at the bedside14. I often demonstrate skills in the proper techniques i 2 3 4 5of physical examination15. I provide an atmosphere that is conducive to 1 2 3 4 5learning16 I often refer students to the medical literature 1 2 3 4 517. At the bedside, I provide a model of appropriate1 2 3 4interactions with patients for the studentIV. Interest in Teaching1. I routinely ask students for feedback on my 1 2 3 4 5teaching effectiveness2. Overall, I put more effort into teaching than most 1 2 3 4 5of my peers3. I have had previous “teacher training”TIPS course (Yes/No)Other (specify)4. If time situations were ideal, I would prefer to 1 2 3 4 5spend more time teaching5. I would be interested in attending a workshop / 1 2 3 4 5seminars on teachingTHANKS FOR YOUR HELP!!Ric Arseneau, MD, FRCPCDirector of Undergraduate Teaching (Medicine),St. Paul’s Hospital, IJ.D.C.page 5295Resident Teaching QuestionnaireChief Investigator: Ric Arseneau, MD, FRCPC 682-2344Faculty Advisor: Kip Anastasiou, PhD 822-5316The purpose of this questionnaire is to collect data on Residents’ beliefs regardingteaching and their teaching behaviors. The data is part of a “needs assessment” that willhelp us determine the most useful content for the upcoming workshops on “Residentteacher training.”Although your participation would be greatly appreciated, you can refuse to participate atany time without any consequences.The questionnaire takes about 10 minutes to complete, and consent will be assumed to begiven if the questionnaires is completed.This document is confidential; do not write your name on it. Although the date andthe ward are recorded, this is only used to match pre and post questionnaires forstatistical evaluation. After the documents are matched, this cover sheet will be removedand destroyed.Thank your for agreeing to participate!Today’s Date:________________Ward (circle one) A B C DLevel of trainingR2R3R4Other (specify)296I. Teaching Scale1. I significantly contribute to student learning2. Students learn because of the experience they get onthe wards rather than my specific teaching skills3. I look forward to rotations with teachingresponsibilities4. If teachers have adequate skills they can get throughto even the most difficult students5. The work teachers do with students is important andmeaningful6. I enjoy working with students and teaching7. I do not feel responsible if a student fails8. I often think of new ways of presenting material9. Teaching students is good for my self esteem10. Teachers contribute significantly to student learning11. When a “borderline” student makes significantachievement, it is because the teacher had a chance togive them extra attention12. I feel confident as a teacher13. My teaching is well organized14. If a student isn’t doing well, I examine my methodsto see how I can improve things15. I have the skills to be an effective teacher16. When all factors are considered, teachers are not animportant influence on student achievementResident Teaching QuestionnaireStrongly Disagree Neutral Agree StronglyDisagree Agree1 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 41 2 3 41 2 3 41 2 3 41 2 3 455555page 1297Strongly Disagree Neutral Agree StronglyDisagree Agree17. If a student masters a new medical concept quickly,it is because the teacher knew the steps in teaching that 1 2 3 4 5concept18. It is my responsibility to see that students learn i 2 3 4 5while they are working with meII. Residents as Teachers-Opinion1. Teaching is a primary responsibility of residents 1 2 3 4 52. Residents play an important role in teaching 1 2 3 4 5students3. Teaching students helps me be a better clinician 1 2 3 4 54. Lectures are the best way to teach clinical medicine 1 2 3 4 55. Providing students with information on myexperience and my readings is the most effective way to1 2 3 4teach6. There is enough time in the day to effectively teach 1 2 3 4 5students7. It is important that my students enjoy themselves 1 2 3 4 5while working with me8. It is my role to keep students motivated and 1 2 3 4 5interested9. MSI’s (clinical clerks) are primarily physicians and4 5should be treated as such (i.e., given the same 1 2 3responsibilities as physicians)10. I feel frustrated teaching students because I may not 1 2 3 4know all the facts11. I worry that MSI’s poor performance will reflect on 1 2 3 4 5me12. Given the day to day demands of ward work, there 1 2 3 4 5is no time left over to effectively teach medical studentspage 2298Strongly Disagree Neutral Agree StronglyDisagree Agree13. MSI’s are primarily students and care must be takennot to give them too much responsibility 1 2 3 4 514. I have difficulty giving MSI’s too many patient careresponsibilities because I am ultimately responsible fortheir mistakes 1 2 3 4 515. Residents are important role models for medical1 2 3 4 5studentsIII. Teaching Skills1. I set specific learning goals for my students 1 2 3 4 52 I know the difference between feedback and 1 2 3 4 5evaluation3. I routinely use feedback in student teaching 1 2 3 4 54. I routinely use evaluation students as part of my 1 2 3 4 5teaching5. I have an organized approach to teaching problem 1 2 3 4solving strategies6. I am aware of which behaviors can inhibit studentlearning and take specific steps to avoid them 1 2 3 4 57. I foster self directed learning about patients in my 1 2 3 4 5students8. I understand the principles of small group dynamics 1 2 3 4 sduring teaching9. I apply the principles of small group dynamics when 1 2 3 4 5teaching small groups of students10. I am familiar with the principles of “one-on-one”teaching and use these principles when working with 1 2 3 4 5individual students11. I know how to use questioning to bring abouteffective student learning 1 2 3 4 5page 312. I routinely confirm and review medical studentsphysical findings at the bedside13. I often demonstrate skills in the proper techniques ofphysical examination14. I provide an atmosphere that is conducive tolearning15 I often refer students to the medical literature16. At the bedside, I provide a model of appropriateinteractions with patients for the studentIV. Interest in Teaching1. I routinely ask students for feedback on my teachingeffectiveness2. Overall, I put more effort into teaching than most ofmy peers3. I have had previous “teacher training”TIPS course Yes Noother (specify)4. If time situations were ideal, I would prefer to spend 1 2 3 4more time teaching5. I would be interested in attending a workshop Iseminars on teaching 1 2 3 4 5THANKS FOR YOUR TIME 11Ric Arseneau, MD, FRCPCDirector of Undergraduate Teaching (Medicine),St Paul’s Hospital, U.B.C.299Strongly Disagree Neutral Agree StronglyDisagree Agree1 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 5page 4300301Resident Teaching Questionnaire . Post I RetroChief Investigator: Ric Arseneau, MD, FRCPC 682-2344Faculty Advisor: Kip Anastasiou, PhD 822-5316The purpose of this questionnaire is to collect data on Residents’ beliefs regardingteaching and their teaching behaviors. The data is part of a “needs assessment” that willhelp us determine the most useful content for the upcoming workshops on “Residentteacher training.”Although your participation would be greatly appreciated, you can refuse to participate atany time without any consequences.The questionnaire takes about 10 minutes to complete, and consent will be assumed to begiven if the questionnaires is completed.This document is confidential; do not write your name on it. Although the date andthe ward are recorded, this is only used to match pre and post questionnaires forstatistical evaluation. After the documents are matched, this cover sheet will be removedand destroyed.Thank your for agreeing to participate!Today’s Date:_________________Ward (circle one) A B C DLevel of trainingR2P3R4Other (specify)302Resident Teaching InstrumentI. Teaching Scale1. I significantly contribute to student learning2. Students learn because of the experience they get onthe wards rather than my specific teaching skills3. I look forward to rotations with teachingresponsibffities4. If teachers have adequate skifis they can get throughto even the most difficult students5. The work teachers do with students is important andmeaningful6. I enjoy working with students and teaching7. I do not feel responsible if a student fails8. I often think of new ways of presenting material9. Teaching students is good for my self esteem10. Teachers contribute significantly to student learning11. When a “borderline” student makes significantachievement, it is because the teacher had a chance togive them extra attention12. I feel confident as a teacher13. My teaching is well organized14. If a student isn’t doing well, I examine my methodsto see how I can improve things15. I have the skifis to be an effective teacher16. When all factors are considered, teachers are not animportant influence on student achievementStrongly Disagree Neutral Agree StronglyDisagree Agree1 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 51 2 3 4 5page 1303Strongly Disagree Neutral Agree StronglyDisagree Agree17. If a student masters a new medical concept quickly, 1 2 3 4 5it is because the teacher knew the steps in teachingthat concept18. It is my responsibffity to see that students learn while 1 2 3 4 5they are working with meIL Residents as Teachers - Opinhin1. Teaching is a primary responsibility of residents 1 2 3 4 52. Residents play an important role in teaching 1 2 3 4 5students3. Teaching students helps me be a better clinician 1 2 3 4 54. Lectures are the best way to teach clinical medicine 1 2 3 4 55. Providing students with information on my 1 2 3 4 5experience and my readings is the most effective wayto teach6. There is enough time in the day to effectively teach 1 2 3 4 5students7. It is important that my students enjoy themselves 1 2 3 4 5while working with me8. It is my role to keep students motivated and 1 2 3 4 5interested9. MSI’s (clinical clerks) are primarily physicians and 1 2 3 4 5should be treated as such (i.e., given the sameresponsibilities as physicians)10. I feel frustrated teaching students because I may 1 2 3 4 5not know all the facts11. I worry that MSI’s poor performance wifi reflect on 1 2 3 4 5me12. Given the day to day demands of ward work, there 1 2 3 4 5is no time left over to effectively teach medical students13. MSI’s are primarily students and care must be 1 2 3 4 5taken not to give them too much responsibility14. 1 have difficulty giving MSI’s too many patient care 1 2 3 4 5responsibffities because I am ultimately responsible fortheir mistakes15. Residents are important role models for medical 1 2 3 4 5studentspage 2NN--.-r————CD—CD’‘%‘-a’CQCtDôEc——;qCDCDC0—-<‘<‘<CDCDCDCCDzCDg’a‘.‘a’a’ (D‘a’a’a’a’———————ckzç,)tc)ç.,.4...l.C’,uiVIViViViViVi‘I a C”C91cl—c—CDCD0•..0OCD0—-CDrCDCDci—.CD0 . 0 0-—0 q0D0- CD0 00UiU]LI’-)------.J1U1.I--,-CD,-,-0CD0P‘g•aI;d-CDCD0-•‘0(DO“!.hH—0-j00çjCDCD2CDCDjCDCDIH1---I If00(DCD0_E0000o00-0-0(-•,.0.CDCDg0..00.CDCD‘- 0——————————zC3c)UU)U)U)U)U)-...........>UiU]UiUiUiU]UiU]UiU]UiUIUiUI,2.‘<a CDC Ui306307APPENDIX BPROGRAM EVALUATIONProgram Evaluation Instrument 308Item Response Statistics 311Attendance and Session Relevance 313Program Evaluation: Open Ended Questions 316Note: Instrument have been printed at 75% the originalsize to allow binding.308Resident Education Program: EvaluationStrongly Disagree Neutral Agree StronglyDisagree AgreeOverall, it was a worthwhile course 1 2 3 4 5My personal goals for taking this course were 1 2 3 4 5Nor metI would recommend this course to other residents 1 2 3 4 5who have a teaching assignmentI would take another course that was taught this way 1 2 3 4 5I would like to take a follow up course on this topic 1 2 3 4 5I would have preferred another method of teaching this 1 2 3 4 5courseThe course content addressed my needs for my teaching 1 2 3 4 5role as a CTU residentThe course was interesting 1 2 3 4 5The instructor encouraged the development of new 1 2 3 4 5viewpoints and appreciationsThe instructor demonstrated a thorough knowledge of the 1 2 3 4 5subject matterThe instructor was an effective teacher 1 2 3 4 5Regarding Specific Sessions:1) Introduction: Teaching Styles & Learning Styles• Did you attend this session Yes NoStrongly Disagree Neutral Agree StronglyDisagree Agree• This topic was helpful to me in my teaching role as a 1 2 3 4 5CTU resident• This topic should be replaced with another more Yes Norelevant fopic in future courses2) Work Rounds and One Minute Teaching Skills• Did you attend this session Yes NoStrongly Disagree Neutral Agree StronglyDisagree Agree• This topic was helpful to me in my teaching role as a 1 2 3 4 5CTU resident• This topic should be replaced with another more Yes Norelevant topic in future coursespage 13093) Feedback and Evaluation• Did you attend this session Yes NoStrongly Disagree Neutral Agree StronglyDisagree Agree• This topic was helpful to me in my teaching role as a 1 2 3 4 5CTU resident• This topic should be replaced with another more Yes Norelevant topic in future courses4) Questioning and Non Facilitating Teaching Behaviors• Did you attend this session Yes NoStrongly Disagree Neutral Agree StronglyDisagree Agree• This topic was helpful to me in my teaching role as a 1 2 3 4 5CTU resident• This topic should be replaced with another more Yes Norelevant topic in future courses5) Cognitive Learning Principles and Problem Solving Strategies• Did you attend this session Yes NoStrongly Disagree Neutral Agree StronglyDisagree Agree• This topic was helpful to me in my teaching role as a 1 2 3 4 5CTU resident• This topic should be replaced with another more Yes Norelevant topic in future courses6) Small Group Teaching• Did you attend this session Yes NoStrongly Disagree Neutral Agree StronglyDisagree Agree• This topic was helpful to me in my teaching role as a 1 2 3 4 5CTU resident• This topic should be replaced with another more Yes Norelevant topic in future coursespage 2310Resident Education Program: EvaluationHow did this series of seminars change your approach to teaching I learning on the CTUand teaching /learning in general?What was the most helpful aspect of this course?What was the least helpful aspect of this course ?Suggestions for improvement(Use reverse side if more space is needed) Thanks! Ricpage 3311Program Evaluation: Item Response Statistics#1 Overall, it was a worthwhile course. #2 My personal goals for taking thiscourse were NOT met.Mean 4.77 Mean 2.38Median 5.00 Median 2.00Standard Deviation 0.44 Standard Deviation 1.12#3 1 would recommend this course to other #4 I would take another course that wasresidents who have a teaching assignment taught this wayMean 4.62 Mean 4.46Median 5.00 Median 5.00Standard Deviation 0.51 Standard Deviation 0.66#5 1 would like to take afollow-up course #6 1 would have preferred another methodon this topic of teaching this courseMean 4.31 Mean 2.31Median 4.00 Median 2.00Standard Deviation 0.63 Standard Deviation 1.03#7 The course content addressed my needs #8 The course was interestingfor my teaching role as a CTU residentMean 4.23 Mean 4.62Median 4.00 Median 5.00Standard Deviation 0.83 Standard Deviation 0.51312Program Evaluation: Item Response Statistics#9 The instructor encouraged the development #10 The instructor demonstrated a thoroughofnew viewpoints and appreciations knowledge of the subject matterMean 4.23 Mean 4.69Median 4.00 Median 5.00Standard Deviation 0,73 Standard Deviation 0.48#11 The instructor was an effective teacherMean 4.62Median 5.00Standard Deviation 0.51313Program Evaluation: Attendance and Session Relevance#1 Introduction: Teaching Styles and Learning Styles#JA Did you attend this session? #JB This topic was helpful to me in my______________________________________teaching role as a CTU residentYes 12 (92%) Mean 4.42No 1 (8%) Median 4.00Standard Deviation 0.51#JC This topic should be replaced withanother more relevant topic in futurecoursesYes 0 (0%)No 11/12 (92%)#2 Work Rounds and One Minute Teaching Skills#2A Did you attend this session? #2B This topic was helpful to me in myteaching role as a CTU residentYes 12 (92%) Mean 4.67No 1 (8%) Median 5.00Standard Deviation 0.49#2C This topic should be replaced withanother more relevant topic in futurecoursesYes 0 (0%)No 12/12 (100%)314Program Evaluation: Attendance and Session Relevance#3 Feedback and Evaluation#3A Did you attend this session? #3B This topic was helpful to me in my__________________________________________teaching role as a CTU residentYes 12 (92%) Mean 4.67No 1 (8%) Median 5.00Standard Deviation 0.49#3C This topic should be replaced withanother more relevant topic in futurefuture coursesYes 0 (0%)No 12/12 (100%)#4 Questioning and Non Facilitating Teaching Behaviors#4A Did you attend this session? #4B This topic was helpful to me in my____ ___ ____teaching role as a CTU residentYes 13 (100%) Mean 4.46No 0 (0%) Median 5.00Standard Deviation 0.78#4C This topic should be replaced withanother more relevant topic infuturecoursesYes 0 (0%)No 13/13 (100%)315Program Evaluation: Attendance and Session Relevance#5 Cognitive Learning Principles and Problem Solving Strategieso (0%)10/11 (91%)#5B This topic was helpful to me in myteaching role as a CTU residentMeanMedianStandard Deviation#6B This topic was helpful to me in myteaching role as a CTU residentMeanMedianStandard Deviation4.254.000.713.734.000.47#5A Did you attend this session?Yes 8 (62%)No 5 (38%)#5C This topic should be replaced withanother more relevant topic infuturecoursesYes 0 (0%)No 8/8 (100%)#6 Small Group Teaching#6A Did you attend this session?Yes 11 (85%)No 2 (15%)#6C This topic should be replaced withanother more relevant topic infuturecoursesYesNo316Program Evaluation: Open Ended QuestionsA. How did this series of seminars changeyour approach toteaching / learning on the CTU and teaching / learningingeneral?1. More conscious to what I am doing or saying!2. I’m more cognitively aware that the teaching by teacher isnot equal to learning by learn. Ultimate end result is that oflearning.3. Made me more aware of the need of interaction, toencourage participation.4. It certainly made me more cognizant of teaching andlearning as a process. Aware of good practices and bad. Ihoped it changed or improved my approach.5. I was more aware of good teaching skills and behaviour.6. More aware of how I was asking questions. More aware ofhow much teaching I was doing. More aware of role model.7. Expanded my teaching style. Increased ease with teaching317Program: Evaluation: Open Ended Questions (cont’d)2. Gave me ideas about how to attempt better / more effectiveteaching strategies / style. 3. Better appreciation of howinappropriate lecture style teaching is for small groups.11. I never thought about how I learned or how I teach. It atleast made me “aware”. It also made me realize that to teach Idid not have to be an almighty God of knowledge. I changesomewhat from expert to socratic and with the better MSI5 —interactive.12. It provided an explicit framework to deal with teachingof MSIs. Up to now I have been using an intuitive approach toteaching and haven’t really thought about CTU teaching in aformal manner.13. Made me aware of what I do and what I should andShould not do. Lots of new ideas to encourage students tolearn. pressure to impart knowledge. Show students how tolearn rather than teaching them.318Program: Evaluation: Open Ended Questions (cont’d)B. What was the most helpful aspect for this course?1. Well presented. I learned a lot about teaching methods.2. Provide a “thinking” method of previously “semi-conscious”process.3. I felt more comfortable directing rounds or teaching. Ididn’t mind so much, not to know all the answers myself.4. Again, making me aware of good practices and reinforcingthem. I actually felt the learning theory section, though lessapplicable made some points I’m sure that I will remember.5. Learning above effective teaching skills and how studentslearn best (methods of problem solving).6. Technique of how to ask questions and “Reflection inAction”.7. Timing and course content.8. Lots of good examples during course - helps to remember319Program: Evaluation: Open Ended Questions (cont’d)them. Lots of application between sessions makes them moremeaningful.9. Identifying and formally naming teaching / learning skillsand behaviours because I did find that I was already doing alot of teaching but was not aware of it. With increasedawareness it was easier to make more of an effort to beeffective. Found the role playing quite effective (when wetried giving each other feedback etc.).10. Change to hear from other residents - what theirexperiences and frustrations are. Practical tips. Gooddemonstrations. Organized approach and discussion.11. Awareness of teaching strategies and goals. Realizationthat teaching was not just giving facts.12. Providing a formalized approach to CTU teaching.13. Teaching techniques, i.e. how students learn whenexposed to different teaching styles and therefore which styleis most appropriate for each student. How teaching methodsaffect learning.320Program: Evaluation: Open Ended Questions (cont’d)C. What was the least helpful aspect for this course?1. May be a bit too quick. I would like more time to apply thenew knowledge.2. Lack of actual on the ward feedback - how is it going.3. None4. Whole course helpful.5. Difficult to say because I found it very helpful!6. The ideas were very good in theory, but difficult toincorporate given the realities and demands of CTU. Moreaware of where I was going wrong, but without theopportunity to fix it in most cases.7. We the learning got no feedback that is relevant.8. Large group vs. small group teaching.321Program: Evaluation: Open Ended Questions (cont’d)ILSnggestions for improvement.1. Less material per session.2. A bit longer -? More practical points or pretend situations.3. Some mechanism for actual on ward evaluation would behelpful.4. None - would suggest more practice in teaching andfeedback on teaching skills.5. I think all residents should have this course.6. Can the course be offered to more of the residents? It wasgreat - thanks.7. Would be interesting to have 1-2 sessions with MSIs /interns in attendance, to hear their ideas about teaching andlearning. Disappointing not to receive feedback on ourteaching, more efforts should be made to ensure this occurs.8. Make the sessions briefer (i.e., 45 mm.)Program: Evaluation: Open Ended Questions (cont’d)9. Find a better time for course.322323APPENDIX CSESSION CONTENTSession 1Introduction: Teaching and Learning 324Session 2Work Rounds and One Minute Teaching Skills 339Session 3Feedback and Evaluation 360Session 4Questioning and Non-Facilitating Teaching Behaviours 381Session 5Cognitive Learning Principles and Problem Solving 393Session 6Small Group Teaching 410324Session 1 - Introduction: Teaching and LearningAgendaIntroductionGoals and Objectives for the ProgramCourse ContentTeaching and LearningWhat Makes a Good Teacher?Residents as TeachersLearning Environment / ClimateClinical Teaching Techniques for ResidentsTasks for the WeekIntroductionDocere = to teachRoot of the word “doctor”See one. Do one. Teach one.See one. Screw one. Do one.Teaching as an Art LCL, Behavioural Science)Implications of changing name from teacher training toteacher educationContent versus process325There is no single effective teaching methodIt is hoped that residents will develop their own teachingstyles through these sessionsGoals and ObjectivesMake residents aware of their beliefsChallenge their beliefsTeaching as a way of “being” rather than “doing”Reflection-on-action — reflection-in-actionBehavioural objectivesBeyond behavioural objectives - creative medical teachingCourse Content1. Orientation / Teaching & Learning / Resident as TeacherManager2. Work Rounds / “One Minute Teaching Skills”3. Feedback & Evaluation4. Asking Questions / Non-facilitating Teaching Behaviours5. Problem Solving / Cognitive Learning Principles6. Small Group Teaching326TASK:Have residents generate their priorities while on the CTUPatient careSelf education (i.e. learning)Junior housestaff education (i.e. teaching)Now demonstrate how they can all be one and the same,i.e., Patient care is the best environment to learnTo teach is to learn twice“Three legged stool”Teaching and LearningTeaching Versus LearningWhat is Teaching and LearningiTo help you understand teaching and learning, consider thefollowing statement:“If the learner didn’t learn, then the teacher didn’tteach”Do you agree or disagree?Picture the following cartoon strip:327A little boy tells his friend, “I taught Rover how towhistle!” With an ear up to the dog’s face, the friendresponds, “I don’t hear him whistling.” The first boyreplies, “I said I taught him to whistle. I didn’t say helearned it.”TASK:Define teachingDefine learningSome people believe that if there is no learning, there was noteachingAccording to this view to teach is to giveOther people believe that teaching is anything done by theteacher that intentionally promotes learningAccording to this view to teach is to offerIchinstviesTASK:328Explore the meaning of the following teaching styles1. Expert consultant2. Socratic3. Collaborative teaching1. Expert consultant: Expert knowledge is conveyed to thestudent in response to a question2. Socratic: Teacher draws information from the student bythoughtful questioning in an effort to explore the limit ofthe student’s knowledge and problem solving strategies.The teacher needs a clearer understanding of the desiredoutcome3. Collaborative teaching: A subtle difference from theSocratic styleIn this approach, neither the student nor the teacher knowsthe answers or solutions to the problem presentedThey engage in a question and answer process seeking tobetter define the problem and to develop an approachtowards itUnlike the socratic style, the teacher does not have apredetermined goal nor a clear knowledge of the solution tothe problemCollaborative teaching is a process of mutual explorationand discovery329Teacher Directed Versus Student DirectedThe LearnerMost text on teaching focus on the teacher and how to bemore effective. The characteristics of the learner aresometimes overlookedIndividuals differ greatly in their learning potential, theirreadiness to learn, and how they learn most effectivelycf., learning styles, teaching stylesTeaching MethodsTwo possible actors, the teacher and the learnerTwo modes of behaviour, active and passiveTwo locations for teaching and learning, a classroom (anyroom where people can sit and talk) and application sitesTASK:Create a two by two matrix with active teacher, passiveteacher, crossed by active learner, passive learnerWhat is your preferred learning method?330LearningI hear and I forget. I see and I remember. I do and Iunderstand.Importance of student involvement in the learning processStudent Directed LearningThomas C. King believes that the overriding purpose ofeducation is to make the learner independent of any need fora teacher (1983)He contends that anything you do to build dependency is bad,and anything you do as a teacher to build independence isgoodHe concludes that the teacher as an information giver isperforming an immoral actThe best teachers make themselves obsoleteAdult Learning TheoryAdult Learners-Want to use what they learn soon after they learn it-Interested in learning concepts and principles; they like tosolve problems and not just learn facts. If they participateactively in the learning process, it is easier for them to apply331the concepts and principles they are learning.-Learning is best when adult learners can proceed at their ownpace.-Motivation increases when adult learners help to set learningobjectives. Motivation is usually highest when the subjectmatter relates to the immediate interest and concerns of theadult learners.-Adult learners like to know how well they are doing;feedback helps them to evaluate their own progress.Adults who seek to enhance their proficiencies see themselvesas users, instead of recipients of education.CASE:RF is an R2 in medicine. She is scheduled for a CTU rotation atSPH. She looks forward to her new role as team leader andteacher. In fact, she spends many hours preparing small“talks” for the juniors before starting the rotation.Her intern and MSI are particularly strong academically.During the first week, she gives one of her mini lectures -nephrotic syndrome - with well prepared overheads. Shesenses that the juniors are not very interested. She concludesthat the juniors are not motivated and decides not to give any332more talks.As the rotation proceeds a power struggle develops betweenthe RF and the juniors. She tries to maintain control of theteam and to teach by imparting information and her opinionson patient management. The juniors see her as controlling andoverbearing.What went wrong?What Makes a Good Teacher?TASK:Think of your best and your worst clinical teacher.List the characteristics of eachRating forms (i.e., student rating of resident teaching-seeappendix ***)No coincidence that rating forms are constructed as they are333TASK:Compare list of characteristics generated above with ratingformAlso, compare with the following list:Helpful Clinical Teachers1. Answers questions clearly2. Enthusiastic3. Explain the basis for their actions and decisions4. Provides students with opportunities to practice bothtechnical and problem solving skills5. Summarizes major points6. Gives feedback without belittling7. Demonstrates a genuine interest in students8. Strives to make difficult concepts easy to understand9. Emphasizes conceptual comprehension rather thanfactual recall10. Accessible to students11. Provides competent patient care and role modelling12. Approaches their teaching with dynamism andenergy13. Prepare well for rounds and other contact withstudents14. Explains lucidly33415. Identify what they consider important16. Discuss practical application of knowledge and skillsResidents as TeachersWhy do residents make particularly_good teachers?Faculty attendings are often too competent to do a good job.They may be so advanced in their own work that they havebecome oblivious to the needs of the novice.They are unconsciously competent.Residents as Role ModelsQUESTIONS:What is a role model?Does it always imply something positive?Do you have a choice of whether or not to be a role model?In what situations can role modelling be a powerful teachingtool?What does it mean to be an “intentional role model”?335The socialization processRole ModellingRole model does not always imply goodYou don’t have choice of being or not being a role modelThe intentional role modelPowerful teaching toolInstruction of attitudesWe cannot tell someone else how to beSetting tone, pace and expectationRole ModellingPhysicians model for students and residents the way tointeract with the nurses, nursing assistants, secretaries,physical therapists, social workers, and other personnel.If physicians are courteous, even when frustrated, if theyare friendly even when tired, if they try to correct errorsinstead of just complaining, they fulfil their hospitalstaff responsibilities willingly, by example they arehelping to socialize the learners to their future roles asphysicians in this setting.TASK:“Reflection in action” taskThis week watch for and report good and bad role modelling336by yourself and others (i.e. attendings of other seniorresidents)- what impact do you think it had?Learning EnvironmentQUESTIONS:What is meant by “learning environment”?What is meant by “safe to make mistakes”?What is the interplay between learning environment,motivation, positive and negative reinforcement, and selfesteem?What is pimping?How can you provide a positive learning environment?Learning Climate: Favourable Learning EnvironmefflEnthusiastic teacherTime set aside for teachingLearners treated with respect, not intimidatedInteraction by learners encouraged “supportive atmosphere”“Safe” to make mistakesPositive attitude to differences of opinion337Teacher not seen as all knowingTeacher is a good role modelMSI tended to rate residents much higher than the residentsrated themselvesResidents didn’t recognize this as an important aspect of theteaching roleMotivation-My understanding of human behaviour is that when peopledo a good job and are told so, they feel motivated to do aneven better job-Whether you believe in carrots or sticks, motivation should beyour concern because the formula for student learning can beexpressed as motivation x ability-Emotions play a key role in learning.-Essentially, we remember what we understand, we understandwhat we pay attention to, and we pay attention to what wewant to338TASKS FOR THE WEEK1. Reflect on the way you interact with the juniorsWhat is your main teaching style?2. Watch your attending in actionsWhat is their main teaching style?3. Watch for and report good and bad role modelling byyourself and others (i.e. attendings of other senior residents)What impact do you think it had?4. Watch for and report on the learning environment youprovide to your students339Session 2 - Work Rounds and One Minute Teaching SkillsAgendaReview of Last Weeks TasksModels for Work RoundsTips for Running Efficient Work RoundsDelegating WorkOne Minute Teaching Skills During Work RoundsMicroskills Role Play: One Minute Teaching SkillsTasks for the WeekReview of Last Weeks Tasks1. Reflect on the way you interact with the juniorsWhat is your main teaching style?2. Watch your attending in actionWhat is their main teaching style?3. Watch for and report good and bad role modelling byyourself and others (i.e. attendings of other senior residents)What impact do you think it had?4. Watch for and report on the learning environment youprovide to your students340Models for Work RoundsCASES:1. Each day after morning report, the team does work rounds.They take the chart rack and see all the patients as a group.The resident usually questions and examines the patients. Thejuniors write the orders based on the resident’s findings. Theyalso make a “to do” list for the day.2. Each day after morning report, the juniors go off to seetheir own patients. The resident “trouble shoots” from thenursing station and is available to answer the juniorsquestions. The resident will go to the bedside at the request ofthe junior, if they are uncertain about something. At the endof the day, each junior signs out with the resident, usuallyone-one-one.3. Each day after morning report, the team does work rounds.They take the chart rack and see all the patients as a group.The team usually takes 15-20 minutes for each of the first fewpatients. The resident often gives mini-lectures at the bedside.The end of rounds are usually frantic as the team tries to seethe remaining half of the patients in 30 minutes. This often341leaves the juniors frustrated and confused.4. Each day after morning report, the team does work rounds.They take the chart rack and see all the patients as a group.The juniors haven’t seen the patients since the previous day.Much time is spent looking over the chart (while other teammembers wait), or chasing lab results etc.. Rounds usually takeseveral hours. The housestaff are usually in the hospital untilthe evening if they attend their scheduled teaching sessions.5. A resident is doing her first rotation on the CTU. She isworking with an intern and two MSIs. She is worried aboutdelegating too much work to the juniors and is carryingapproximately one quarter of the patient load. She tries to letthe juniors work as independently as possible and sees herown patients during this time. She finds it very frustratingbeing constantly interrupted by the juniors for help. She isfeeling overwhelmed and doesn’t feel on top of things.Yesterday, a junior overlooked an important lab result with abad outcome for the patient. The staffperson came downheavily on the resident.342QUESTIONS:What are your objectives for work rounds?How do you organize your CTU?Role of the juniors?Distribution of patients?Should the resident take patients?prosconshow manywhich onesPlanning ahead?Pre-rounding by juniors?Going around as a group?Tips for Running Efficient Work RoundsClear Objectives-At the end of rounds each person should know enough aboutall patients so that if the person responsible for primary careis absent, another team member can assume responsibility-By the end of rounds, everyone should know the tasks thatmust be accomplished during that day343-They should also know with what urgency these tasks must becompleted-The resident should ascertain whether the studentsunderstand how to accomplish their tasks-New areas for learning for juniors include organizationalskills, such as, how to plan their day and how use their timeeffectivelyPlan Ahead-Hold work rounds early-Make a work list-Group and divide the tasks for maximum efficiency-Meet with team at the end of the day to plan the next dayPre-Roundingiyjunicrs-Insist on pre rounding by interns and students to improveefficiency of work roundsClarify Ahead of Time How Much Time Can be Spent PerPatient-see sickest / most complicated firstReview with team how to do brief presentationsEncourage use of problem lists344Avoid lectures unless few patients-one to two brief teaching points per patientIn_your supervisoryrole,_you should flipithroiigh orders andcharts for completeness periodically-Provide students with the importance of documentation-What should and should not be included in a chart and howto convey information clearly in written formatDelegating WorkCASES:1. The resident assigns a patient in ER to the intern. Hewatches over the intern as he takes the history. He interruptsfrequently when a question comes to mind, and often takesover the history. The intern gets frustrated and they have asmall confrontation. Similarly, during attending rounds, theresident interrupts the juniors while they are presenting andoften takes over the presentation.2. The resident has a strong belief in having MSIs develop asense of independence. She allows them to see their patients345independently and to make their own decisions and writetheir own orders. The MSI feels overwhelmed, and oftendoesn’t understand what should be done for the patient. Hefeels like there is no safety net.3. A busy resident tries to make the ward run more efficientlyby delegating work. He provides clear plans for each patientand what should be done for each. Early each day, hedelegates the tasks that need to be done for that day. The MSIsdon’t always understand why things are being done. Amongeach other they grumble that they are the resident’s “skutmonkeys.”Steps for Effective DelegationCommunicationDescribe the framework of the assigned taskDescribe the desired resultsAsk for commitmentAgree to a timetable and an evaluation planExpectationsExpectations must match maturity and skill346If you delegate responsibility.. .you must also delegateauthorityDon’t breathe down their necksThe person delegated to must be made accountable to thedelegatorYou’re still on the lineWhile the student is accountable to you s/he is notaccountable to the next higher levelOne Minute Teaching Skills During Work Rounds1. Get a commitment2. Probe for supportive evidence3. Teach general rules4. Reinforce what was right5. Correct mistakes6. Self directed learning1. Get a commitmentCue:After presenting the facts, the students stops to wait for yourresponse or asks for your guidance347RenAsk the student to share what they think about the issuepresented by the dataIssues may include coming up with more data, proposinga hypothesis or plan, developing a management plan,figuring out why the patient is noncompliant, decidingon whom to consult, etc.“Get off the fence”Rationale:Asking students for their interpretation of the data assumes,respectfully, that they are processing, as well as collecting dataand are engaged as problem solving professionalsFeel in charge - motivation2. Probe for supportive evidenceCue:When discussing the case, the student has committedthemselves and looks for you to either confirm the opinion orsuggest an alternativeYou may or may not agree348Response:Before offering your opinion, ask the student for whatevidence they feel supports their opinionA corollary approach is to ask what other choices wereconsidered and what evidence supported or refutedthese alternativesRailona1Problem solving is dependant on knowledge baseGet an understanding of the thought processAssess faulty reasoningHelps avoid, “the right answer for the wrong reason”3. Teach general rulesCue:While discussing the case, you see an opportunity to provide avaluable teaching pointi.e., You know something about it that the student needsor wants to knowi.e., Pearls and pitfallsResponse:Provide general rules, concepts and considerations, and target349them to the students’ level of understandingRationakGeneral rules are easier to rememberHigher level of understanding for future applicationGo beyond the ward routineStudents can often get by with simply learning the “wardroutine” and not fully understanding the principles thatunderlay themRoutines often change, principles are more long lasting4. Tell them what they did rightCue:Student has handled a situation in a very effective mannerThey may not realize that the action was effective andhad a positive impactResponse:Take the first chance you find to comment on the specificgood work and the effect it hadRationale:Some good actions are pure luck while others are deliberate350reinforcement is important in firmly establishing skills /competenciesDon’t confuse this with praise5. Correct mistakesCue:student makes a mistakeOmission or commissionResponse:Discuss what was wrong and how to avoid or correct the errorin the futureAllow the student to critique their performance firstRationale:Pre-empt mistake from being repeatedexcellent teaching opportunity - learning from mistakesHelp students develop ability for self assessment and admitmistakes6. Self directed learnina351Cue:While discussing the case, you see an opportunity to provide avaluable teaching pointYou may or may not know the answerIf there is no urgency to act on the answerRespon&eAssign the task for the student to “look up”When you assign a topic to look up make it understood thatyou will follow-upGive a time frame of when you expect the answerReserve five minutes of the beginning of the next dayswork rounds for the answersIf the student has not done the work, reassign the taskwith a clear understanding that these tasks areimportant and that you will follow upRationale:Motivating self directed learning is one of the most importanttasks that you can do as clinical teacherRemember from last weeks sessionEspecially encourage self initiated tasks and contributions352Microskills Role Play: One Minute Teaching SkillsINSTRUCTIONS:One student, one preceptor and the rest observersUse scenarios and advise residents to use as many of themicroskills as they can1. & 2. should be used all the timethe rest according to the situationThe observers should take brief notes on the dialogue andresponses. What microskills are being used?After completing the simulation allow the preceptor to critiquethemselves, then the students, then the observersSCENARIOS:1.Student presentation:HB is a 65 yo woman with a history of CHF presents with a 2day history of increasing SOB. She had a “cold” last week andwas feeling unwell. She thinks she may have had a fever, butshe didn’t take her temp. She also had some cough with asmall amount of yellowish sputum. She sleeps on 3 pillows at353night and said she had difficulty sleeping last night because ofSOB, so she came into ER today.Her CHF is usually well controlled with dig, Lasix, andCaptopril. She is compliant with her meds. She’s never beenhospitalized for CHF before and her history is otherwiseunremarkable.O/EP110, BP 160/90, R30, T38JVP 6 cm ASA, + HJRCrackles to the base of the scapula+ S3SOAThe remainder of the Px was unremarkableStudent commitment:I think she has an exacerbation of CHFStudent supporting evidence:Sign of fluid overloadA corollary approach is to ask what other choices wereconsidered and what evidence supported or refuted thesealternatives354General rulee.g., SOB can be CVS or lung or bothe.g., CHF is not a dx - what was the precipitant2.Student presentation:RU is a 70 yo man who presents with a first episode ofcollapse. He was working in his garden, felt “funny” for a fewseconds. And the next thing he remembers is waking up. Therewas no witness and he doesn’t know how long he was out for.He doesn’t remember any palpitations or chest pain but hisPMH is positive for cardiac disease with a previous MI 3 yrsago. He also has a hx of hypertension. His medications includea beta blocker and ECASA.O/EP 70 regular, BP 155/90, R 12Chest- clearCVS - JVP 2 cm ASA, precordium unremarkable, HS normal, nomurmurs, no SOACNS- grossly normalThe remainder of the Px was unremarkable355Student commitment:I think he had an arrhythmiaStudent supporting evidence:His cardiac history is suggestive of the possibility of a cardiaccause. The px is often normal between bouts of arrhythmias.A corollary approach is to ask what other choices wereconsidered and what evidence supported or refuted thesealternativesGeneral rules:e.g., Importance of pre, during, and post as an approach tocollapsee.g., Similarities of syncope and seizure3.Student presentation:SO is a 60 yo female admitted 3 days ago with coffee groundemesis secondary to NSAID use. She was transfused a total of 3units and her Hb is now 105. Her OGD revealed erosivegastritis and she was started on IV zantac. Overall she seems tobe doing well but the nurses have commented that she is moreconfused. I saw her this morning and she didn’t know who Iwas. I did a quick px and could find anything.356Student commitment:I think it may be a combination of her GI bleed and theunfamiliar environment.Student supporting evidence:Well, I couldn’t find anything suggestive on the pxA corollary approach is to ask what other choices wereconsidered and what evidence supported or refuted thesealternativesGeneral rule:e.g., Causes of acute confusion in the elderly4.StiidmiLpresentation:JK is the 27 yo female IVDU who came in with leg cellulitis.Her blood cultures remain negative and she is on day 4 of IVcloxacillin. Her withdrawal is being controlled with 0clonidine and her BP is 105/70. Yesterday, she developedsome SOB, so I gave her some 02 and a Ventolin mask. Sheimproved and she looks good this morning.Student commitment:I thought she might have a touch of asthma357Student supportive evidence:She improved with treatmentA corollary approach is to ask what other choices wereconsidered and what evidence supported or refuted thesealternativesMistake:Possible DVT & PEPossible SBE & PEGeneral rule:e.g., Its unusual for someone to develop asthma for the firsttime while in hospitale.g., If a patient develops a new problem while in hospital, youshould think of possible complications of the presentingcomplainte.g., Bedridden patients are at risk for DVT5.Student presentation:OD is a 63 you man with a longstanding history of COPD. Hewas admitted 2 days ago with an exacerbation of COPDsecondary to a URI. We put him on nebulized Atrovent andVentolin, and gave prednisone 40 mg OD. When I saw him this358morning, he was more tachypneic, so I upped his 02. Althoughhis RE is improved, he is more confused.Student commitment:I think his COPD is getting worse and I think that he may needto be intubatedStudent supportive evidence:His decreased RE may mean that he is going into respiratoryfailure. His confusion is in keeping with decreased 02 to thebrain.Mistake:Likely COPDer with C02 retention; needs hypoxic drive tobreatheGeneral rule:e.g., Don’t use more than 28% 02 unless you know patient isnot a C02 retainere.g., C02 retainers need their hypoxic drive to breathe359TASKS FOR THE WEEK-Before each workround, review the “One minute teachingskills”-Use 1. & 2. for every Student / Patient encounter (i.e., “Get acommitment” and “Probe for supportive evidence”)-Try to teach on short general point on most patients (i.e., 3.)-Use 4. & 5. where appropriate (i.e., “Reinforce what was right”and “Correct mistakes”)-Assign “Self directed learning” tasks-Use these relatively sparingly (i.e., no more than 1-2/day)-Give a time frame of when you expect the answer-Follow up360Session 3 - Feedback and EvaluationAgenda1. Review of Last Weeks Tasks2. Feedback vs. Evaluation3. Feedback: The Psychological Meaning4. Content of Effective Feedback5. Role Play: Evaluation & Feedback6. Managing Mistakes7. Tasks for the WeekReview of Last Weeks Tasks-Before each workround, review the “One minute teachingskills”-Use 1. & 2. for every Student / Patient encounter (i.e., “Get acommitment” and “Probe for supportive evidence”)-Try to teach on short general point on most patients (i.e., 3.)-Use 4. & 5. where appropriate (i.e., “Reinforce what was right”and “Correct mistakes”)-Assign “Self directed learning” tasks-Use these relatively sparingly (i.e., no more than 1-2/day)361-Give a time frame of when you expect the answer-Follow upFeedback vs. EvaluationQUESTIONS:What is feedback?What is evaluation?How do they differ?Distinct from evaluation, feedback presents information, notudgement.Evaluation is expressed as normative statements, pepperedwith adverbs and adjectives; feedback is neutral, composed ofverbs and nouns.QUESTIONS:Praise & CriticismHow do these differ from feedback and evaluation?362Try to avoid confusing positive feedback with complimenting,and negative feedback with criticism.If a resident feels let down by a student they may wish tocriticize the student rather than provide feedback.Try to avoid the incessant use of “good”, “excellent”, “that’sperfect”, responses to trainees every statement thatapproximates a correct answer.Feedback“Feedback”The term feedback was originally used by rocket engineers inthe 1940’sServo-mechanismGoal seekingAnother example: thermostat“Eefdforward”Taken for granted that “target” is knownStudents complain that at the start of the rotation they are nottold what is expectedFeedforward refers to prior specification of criteria so thatstudents know what to aim for363Giving feedbackSet a goal (target)What did the learner do right that you want them to do again -tell themWhat did the learner do wrong that needs to be changed - tellthemSuccessful coachesMany successful coaches and managers were not “hall offamers”Perhaps because they were less gifted athletes who workedhard to master the necessary skills to do well, they canidentify with and teach others trying to accomplish the samethingEffective learning can take place when the subject matter isdifficult to learn, if the teacher can show learners their majorareas of weakness, and motivate them to changeFeedback:: The Psychological MeaningQUESTIONS:1. What is the capacity of feedback to elicit an emotional364reaction?2. Which do you think is more effective positive or negativefeedback?3. What happens when you provide only negative feedback?4. What happens when the student comes to associatefeedback with criticism?5. How does it affect you as a teacher if you’ve had badexperiences with “feedback” as a learner?Negative judgement is common on all levels of medicaleducation; direct feedback, which sites specifics and offerssuggestions for improvement, is rare.Like adults who were scolded more than they wereinstructed as children, physicians have difficultydiscerning the differences between describing behaviourand labelling the person “good” or “bad”.Because clear feedback is rare and correction is morecommon than affirmation, the medical trainee hasdifficulty feeling competent.Receiving punishing comments about mistakes teachestrainees to hide errors, by lying, if necessary.Like emotionally abused children, residents becomeunwilling to risk the pain they have come to associatewith close supervision.365The absence of honest constructive feedback and theoverabundance of placing blame in medical educationperpetuates physicians perfectionism and leaves them atrisk for impairment. (Mckegney, 1989)The capacity of feedback to elicit an emotional reactionExperiences with feedback that was handled poorly, in whichthe technique for limiting the emotional reaction wereappreciated, may inhibit giving, or receiving, feedback in thefutureThe teacher may be concerned the student will be hurt bynegative feedback; that it will damage the student/teacherrelationship, or the teacher’s popularity; that it will result inmore harm than goodThe student may view feedback as a statement about his orher personal worth or potentialStudents may ostensibly want information about theirperformance but only in so far as it confirms their selfconceptsIn this sense, they want feeding not feedbackIn one longitudinal study_, house officers confirm the neartotal absence of feedback from attendingphysiciansTo fill this void, the house officers generated a system of selfvalidation, largely based on unintended cues366Their system developed in tandem with their own sense ofmastery.As they began to feel more and more confident, they alsobegan to feel more capable of judging their own performanceUnfortunately, their system of self evaluation excludedevaluation from external sources.In fact, much to the amazement of the investigators, the houseofficers seemed to employ a whole barrage of defences fordealing with criticism from superiors.They disparaged the source.They regarded the issues as irrelevant.They attributed the criticism to difference in style.Or, they concluded that criticism was no longer relevant totheir current level of performance.The problem is that their educational environment had failedto provide them with a model for constructive, nonevaluativeperformance appraisal.When feedbacks fails, it is usually because it led to anger,defensiveness, or embarrassment on the part of the trainees.Most of us experience some discomfort giving and receivingfeedbackBecause of that, we may in the teacher role transfer those367feelings to the learner, and be reluctant to provide feedback.Try to avoid association of feedback with negatives.Don’t internalize feedback, it does not mean you are a badstudent.When a person feels criticized his energy may_go into self-protection rather than self-improvementImportance of not belittling when wrong.Positive FeedbackGood performance is expected and taken for granted.Catch them doing something right.Do not wait for perfect behaviour to give positive feedback,but give positive feedback as you observe any step in the rightdirection.Positive feedback is a more powerful motivator than negative.Positive feedback may make a person feel good, which isrewarding, but it also should be informative.Content of Effective Feedback“12 Stens to Effective Feedback”1. Well-Timed:368The closer to the performance the better2. Two Way Communication:Sharing of informationGives the student an opportunity for self evaluation3. Ownership:Begin with an I statementBased on first hand observation, not on hear saySubjective data should be labelled as such4. Descriptive Rather than EvaluativeDescribe, do not label5. Focused on Behaviour Rather than on the Person orPersonalityFocus on the behaviour, don’t make assumptions regardingmotives or intentBehaviour must be changeable6. Specific Rather than General7. Balanced:Provide both positive and negative comments369RportBased on trust, honesty, and concernBoth on the same sideCommon goals: Quality patient care / learningp...arid iistn:Resistance means non-receptivenessUnderstood: have the receiver try to rephrase the feedback1OAgreement of Others:When feedback is given in the presence of others, both giverand receiver have an opportunity to check with others in thegroup about the accuracy of the feedback11. Avoid Overload:It involves the amount of information the receiver can userather than the amount he would like to give12. Be Brief:Say it once3701. Well-Timed: The Closer To The Performance TheBeflerTASK:Give good and bad examplesTiming of feedback is criticalImmediate is bestIt may be preferable to delay if there is a need forprivacyIf either person is upset, it is recommended that sometime pass so that emotions can settle2. Two Way Communication: Sharing of InformationClarify the goals of the feedback session itselfProvide opportunities for mutual problem solvingGive the student an opportunity for self evaluationDemonstrate responsivenessBegin with the learnerAsk the student for their assessmentThis shows willingness to listenThe trainee should take an active part in the process; the371teacher’s open-ended questions can help break the iceFor example, an attending physician, after hearing astudent’s presentation may begin by asking “How do youthink it went?”TASK:Give good and bad examples3. Ownership: Begin With an I StatementBased on first hand observation, not on hear sayWhen included as part of the feedback, subjective data shouldbe clearly labelled as such“I” statementsTASK:Give good and bad examples3724. Descriptive Rather Than EvaluativeThe language of feedback is descriptive and nonevaluativeStatements like “The differential diagnosis did not include thepossibility of tuberculosis” are preferable to “Your differentialdiagnosis is inadequate”Describe, do not labelTASK:Give good and bad examplesExamplesYou interacted poorly with that patient.When you were talking with Mrs. Jones, you did notmake eye contact.You did a good job with Mr. Adams.Asking Mr. Smith to repeat your instructions abouttaking his medications was a good patient educationtechnique.3735. Focused on Behaviour Rather Than on The Person orPersonalityFocus on the behaviour, don’t make assumptions regardingmotives or intentThe information that is fed back to the trainees shoulddeal with actions, not interpretations or assumedintentions.This allows for psychological distance.For example, “The antibiotic regimen chosen did notprovide coverage for enterococcus”, is less likely tooffend than would, “Your choice of antibiotic indicates alack of appreciation for the possibility of enterococcalinfection.”Focus on the decision not the decision maker.Behaviour must be changeablePersonality traits, unless they are manifested in behavioursthat can be observed and reviewed, are not appropriate forfeedback.If behaviours are observed that are not within the trainee’spower to change, these should not be included as feedback.374TASK:Give good and bad examples&Specific Rather Than GeneralThe information should deal with specifics, making use of realexamplesGeneralizations, such as references to the trainee’sorganizational ability, efficiency, or diligence, rarely conveyuseful information and are far too broad to be helpful asfeedbackTASK:Give good and bad examples7. Balanced: Provide Both Positive and Negative Comments375&Rapport: Based on Trust, Honesty, and ConcernBoth on the same sideCommon goals: Quality patient care / learningTask:Give good and bad examples9Stop and Listen: Resistance Means Non-ReceptivenessUnderstood: have the receiver try to rephrase the feedbackWhile giving feedback, if you feel resistance, it is best to stopand listen. If the learners become resistant, they stop listeningand begin thinking about their responses. By being alert tononverbal cues of inattention, you can stop and allow thelearner to respond.Task:Give good and bad examples376IQ. Agreement of Others:When feedback is given in the presence of others, both giverand receiver have an opportunity to check with others in thegroup about the accuracy of the feedbackTask:Give good and bad examples11. Avoid overload:It involves the amount of information the receiver can userather than the amount he would like to giveI 2. Be brief: Say it onceOther Tips for GivingFeedback“Feedforward”Let students know what is expected377Solicited feedback is bestFeedback works best when it is solicited rather than imposedTake advantage of students’ requestsSnaitivi1y to your valuesIf an answer has no right or wrong answer, then be sensitive toyour values, and do not impose them on the learner“My way to skin a cat”Ego sandwich”i.e., “Good / Bad / Good Sandwich”Avoid the bologna sandwichDon’t sandwich negative feedback in between too manyaccolades or the person may not hear the reprimandRole Play: Evaluation & FeedbackINSTRUCTIONS:Resident gives feedback to their current MSIAnother resident takes on role of MSIOther residents use checklist to determine effectiveness offeedback378Debriefing“MSI” firstResident secondChecklist lastManaging MistakesCan you picture that the experience of most medical studentsand residents is that disclosing their needs is punished, whilehiding their needs is rewarded? In other words, medicalstudents and residents often find that they are treated betterwhen they appear competent, even when they are not.Goethe (1991)The most fruitful lesson is the conquest of one’s ownerror. Whoever refuses to admit error may be a greatscholar but he is not a great learner. Whoever isashamed of error will struggle against recognizing andadmitting it, which means that he struggles against hisgreatest inward gain.379Managing Student MistakesStep One:Create an atmosphere that is nonthreatening andnonjudgemental, so that open discussion of mistakes can occurStep Two:Ensure that supervision is adequate so that errors are detectedStep Three:Determine the cause of the errorEvery attempt should be made to separate the action(mistake) from the personStepEoDetermine a course of action for remediationFor the patientFor the studentInconsequential mistakes can be used to demonstrate whatneeds to be done should a serious error occurStudents need to learn to recognize their limits, learn to askfor help and how to get itStep Five:Address the emotional needs of the learner380Conducive to emotional supportHelp students deal with distress and guiltTasks for the Week1. Sit down with your MSIs for a formal feedback session - usethe “12 Steps”2. Use informal feedback constantly - keep track of examplesFeedforwardHave the group provide feedback to each other381Session 4- Questioning and Non-Facilitating TeachingBehavioursAgendaReview of Last Week’s TasksIntroductionLevels of Questioning-”KAP”:Knowledge, Application, & Psychomotor SkillsQuestioning TechniquesMicroteaching: QuestioningSix Common Nonfacilitating Teaching BehavioursReflection Exercise: Nonfacilitating Teaching BehavioursTasks for the WeekReview of Last Week’s Tasks1. Sit down with your MSIs for a formal feedback session - usethe “12 Steps”2. Use informal feedback constantly - keep track of examplesFeedforwardHave the group provide feedback to each other382IntroductionTrue learning begins by not knowing the answer.Questioning is an activity that is all too often interpreted bystudents or designed by instructors to be akin to theinquisition.“Pimping”Instructors can use questions to lead students through alllevels of thinking, from simple remembering to high levelcritical thinking. Unfortunately, however, all too often thefocus of the questioning is at the simplest level - askingstudents only to remember and repeat what they havelearned.Levels of Questioning- “KAP”: Knowledge, Application, &Psychomotor SkillsMnemonic: “KAP”Knowledge: RememberApplication: UnderstandProblem Solve: Analyse, synthesize, evaluateSame mnemonic as CAP: Cognitive Affective Psychomotor383“Fact” questions are of even lower levele.g., What was the Hb today?e.g., What was the urine output?This is by far the most common type of question askedby residents !!TASK:Give examples of each type of question on the following topicsCaptoprilCOPDCHFetc.“double barrel”One strategy for teaching is to give the students newknowledge (i.e., a fact) and immediately ask a follow-upquestion that requires application or another higherlevelQuestioning TechniquesQuestioningBgin With Assessment384If you are not aware of the learner’s current knowledge,attitude and skills, teaching may be inefficient andunproductive.Through questioning you can find out, what the learners’ doand don’t know so you can aim instruction towards what theydon’t know.This also “activates” prior knowledge.The difficulty with assessing knowledge is that the studentsand residents may feel that they are being tested.ElicitingQuestionsEliciting questions are used to start a discussion.Like a good history, it is often better to start with an openended question, then move in with more closed questions.When you move onto a new topic, start with an openended question again.Think of using open and closed questions as like playingthe accordion.If the response to the eliciting question is incorrect,incomplete, inappropriate or disorganized, the instructor hasan option.They can utilize probing questions to guide the studentto the desired response, orthey can correct, complete, clarify or organize the385answer for the student.PmngQjsnProbing questions are designed to lead students to thearticulation of the correct or more appropriate response andaid the instructor in determining depth of student’scomprehensionProbing questions are more likely to be necessary with higherorder questionsThere are five categories of probing questions:1. Prompting2. Justification3. Clarification4. Extension5. Redirection1. Prompting.Follow up Q(s) with hints or cuesInstructor follows-up a student’s initially weak or incorrectanswer with another question or series of questions containinghints or clues.Can often trigger the student’s thinking.386Can also be used to encourage and support a student who isreluctant to answer because he is afraid.TASK:Give examples of prompting questions2. Justification.“Why ?“Asks the student to give the reason for his particular responseor to explain why he chose to respond as they did.This permits the instructor to determine the student’sperception and understanding of his own answer.Allows one to assess a faulty reasoning strategy.Often, it is important for the student to have not only acorrect response to a question, but also to understand whythat response is correct.“The right answer for the wrong reason”TASK:Give examples of justification3873. Clarification.Rephrase / explain (i.e., no hints or clues)Useful when the student has given a poorly organized orincomplete (not incorrect) response.No hints or clues are added.You simply ask the student to rephrase or explain theresponse.TASK:Give examples of clarification4. Extension.Elaboration / detailBoth clarification and extension questions are used to keep thestudents on the same train of thought, but to make certainpoints more explicit and complete.Extension questions asks the student to elaborate on a correctresponse by providing additional information or more detailedexplanation of the answer.388TASK:Give examples of extension5. Redirection.Involve another studentAsking the same question of another student.This increases student interaction.This increases wait time and therefore indicates to studentsthat they should not turn off their thinking because somebodyelse has answered the question.TASK:Give examples of redirectionMicroteachingINSTRUCTIONS:Each resident will assume that the other residents are students389and teach a topic of their choice using the Socratic Q-Amethod (5 mm each).Six Common Nonfacilitating Teaching Behaviours1. Insufficient “Wait Time”Students who note that the instructor answers apreponderance of his own questions without waiting for aresponse, soon grow dependent upon the teacher to do theirthinking for them.2. The Rapid RewardSimilar effect to insufficient wait time.Learning is a highly individualistic process, people learn atdifferent rates and in varying ways.Rapid acceptance of a correct answer favours the fast thinkeror speaker who has completed his thought process; those inmidthought are terminated prematurely.To ameliorate this situation, encourage student to studentdialogue, discussion, and peer critiquing of each others’ ideas.3903. The Programmed AnswerE.g. Look at this shrub and tell me, what observations you canmake? Do you see the dead stems? Are they damaged frominsects feeding?The programmed answer not only deprives the respondent ofexpressing his own thoughts by steering him towards theanswers that the questioner expects, but also conveys themessage that there is really little interest in what he thinks orsays.While programming can be an effective tool when one desiresto guide students’ thinking, suggest possibilities, or modellogical thought processes, it is important to be aware of it’slimiting effects in opening up a wide variety of possible ideas.4. Nonspecific Feedback QuestionsMany instructors feel justified in assuming that their studentshave no questions if no one responds when they ask, “Arethere any questions? Do you all understand?”What type of student will bravely call attention to his ownignorance when the question is posed in such a way?3915. The Teacher’s EgoStroking and Classroom ClimateStudents need to feel that it is psychologically “safe” toparticipate, to try out ideas, to be wrong as well as right.6. Fixation At Low Level Of QuestioningSkillful teachers use questions to guide thinking as well as testfor comprehension.Too often, however, questions become fixated at theinformational level, requiring students only to recall bits andpieces of a rote memorized data.Remember “KAP”REFLECTION EXERCISE:Now that you are familiar with non facilitating teachingbehaviours, review the teaching that you did in the task above.Critique your teaching for non facilitating teachingbehaviours.Now give the others a chance to critique your teaching.392Tasks for the Week1. Learn the mnemonic KAP (Knowledge, Application, ProblemSolving). Reflect while you are teaching: are you fixed at a lowlevel of questioning? Try to move to higher levels.2. Use the 5 types of probing questions rather thananswering your own questions when a student doesn’t know orgets the wrong answer.1. Prompting2. Justification3. Clarification4. Extension5. Redirection3. Review the list of non facilitating teaching behaviours.Catch yourself using them.393Session 5 - Cognitive Learning Principles and Problem SolvingAgendaReview of Last Week’s TasksCognitive Learning PrinciplesDiscovery Learning ExercisesReflection ExerciseProblem Solving StrategiesTasks for the WeekReview of Last Week’s Tasks1. Learn the mnemonic KAP (Knowledge, Application, ProblemSolving). Reflect while you are teaching: are you fixed at a lowlevel of questioning? Try to move to higher levels.2. Use the 5 types of probing questions rather thananswering your own questions when a student doesn’t know orgets the wrong answer.1. Prompting2. Justification3. Clarification4. Extension5. Redirection3943. Review the list of non facilitating teaching behaviours.Catch yourself using them.Cognitive Learning PrinciplesIntroductionHow does learning actually occur?TASK:Memorize the following text - give approx. 1 mm.Nobody tells productions when to act; they wait untilconditions are ripe and then activate themselves. Bycontrast, chefs in the other kitchens merely followorders. Turing units are nominated by theirpredecessors, von Neumann operations are all tooscheduled, and LISP functions are invoked by otherfunctions. Production system teamwork is more laissezfaire: each production acts on it’s own, when and whereit’s private conditions are satisfied. There is no centralcontrol, and individual productions never directlyinteracts. All communication and influence is via395pattern in the common work space - let the anonymous“To whom it may concern” notices on a public bulletinboard.It may of course be possible to learn this text by heart,provided that there is enough time for repetition.An important component of actual learning is that the topic isunderstood.This may not have been difficult for people with extensiveknowledge of computer programming and artificialintelligence.What is the problem?An important component of learning is that the studied topicis understood.Those with an understanding of computer science, especiallyartificial intelligence, will have no problem with the abovetext.396Principle OneThe prior knowledge people have regarding a certain subjectis the most important determinant of the nature and amountof new information that can be processed.See example aboveKnowledge cannot actually be transferred but the pupil has tomaster it.The reason for this is that the already available cognitivestructures that can be found in the pupil limits the extent inwhich he can understand new information.Principle TwoTAS K:Memorize the following text - give approx. 1 mm.A newspaper is better than a magazine. A seashore is abetter place than the Street. At first, it is better to runthan to walk. You may have to try several times. It takessome skill but it is easy to learn. Even young childrencan enjoy it. Once successful, complications are397minimal. Birds seldom get too close. Land however,soaks very fast. Too many people doing the same thingcan also cause problems. One needs lots of room. Ifthere are no complications, it can be very peaceful. Arock will serve as an anchor. If things break loose fromit, however, you will not get a second chance.The availability of relevant prior knowledge is a necessary,yet not sufficient, condition for understanding andremembering new information. Prior knowledge also needs tobe activated.Subjects having studied this text with the accompanying title“Making and Flying a Kite”, afterward, remembered almosttwice as much information than those who studied the textwithout the title.Regular education, does however, know quite a lot of examplesin which people do not seem to be able to relate newinformation to what they already know about certain subjects.Prindp1ThreeKnowledge is structured in a certain way within memory.398That structure makes it more or less accessible to be used.Knowledge consists of propositions that are structured insemantic networks. A proposition is an allegation thatcontains two concepts and their interrelation.ischemiavolume BPt preload inotropy f afterloadCHFLHF - RHFbackwards low backwards lowpressure output pressure outputSOB SOAcrackles jvPorthopneaPNDSemantic networks consists of large amounts of propositions399that relate to each other.They are idiosyncratic, and they structure knowledge that aperson already has about a part of reality and at the sametime being structure in reality as it is.Knowledge that is structured in a semantic network shouldabsolutely not be confused with book knowledge.It is a reflection of a person’s experiences, views, and ideas.It may contain inaccuracies, obscurities, and generalities.It will be obvious that the detailed composition of such aknowledge structure, a large amount of relations betweenconcepts and the way in which the structure is made, willstrongly influence that what may be done with thatknowledge.Principle FguTASK:Without using any “tricks”, memorize as many as possible ofthe following pairs:Paired associate tasksWhen you are presented with the first word, you will beexpected to reproduce the second (i.e., write it down) - allow30 sec.400dog bikeschool crowchair flowerman housecomputer pailTV candlepillow discbook curtainplant frameice paperNow, memorize the second list. This time, however, establishan association between the two elements - allow 30 sec.sink carCD picturepaper blanketwire boxplug chairlamp pigpen stampowl shirthelmet phonebox window401Remembering information and recalling information fromone’s memory can be strongly improved when elaboration onmaterial takes place in the learning phase.The second pair elements supposed to be associated with thefirst in the subjects’ memories.The other half was to do the same task, it was advised toactively establish, with every pair, relations between the twocomponents.Researchers called this active way of dealing with learningmaterial elaboration because the pupil “dwells” on the relationbetween two concepts.According to the researchers this approach is so successfulbecause the elaboration within the resulting semantic networkcreates multiple redundant retrieval paths.This facilitates the retrieval of a concept in the memory, whichis necessary because there are several ways to find a certainconcept.e.g., Flash cardsMost of the learning comes form making the flash cardsnot from their subsequent usePurchased flash cards are therefore much less effective402Principle FiveThe ability to activate certain knowledge in the long termmemory and to make it available for use depends on context.An interesting paired associate taskOne half of the group learned the list under water in apool, whereas the other half worked on the edge of thepool.Subsequently, half of the subjects studying under waterwere taken out of the pool and half of those on the edgewere placed in the pooi.Those subjects who did the memory task in the samesurroundings, as in which they had learned the word list,achieved considerably better scores.It is apparent that information which is intentionally learnedand information about context are simultaneously stored in aperson’s memory (even if the context is absolutely irrelevantto the learning task).This process facilitates retrieval of that information later on,that is, if that knowledge can be recalled within the samecontext!403Contextual dependence on learninge.g., can’t remember who someone is out of contexte.g., can’t remember what was studied at home when you getto the exam - different environment, different stress level, etc.Principle SixTo be intrinsically or extrinsically motivated to learn, prolongsthe amount of study time (or to put it in cognitive terms: theprocessing time) and subsequently improves achievement.Hence, there is a linear relationship between the time spent onprocessing the subject matter and the achievementIn intrinsic motivation, the inclination is aimed atunderstanding the subject matter.Extrinsic motivation is characterized by the fact that thesubject matter is studied, not for a purpose in itself, but toachieve other objectives, such as passing an examination,obtaining a degree certificate, increasing self confidence, orhaving a well paid job.ConclusionsBy means of the above given principles, a distinction betweenroughly three different learning processes can be made.4041. Accretion of existing semantic networks by means of addingnew informationActivation of prior knowledge has an important part in thisprocess.2. Restructuring of those networks under the influence of newinformation, for instance, when the pupil is confronted withfacts that conflict with propositions in the existing networkHere, the determining cognitive mechanism is elaboration:producing hypotheses that can give new content to both oldand new informationWhat is considered to be an important facilitating factor, is theconfrontation with problems that challenge someone to thinkof new explanations3. Tuning of available information in the context in which thatinformation has to be appliedIn the above, it has already been stated that activation of priorknowledge is context restrictedKnowledge activation in various situations in which thatknowledge is applicable, is a way to conquer that restrictionIt can be called tuning by facilitation or generalizationimportant to associate acquired knowledge with specificpractical conditions in which that knowledge can be used.405TASK:Consider the above 6 cognitive principles:1. Amount of prior knowledge2. Activation of prior knowledge3. Construction of semantic networks (propositionsbetween two elements)4. Elaboration (“dwelling”)5. Learning (and remembering) in context6. Motivation and time spentWhat circumstance in medical education work for or againsteffective learning ?How can we facilitate effective learning?Problem Solving StrategiesThe Four Strategies of Clinical DiagnosisSackett, Haynes, & Tugwell (1985)1. Exhaustive ApproachMost common method used by medical students406“My little pony” methodLesta1tMthod“Aunt Millie” approachPattern recognition3. Algorithm“Recipe” method4ILypothetico-Deductive MethodProblem solvingImportance of checking process and not just endpointi.e., steps in hypothetico-deductive reasoningMaking other learners aware of the clinical reasoning processso that intuitive problem solving abilities can be developed.IntroductionThere is no general consensus to what it means to problemsolve.Education research negates the possibility of an underlyingproblem solving skill which is widely generalizable.Knowledge is the most important factor in problem solving407ability.Although we may not be able to specifically teach problemsolving, we can provide students with practice.View the Skill From the Learner’s Point of ViewYvan Binette, a Quebec dogsled driver commented that, “Toget a dog to run for you, you have to be real friendly. Youhave to think like a dog. You have to lie down on all fours tosee what the world looks like to a dog...”Become consciously competentProblem Solving Session- Whyl1. Why versus What (i.e. The greater importance of why aquestion is asked, rather than what the answer is)2. The right answer for the wrong reasonWhy is that the right answer?3. Assess faulty reasoning strategiesWhy is that important?Why would you do that?408Two Most Effective Technignes for Teaching Problem Solving1. “Why ?“ QuestionsStudents should be challenged by asking them to support,justify, and defend their answers2. “Model” Problem Solving SkillsThink out loudExplain your “why”Become consciously competentClinical Reasoning Process Can be Divided Into Five BehavioursIt is recommended that you point out these behaviours in alearner centred discussion as they occur so as to bring these toa conscious level1. Information perception and interpretation2. Hypothesis generation3. Enquiry strategies4. Problem formulation5. Diagnostic and or therapeutic decisions409Tasks for the Week1. Memorize and apply the “Cognitive Learning Principles”1. Amount of prior knowledge2. Activation of prior knowledge3. Construction of semantic networks (propositionsbetween two elements)4. Elaboration (“dwelling”)5. Learning (and remembering) in context6. Motivation and time spentTake advantage of these in the way you approach yourteaching.Reflect during your teaching (i.e., reflection-in-action) andreport back next week.2. Use the following techniques for teaching problem solvingA. Why ?“ questionsStudents should be challenged by asking them tosupport, justify, and defend their answersB. “Model” problem solving skillsThink out loudExplain your “why”Become consciously competent410Session 6 - Small Group TeachingAgendaReview of Last Week’s TasksIntroduction / ObjectivesTeacher & Session CharacteristicsGroup Discussion Teaching TechniquesManaging Group DynamicsProgram Evaluation FormsReview of Last Week’s Tasks1. Memorize and apply the “Cognitive Learning Principles”1. Amount of prior knowledge2. Activation of prior knowledge3. Construction of semantic networks (propositionsbetween two elements)4. Elaboration (“dwelling”)5. Learning (and remembering) in context6. Motivation and time spentTake advantage of these in the way you approach yourteaching.Reflect during your teaching (i.e., reflection-in-action) andreport back next week.4112. Use the following techniques for teaching problem solvingA. “Why ?“ questionsStudents should be challenged by asking them tosupport, justify, and defend their answersB. “Model” problem solviiigsicillsThink out loudExplain your “why”Become consciously competentIntroduction / ObjectivesEffective InstructionEffective teachers generally accomplish certain events ofinstruction:1. Begin a session of a short review of previousprerequisite learning2. Follow with a short statement of goals for the session3. Present new material in relatively short steps withlearner practice after each step4. Give clear and detailed explanations5. Ask many questions and obtain responses from alllearners6. Guide learners during initial practice4127. Provide a high level of successful practice8. Provide systematic feedback and constructivecriticismto each learnerTASK:Discuss the “organization” of the Resident Education Teachingsessions and compare to the modelRobert Sega! says that the group discussion leader serves as amidwife to students pregnant with ideas. Thus, a gooddiscussion leader does not direct or convey what he knows,but uses what he knows to convey to students what theythemselves already know or can learn.Objectives“CAP”CognitiveAffectivePsychomotor413Ccgnitive Objectives, Bloom (i956)Recall from the last session:“KAP” - Knowledge; Application; Problem SolvingBelow is a more detailed breakdownFrom the lowest to highest levels1. Knowledge2. Comprehension3. Application4. Analysis5. Synthesis6. EvaluationTASK:Get the residents to brainstorm on the best method forachieving each of the cognitive objectives, making them realizethat more and more active participation is required withincreasing levels of objectives and also that each subsequentlevel builds on prior ones.The lowest level of knowledge can be taught in lectures butnot suitably in group discussions.414The lecture becomes less effective with the successively higherlevels of cognitive learning.At best, a teacher in the lecture can model comprehension,application, analysis, synthesis and evaluation.However, for the students really to reach these objectives amore active role is needed.Here is where the group discussion can be an effectiveteaching method.Of course, knowledge is a prerequisite for achieving thesehigher level objectives.Often group discussions are a disappointment becausestudents lack basic knowledge.Thus, a lecture followed by a group discussion can be aneffective combination.If a lecture is not feasible then a reading assignment can beused as a source of preparatory knowledge.Lectures are very limited in the affective domain.People need to develop their own understanding of theneed for change with an awareness of how they feelabout it and what can be done about those feelingsIn the words of the 19th century, New Englandtranscendentalist, A. Bronson Alcott, “The true teacherdefends his pupils against his own personal experience.”415Teacher & Session CharacteristicsTeacher CharacteristicsTeacher behaviour is associated with successfully leading agroup discussion1. An innate ability in, and belief in the value of, usinginterpersonal interaction as a teaching modality2. A capacity for professional intimacy, and3. An ability to measure and modify the tension level ofthe learner group so as to enhance the learning processIn a group discussion, the leader must give up some controlover the teaching process and its outcome.Share the leadershipA willingness to pause while learners deal with their ownagendas.Tolerance of, and empathy for, the opinions and valuesexpressed.Nonjudgemental acceptance of learners’ statements andopinions, without implying that all statements arecorrect.416Session CharacteristicsGroup discussions can be labelled according to whether theyare:Teacher centredGroup centredLearner centred— A continuum —Based on six characteristics:1. The amount of leadership and direction required ofthe teacher2. The amount of responsibility for the educationaloutcome to be assumed by the teacher3. The degree to which the teacher is responsible forrewarding and reinforcing the learning that occurs4. The level of knowledge of the particular subjectrequired of the learner5. The dominant style of interaction among theparticipants6. The specific techniques of teaching used by thelearner417TASK:Create a matrix with the left hand column including the sixcharacteristics described above and teacher centred, groupcentred, and learner centred as the titles of the three columns.Characteristics Teacher-Centered Group-Centered Learner-Centered1. Amount of High Medium Lowleadership fromteacher2. Degree of High Medium Lowresponsibility byteacher foroutcome3. Amount of High Medium Lowreinforcement oflearner requiredof teacher4. Previous Low Medium Highlevel ofknowledge ofsubject requiredof learner5. Dominant Teacher directed Mutual Problem Open-EndedStyle of Solvinginteraction6. Specific Question & Answer Brainstorming Case Basedtechnique of Reasoningteaching418Group Discussion Teaching TechniquesOjistioningBegin With Assessment“dx the learner”“activate” prior knowledgeElicitingiuestionsProbingQuestions1. Prompting• Follow up Q.(s) with hints or cues2. Justification• “Why ?“3. Clarification• Rephrase / explain (i.e., no hints or clues)4. Extension• Elaboration / detail5. Redirection• Involve another student(s)Nonfacilitating Teaching Behaviours1. Insufficient “wait time”2. The rapid reward4193. The programmed answer4. Nonspecific feedback questions5. The teacher’s ego stroking and classroom climate6. Fixation at low level of questioningQuestioning often is used in a teacher centred groupdiscussion because it allows the leader to initiate discussion,encourage participation, and keep the discussion on track.Avoid playing the game “Guess what I am thinking?”Use both open and closed ended questions.When asking a question, be clear whether you are directing itto the group or a specific individual.Welcome questions from other participants.The options include answering it yourself, redirecting itto the asker, or directing to the group or to a specificindividual.BrainstormingOften used in group centred discussion because it helps agroup explore and expand ideas.Idea generation that allows for suspension of judgement andevaluations so that individuals feel that they can voice ideaswithout criticism by other group members.420Usually followed by idea evaluation.Creative problem solving consists of fact finding, idea finding,and solution finding.Brainstorming“Hitchhike” when appropriate (e.g. build on or extend aprevious suggestion)Four Basic Rules to Brainstorming1. Criticism is ruled out2. Freewheeling is welcomed3. Quantity is wanted4. Combination and improvement are soughtEvaluating each idea as it is generated turns off the thinkingprocess.Brainstorming is most effective when the problem is specificand lends itself to many solutions (e.g. differential diagnosis).Its effectiveness depends upon the reorienting the group tothe ground rules.Case Based ReasoningA term used to describe a composite of techniques including421questioning and brainstorming which promotes self directedlearning and application of factual knowledge.Has the potential to help learners assess their own strengthsand weaknesses.As the name implies, provides the learner with theopportunity to discuss a particular case or topic.Need not be a clinical casee.g., ethics topicAlthough, case based reasoning may be employed in teachercentred and group centred discussions, it is especially wellsuited to learner centred discussions.In learner centred discussions, the group leader assumes therole of learner along with other group members.The “leader” while not providing specific knowledge, may leadthe group by bringing the clinical reasoning process to aconscious level.Recall the techniques to “teach” problem solving skillfrom the last sessionManaging Group DynamicsOne of the Most Important Behaviours to Exhibit is SimplyListening422Do not interrupt the student who is speaking, make commentsor ask additional questions after he or she has finished.There Are Two Types Of Situations You May Have to Deal WithThe student who talks too muchThose who contribute too littleEncourage Student To Student ResponseBe careful to avoid establishing a “wheel” communicationpattern0*423Do not require participants to raise their hands if they wish torespond.In fact, unless too many people ask at once, encourageparticipants to speak spontaneously rather than wait for youto recognize them.If the participants are directing the questions solely to you,redirect the questions back to the group rephrasing them asnecessary and let the students supply the answers, if possible.Intervene WhenA digression is taking too much time424Pauses between contributions are becoming too lengthyStudents are confusing values or inferences with factsLogical fallacies are going undetectedArgument replaces discussionPlay Devil’s AdvocateAnother strategy favoured by some instructors is playingdevil’s advocate to elicit divergent positions or attitudesImplicit dangersTo minimize this risk tell the group when you areassuming the devil’s advocate roleSummarize PeriodicallyWhen you detected students are losing continuity or that theyhave exhausted the line of inquiry, briefly restate the majorpoints that have been established.Then provide a transition into your next eliciting question.If the group is engaged in formal problem solving, you mayneed to ask them to reach consensus on each step in theprocess before moving on to the next step.Provide ClosureLearning psychologists have observed that human beingshave a strong need to see things put together to bring them tosome identifiable conclusion satisfactory or not.425“Wrap up”SummarizeProvide the participants with a sense of achievementClimateHelp students develop a positive attitude towards controversy.Be sensitive to the fact that choices are not always right orwrong. There are “different ways to skin a cat.”Don’t Overburden YourselfYou needn’t be an “expert” to run a small group discussionUse the learners as “resources”You needn’t answer all the questions yourself or even have thefinal worde.g., if attendings are part of the discussion groupdon’t, however, let them take over and turn your session intoa mini-lecturePreparing A Small Group DiscussionThings to Keep in MindPhysical setting.Is it conducive to small group discussionNumber of individuals426“Homogeneity of group”Are there many different levels of learnersPre-existing level of knowledge or experience of participantsYour pre-existing level of knowledge or experiencePick a TopicOne that lends itself to discussionNot too straightforwardGroup must have some prior knowledgetOhjectiv“CAP” - Cognitive, Affective, or Psychomotor?Don’t try to get too many points acrossDetermine the Best Session Characteristics for Your NeedsTeacher, Group, or Learner Centredbased on 6 characteristics:1. The amount of leadership and direction required ofthe teacher2. The amount of responsibility for the educationaloutcome to be assumed by the teacher3. The degree to which the teacher is responsible forrewarding and reinforcing the learning that occurs4. The level of knowledge of the particular subjectrequired of the learner4275. The dominant style of interaction among theparticipants6. The specific techniques of teaching used by thelearnerDetermine What Mix Of Discussion Techniques to UseQuestioningBrainstormingCase based reasoningPrepare Qjiestions or TasksFamiliarize Yourself With ManagiugGrcxupilynamics Beforethe Session428429APPENDIX DSESSION HANDOUTSEffective Feedback: Checklist 430Session 1Introduction: Teaching and Learning 431Session 2Work Rounds and One Minute Teaching Skills 433Session 3Feedback and Evaluation 435Session 4Questioning and Non-Facilitating Teaching Behaviors 437Session 5Cognitive Learning Principles and Problem Solving 439Session 6Small Group Teaching 441Student Evaluation of Resident Teaching Form 443Note:All documents have been printed at 75% of original size toallow binding.430“12 Steps to Effective Feedback”1. Well-timed: The closer to the performance the better[] 2. Iwo way communia1ion: sharing of information• give the student an opportunity for self evaluation[1 3. Ownership: Begin with an I statement• based on first hami observation, not on hear say• subjective data should be labeled as such4. Descriptive rather than evaluativeDescribe, do not label5. Focused on behavior rather than on the person orpersonality• Focus on the behavior, don’t make assumptions regardingmotives or intent• Behavior must be thangcablc6. Specific rather than general7. Balanced: Provide both positive and negative comments8. Rapport: Based on trust, honesty, and concern• both on the same side• Common goals: Quality patient care! learning[] 9. Stop and listen: Resistance means non-receptiveness• understood: have the receiver try to rephrase thefeedback10. Agreement of others: when feedback is given in thepresence of others, both giver and receiver have anopportunity to check with others in the group about theaccuracy of the feedback[] 11. Avoid overload: It involves the amount of information thereceiver can use rather than the amount he would like to give12. Be brief: Say it onceTEACHINGSTYLESROLEMODELING1.Expertconsultant2.Socratic3.CollaborativeteachingADULTLEARNERS•Want tousewhat theylearnsoonaftertheylearnit •Areinterestedinlearningconceptsandprinciples;theyliketosolveproblemsandnotjustlearnfacts.Iftheyparticipateactivelyinthelearningprocess,itiseasierforthemtoapplytheconceptsandprinciplestheyarelearning.•I_earningisbestwhenadultlearnerscanproceedattheirownpace.•Motivationincreaseswhenadultlearnershelptoset learningobjectives.Motivationisusuallyhighestwhenthesubjectmatterrelatestotheimmediateinterestandconcernsoftheadultlearners.•Adultlearners liketoknowhowwelltheyaredoing;feedbackhelpsthemtoevaluatetheirownprogress.•Adultswhoseektoenhancetheirproficienciesseethemselvesasusers,insteadofrecipientsofeducation.•Rolemodeldoesnot alwaysimplygood•Youdon’thavechoiceofbeingornotbeingarolemodel•Beanintentionalrolemodel•powerfulteachingtool•Instructionofattitudes•Wecannottellsomeoneelsehowtobe•Settingtone,paceandexpectationLEARNINGCLIMATE:FAVORABLELEARNINGENVIRONMENT•Enthusiasticteacher•Timesetasideforteaching•Learnerstreatedwithrespect,notintimidated•Interactionbylearnersencouraged“supportiveatmosphere”•“safe”tomakemistakes•positiveattitudetodifferencesofopinion•Teachernotseenasallknowing•Teacher isagoodrolemodelRESIDENTTEACHEREDUCATIONPROGRAMTASKSFORTHEWEEKLReflectonthewayyouinteractwiththejuniors•Whatisyourmainteachingstyle?2.Watchyourattendinginactions•Whatistheirmainteachingstyle?3.Watchforandreportgoodandbadrolemodelingbyyourselfandothers(i.e.attendingsofotherseniorresidents)-whatimpactdoyouthinkithad?4.Watchforandreportonthelearningenvironmentyouprovidetoyourstudents(JHELPFULCLINICALTEACHERS1.Answersquestionsclearly2.Enthusiastic3.Explainthebasisfortheiractionsanddecisions4.Providesstudentswithopportunitiestopracticebothtechnicalandproblemsolvingskills5.Summarizesmajorpoints6.Givesfeedbackwithoutbelittling7.Demonstratesagenuineinterestinstudents8.Strivestomakedifficultconceptseasytounderstand9.Emphasizesconceptualcomprehensionratherthanfactualrecall10.Accessibletostudents11.Providescompetentpatientcareandrolemodeling12.Approachestheirteachingwithdynamismandenergy13.Preparewellforroundsandothercontactwithstudents14.Explainslucidly15.IdentifywhattheyconsiderimportantCLINICALTEACHINGTECHNIQUESFORRESIDENTS‘Planahead•Holdworkroundsearly•Makeaworklist•Groupanddividethetasksformaximumefficiency•Meetwithteamattheendofthedaytoplanthenextday•TkJh1pwkLkLditLuathuijthethi•Lseptr1eachingwkte.Th•BdkzuLwkdghc•Associateideas•Organizeideas•Encouragereading•Askquestionsandexplain•Rephraseorsimplifyquestions•Addressquestionsfirsttothestudentresponsibleforthepatient•Waitforstudenttothink•Considerthesetting;patientpresentornot•Selectanappropriatequestioningstyleduringcasepresentation•Usestrategyofopen-closed-openquestiontodiscusscases•SfLGQQd_ExampbL(RoleModeling)•Irg•Appealtocurrentandfutureinterests•Placeastudentinroleofpracticingphysician•Remindstudenttopreparebroadly,regardlessofspecialtyinterest•Remindstudentofcourserequirements•Arouseconflictingthoughts•Attributesuccesstoefforts,andfailuretolackofeffort•Displayhighexpectations•Emphasizeeachlearner’simprovementratherthancompetition•LFKLatefrfrminicg•Findoutevaluationresponsibilities•Writeevaluationnotesperiodically•Adviseattendingphysicianofproblemstudents•Fulfilldueprocessrequirements•Evaluateobtainmentoftheobjectives.P•Havestudentsindependentlygatherpatientdataandformulatethedifferentialdiagnosis•Posehypotheticalcases•Useadatarepositoryforgroupproblemsolving•Studydecisionanalysis•aL•Explaintheprocedure•Demonstratetheprocedure•Providesupervisedpractice(J I)16.Discusspracticalapplicationofknowledgeandskills.assignthetaskforthestudentto“lookup,,•Whenyouassignatopictolookupmakeitunderstoodthatyouwillfollow-up•giveatimeframeofwhenyouexpecttheanswer•Reservefiveminutesofthebeginningofthenextdaysworkroundsfortheanswers•ifthestudenthasnotdonethework,reassignthetaskwithaclearunderstandingthatthesetasksareimportantandthatyouwillfollowuprationale:•motivatingselfdirectedlearningisoneofthemostimportanttasksthatyoucandoasdinicalteacher.EspeciallyencourageselfinitiatedtasksandcontributionsTiesFORRUNNINGEFFICIENTWORKROUNDS1.Clearobjectives2.Planahead•Holdworkroundsearly•Makeaworklist•Groupanddividethetasksformaximumefficiency•Meetwithteamattheendofthedaytoplanthenextday3.Pre-roundingbyjumors4.Clarifyaheadoftimehowmuchtimecanbespentperpatient•seesickest/mostcomplicatedfirst5.Reviewwithteamhowtodobriefpresentations6.Encourageuseofproblemlists7.Avoidlecturesunlessfewpatients•onetotwobriefteachingpointsperpatient8.Inyoursupervisoryrole,youshouldflipthroughordersandchartsforcompletenessperiodicallySTEPSFOREFFECTIVEDELEGATION1.Communication•Describetheframeworkoftheassignedtask•Describethedesiredresults•Askforcommitment•Agreetoatimetableandanevaluationplan2.Expectations•expectationsmustmatchmaturityandskill3.Ifyoudelegateresponsibility...•youmustalsodelegateauthority4.Don’tbreathedowntheirnecks5.Thepersondelegatedtomustbemadeaccountabletothedelegator6.You’restillontheline•WhilethestudentsareaccountabletoyoutheyarenotaccountabletothenexthigherlevelRESIDENTTEACHEREDUCATIONPROGRAMTASKSFORTHEWEEK1.Beforeeachworkround,reviewthe“Oneminuteteachingsidils”2.Use1.&2.foreveryStudent/Patientencounter(i.e.,“Getacommitment”and“Probeforsupportiveevidence”)3.Trytoteachonshortgeneralpointonmostpatients(i.e.,3.)4.Use4.&5.whereappropriate(i.e.,“Reinforcewhatwasright”and“Correctmistakes”)5.Assign“Selfdirectedlearning”tasks•usetheserelativelysparingly(i.e.,nomorethan1-2/day)•giveatimeframeofwhenyouexpecttheanswerONEMINUTETEACHING•youmayormaynot agreeSKILLSDURINGWORKROUNDS1.Getacommitment2.Probeforsupportiveevidence3.Teachgeneralrules4.Reinforcewhatwasright5.Correctmistakes6.Selfdirectedlearning1.GLascmtznitmnz1cue:•afterpresentingthefads,thestudentsstopstowaitforyour responseorasksforyourguidanceresponse:•Askthestudenttosharewhattheythinkabouttheissuepresentedbythedata‘Issuesmayincludecomingupwithmoredata,proposingahypothesisorpian,developingamanagementplan,figuringoutwhythepatientisnoncompliant,decidingonwhomtoconsultetc.•“Getoffthefence”rationale:•Askingstudentsfor theirinterpretationofthedataassumes,respectfully,thattheyareprocessingaswellascollectingdataandareengagedasproblemsolvingprofessionals•feelincharge-motivation2.PnSvdencue:•whendiscussingthecase,thestudenthascommittedthemselvesandlooksforyoutoeitherconfirmtheopinionorsuggestanalternativeresponse:•beforeofferingyouropinion,askthestudentforwhatevidencetheyfeelsupportstheiropinion•Acorollaryapproachistoaskwhatotherchoiceswereconsideredandwhatevidencesupportedorrefutedthesealternativesrationale:•problemsolvingisdependentonknowledgebase•getanunderstandingofthethoughtprocess•assessfaultyreasoning•helpsavoid,“therightanswerforthewrongreason”3.flactgeneralrukscue:•whilediscussingthecase,youseeanopportunitytoprovideavaluableteachingpoint•i.e.,youknowsomethingaboutitthatthestudentneedsorwantstoknow•i.e.,pearlsandpitfallsresponse:•Providegeneralrules,conceptsandconsiderations,andtargetthemtothestudents’levelofunderstandingrafionale:‘generalrulesareeasiertoremember•higherlevelofunderstandingforfutureapplication•gobeyondthewardroutine•studentscanoftengetbywithsimplylearningthe“wardroutine”andnotfullyunderstandingtheprinciplesthatunderlaythem•routinesoftenchange, principlesaremorelonglastingcue:•student hashandledasituationinaveryeffectivemanner•theymaynotrealizethattheactionwaseffectiveandhadapositiveimpactresponse:•Takethefirstchanceyoufindtocommentonthespecificgoodworkandtheeffectithadrationale:•somegoodactionsarepureluckwhileothersaredeliberate•reinforcementisimportantinfirmlyestablishingskills/competencies•don’tconfusethiswithpraise5.Cszrre.cLmislitkncue:•studentmakesamistake•omissionorcommissionresponse:•Discusswhatwaswrongandhowtoavoidorcorrecttheerrorinthefuture•allowthestudenttocritiquetheirperformancefirstrationale:•preemptmistakefrombeingrepeated•excelientteachingopportunity-learningfrommistakes‘helpstudentsdevelopabilityforselfassessmentandadmitmistakes6.SfZfdirecledieanthlgcue:•whilediscussingthecase,youseeanopportunitytoprovideavaluableteachingpoint •youmayormaynotknowtheanswer‘ifthereisnourgencytoactontheanswercJJ4.TelLtljemwhutLtltaujjcLilgkfOTHERTiesFORGIVINGRESIDENTFEEDBACKTEACHER•letstudentsknowwhatisexpectedEDUCATION•Feedbackworksbestwhenitissolicitedratherthanimposed•Takeadvantageofstudents’requestsPR0GRAill£eLsitLvity_t1,_yi,ur_vaIz4e•Ifananswerhasnorightorwronganswer,thenbesensitivetoyourvalues, anddonotimposethemonthelearner•“Mywaytoskinacat”fEgn4ivith•i.e.,“Good/Bad/ GoodSandwich”•AvoidthebolognasandwichDon’tsandwichnegativefeedbackinbetweentoomanyaccoladesorthepersonmaynothearthereprimandTASKSFORTHEWEEK1.SitdownwithyourMSIsforaformalfeedbacksession-usethe“12Steps”2.Useinformalfeedbackconstantly-keeptrackofexamples•feedforward•havethegroupprovidefeedbacktoeachother1.Welltimed:Theclosertotheperformancethebetter2.1wi,wi,iyciimniuiiLciitiwz.:sharingofinformation•givethestudentanopportunityfor selfevaluation3.O_wjiizsliip:BeginwithanIstatement•basedonfirsthandobservation,notonhearsay•subjectivedatashouldbelabeledassuch4.De.icriptheratherthanevaluative•Dsadbe,donotlabe15.EceLiiJ,hiiEiuiratherthanonthepersonorpersonality•Focusonthebehavior, don’tmakeassumptionsregardingmotivesorintent•Behaviourmustbechangeable6.Sprcifkratherthangeneral7.Bi,zIunei1:•Providebothpositiveandnegativecomments8.Kappirt:Basedontrust,honesty,andconcern•you’rebothonthesameside•Commongoals:QualitypatientcareIlearning9.SQpaJJJiJLfeJL:Resistancemeansnon-receptiveness•undeistoodhavethereceivertiytorephrasethefeedback10. AgreemfILLQfJ#llfri:whenfeedbackisgiveninthepresenceofothers,bothgiverandreceiverhaveanopportunitytocheckwithothersinthegroupabouttheaccuracyofthefeedback11. 4yjijyerlp,iiI:Itinvolvestheamountofinformationthereceivercanuseratherthantheamounthewouldliketogive12.Re_b.riçf:SayitonceMANAGINGMEDICALMISTAKESThemoatfruitfullessonistheconquestof one’sownerror.Whoeverrefusestoadmiterrormaybeagreatscholarbutheisnot agreatlearner.Whoeverisashamedoferrorwillstruggleagainstrecognizingandadmittingit,whichmeansthathestrugglesagainsthisgreatestinwardgain(Goethe,1991).&POfte•Nonthxeatemngandnonjudgemental,sothatopendiscussionofmistakescanoccur£teprwt,•EnsurethatsupervisionisadequatesothaterrorsaredetectedSpThr•Determinethecauseoftheerror•Eveiyattemptshouldbemadetoseparatetheaction(mistake)fromthepersonSJLEr•Determineacourseofactionforremediation•Forthepatient•Forthestudent•Inconsequentialmistakescanbeusedtodemonstratewhatneedstobedoneshouldaseriouserroroccur•Studentneedtolearntorecognizetheirlimits,learntoaskforhelpandhowtogetit•Addresstheemotionalneedsofthelearner•Conducivetoemotionalsupport•Helpstudentsdealwithdistressandguilt“12STEPSTOEFFECTIVEFEEDBACK”LEVELSOFQUESTIONINGMemnJcJ’KAP”Knowledge:RememberApplication:UnderstandProblemSolve:Analyze,synthesize,evaluate“Fact”questionsareofevenlowerlevele.g.,whatwastheHbtoday?e.g.,whatwastheurineoutput?Thisisbyfarthemostcommontypeofquestionaskedbyresidents!RESIDENTTEACHEREDUCATIONPROGRAMTASKSFORTHEWEEK1.LearnthemnemonicKAP(Knowledge,Application,ProblemSolving).Reflectwhileyouareteaching:areyoufixedatalowlevelofquestioning?Trytomovetohigherlevels.2.Usethe5typesofprobingquestionsratherthanansweringyourownquestionswhenastudentdoesn’tknoworgetsthewronganswer.1.prompting2.justification3.clarification4.extension5.redirection3.Reviewthelistofnonfacilitatingteachingbehaviors.Catchyourselfusingthem.QUESTIONINGBegin_with_assermiit-becomeawareofthelearner’scurrentknowledge,attitudeandskills-thisalso“activates”priorknowledgeEgq-usedtostartadiscussion-iftheresponsetotheelicitingquestionisincorrect,useprobingquestions1.prompting2.justification3.clarification4.extension5.redirection1.Prg-FollowupQ(s)withhintsorcues-Instructorfollows-upastudent’sinitiallyweakorincorrectanswerwithanotherquestionorseriesofquestionscontaininghintsorclues-Canoftentriggerthestudent’sthinking-Canalsobeusedtoencourageandsupportastudentwhoisreluctanttoanswerbecauseheisafraid2.1-“Why?“questions-Asksthestudenttogivethereasonforhisparticularresponseortoexplainwhyhechosetorespondastheydid-Thispermitstheinstructortodeterminethestudent’sperceptionandunderstandingofhisownanswer-Allowsonetoassessafaultyreasoningstrategy-Oftenitisimportantforthestudenttohavenotonlyacorrectresponsetoaquestionbutalsotounderstandwhythatresponseiscorrect-Therightanswerforthewrongreason”3.C1ari.fiitth,it-rephrase!explain(i.e.,nohintsorclues)-Usefulwhenthestudenthasgivenapoorlyorganizedorincomplete(notincorrect)response-Nohintsorcluesareadded-Yousimplyaskthestudenttorephraseorexplaintheresponse4.Exteiisiait-elaborationIdetail-Bothclarificationandextensionquestionsareusedtokeepthestudentsonthesametrainofthought,buttomakecertainpointsmoreexplicitandcomplete-Extensionquestionsasksthestudenttoelaborateonacorrectresponsebyprovidingadditionalinformationormoredetailedexplanationoftheanswer5.Kdiritkzt-involveanotherstudent-Askingthesamequestionofanotherstudent-Thisincreasesstudentinteraction-Thisincreaseswait timeandthereforeindicatestostudentsthattheyshouldnotturnofftheirthinkingbecausesomebodyelsehasansweredthequestionNONFACILITATINGTEACHINGBEHAVIORS1.ILttLnte’-instructoranswersapreponderanceofownquestions-theteacherthinksforthestudents2.Thrapidrewiird-Similareffecttoinsufficientwaittime-Rapidacceptanceofacorrectanswerfavorsthefastthinker-thoseinmidthoughtareterminatedprematurely3.Lhprt,grammdJnItwfr-i.e.,answerisinthequestion-deprivestherespondentsofexpressingtheirownthoughts-canbeaneffectivetoolwhenonedesirestoguidestudents’thinking,suggestpossibilities,ormodellogicalthoughtprocesses4.Npififdbkqu,itiguts-“Arethereanyquestions?Doyouallunderstand?”-Whattypeofstudentwillbravelycallattentiontotheirownignorancewhenthequestionisposedinsuchaway?5. crmIün-Studentsneedtofeelthatitispsychologically“safe”toparticipate,totryoutideas,tobewrongaswellasright6.FixatiLhnyieyjrLaf-g-Tooften,however,questionsbecomefixatedattheinformationallevel,requiringofstudentsonlythattheyrecallbitsandpiecesofarotememorizeddata00CLINICALREASONINGPROCESSESIDENT-canbedividedintofivebehaviorsJ’J4hER-Itisrecommendedthatyoupointoutthesebehaviorsinalearnercentereddiscussionastheyoccursoastobringthesetoaconsciouslevel1.InformationperceptionandIR0GR4illinterpretation2.Hypothesisgeneration3.Enquirystrategies4.Problemformulation5.DiagnosticandortherapeuticdecisionsTASKSFORTHEWEEK1.Memorizethe“CognitiveLearningPrinciples”1.Amountofpriorknowledge2.Activationofpriorknowledge3.Constructionofsemanticnetworks(propositionsbetweentwoelements)4.Elaboration(“dwelling”)5.Learning(andremembering)incontext6.Motivationandtimespenttakeadvantageoftheseinthewayyouapproachyourteaching2.Usethefollowingtechniquesfor“teaching”problemsolvingA.“Why?“Questions•shouldbechallengedbyaskingthemtosupport,,justifr,anddefendtheiranswersB.“Model”problemsolvingskills•thinkoutloud•explainyour“why”•becomeconsciouslycompetentCOGNITIVELEARNINGPRINCIPLES-Theprior knowledgepeoplehaveregardingacertainsubjectisthemostimportantdeterminantofthenatureandamount ofnewinformationthatcanbeprocessed-Knowledgecannotactuallybetransferredbutthepupilhastomasterit-Thereasonforthisisthattheallreadyavailablecognitivestructuresthatcanbefoundinthepupillimitstheextentinwhichhecanunderstandnewinformation-Theavailabilityofrelevantpriorknowledgeisanecessary,yetnotsufficient,conditionforunderstandingandrememberingnewinformation.Priorknowledgealsoneedstobeactivated-Regulareducationdoeshoweverknowquitealotofexamplesinwhichpeopledonotseemtobeabletorelatenewinformationtowhattheyalreadyknowabout certainsubjectsThr-Knowledgeisstructuredinacertainwaywithinmemory.Thatstructuremakesitmoreorlessaccessibletobeused.-Knowledgeconsistsofpropositionsthatarestructuredinsn1icnork.Apropositionisanallegationthatcontainstwoconceptsandtheirinterrelation-Rememberinginformationandrecallinginformationfromone’smemorycanbestronglyimprovedwhenelaborationonmaterialtakesplaceinthelearningphase-Researcherscalledthisactivewayofdealingwithlearningmaterial elaborationbecausethepupil“dwells”ontherelationbetweentwoconceptsPrinip1eFiv-Theabilitytoactivatecertainknowledgeinthelongtermmemoryandtomakeitavailableforusedependsoncontext-Thisprocessfacilitatesretrievalofthatinformationlateron,thatisifthatknowledgecan.berecalledwithinthesamecontext!PSix-Tobeintrinsicallyorextrinsicallymotiyatedtolearn,prolongstheamountofstudytime(ortoputitincognitiveterms:theprocessingtime)andsubsequentlyimprovesachievement-Hencethereisalinear relationshipbetweenthetimespentonprocessingthesubjectmatterandtheachievementSummary-6cQgnitLve.prthcipksi1Amountofpriorknowledge2.Activationof priorknowledge3.Constructionof semanticnetworks(propositionsbetweentwoelements)4.Elaboration(“dwelling”)5.Learning(andremembering)incontext6.MotivationandtimespentTHEFOURSTRATEGIESOFCLINICALDIAGNOSIS1.E&pth-mostcommonmethodusedbymedicalstudents-“Mylittlepony”method2.(1eti.i1LMrJ1ud-patternrecognition-“AuntMillie”approach3.A1girithin4.HypthettLie_mthiidprmLthgEFFECTIVETECHNIQUESFOR“TEACHING”PROBLEMSOLVING1.“Why?“questions-Studentsshouldbechallengedbyaskingthemtosupport,,justify,anddefendtheiranswers2. thinkoutloud-explainyour“why”-becomeconsciouslycompetent0TEACHERCHARACTERISTICS•mustgiveupsomecontrol•process&outcome•sharetheleadership•opentolearnersagenda•opentoIearnersopinions andvaluesSESSIONCHARACTERISTICS•Acontinuum•teachercentered•groupcentered•learnercenteredSiracte.rLsiki1.Theamountof leadershipanddirectionrequiredoftheteacher2.Theamountofresponsibilityfortheeducationaloutcometobeassumedbytheteacher3.Thedegreetowhichtheteacherisresponsibleforrewardingandreinforcingthelearningthatoccurs4.Thelevelofknowledge oftheparticularsubjectrequiredofthelearner5.Thedominantstyleof interactionamongtheparticipants6.ThespecifictechniquesofteachingusedbythelearnerRESIDENTTEACHEREDUCATIONPROGRAMEFFECTIVEINSTRUCTION1.Beginasessionofashortreviewofpreviousprerequisitelearning2.Followwithashortstatementof goalsforthesession3.Present newmaterialinrelativelyshortstepswithlearnerpracticeafter eachstep4.Giveclear anddetailedexplanations5.Askmanyquestionsandobtainresponsesfromalllearners6.Guidelearnersduringinitialpractice7.Provideahighlevel ofsuccessfulpractice8.ProvidesystematicfeedbackandconstructivecriticismtoeachlearnerI.MANAGINGGROUPDYNAMICSDISCUSSIONTECHNIQUESPREPARINGASMALLGROUPDISCUSSION•Li,thtg•Si•Thestudentwhotalkstoomuch•Thosewhocontributetoolittle•EgLpw•avoid“wheelcommunicationpattern•REDIRECT••digression•Pausestoolengthy•confusingvaluesorinferenceswithfacts•Logicalfallaciesaregoingundetected•Argumentreplaces discussion•DvdMMe•S_uitm.ariz_perLodiia1Ly•dd•“Wrapup”•Summarize•Providetheparticipantswithasenseofachievement•C1t•positiveattitudetowardscontroversy•“differentwaystoskinacat”•DLthr•Youneedn’tbean“expert”•Usethelearnersas“resources”QgseeprevioussessionhandoutFourbasicrulestobrainstorming1.Criticismisruledout•suspensionofjudgment2.Freewheelingiswelcomed3.Quantity iswanted4.Combinationandimprovementaresought•EvaluatingturnsoffthethinkingprocessCaeB,LReaitnithg•compositeoftechniques•selfdirectedlearning&applicationoffactualknowledge•neednotbeaclinicalcase•leaderassumestheroleoflearner•bringingtheclinicalreasoningprocesstoaconsciouslevel•physicalsetting-isitconducivetosmallgroupdiscussionnumberofindividuals•“homogeneityofgroup”-aretheremanydifferentlevelsoflearners•preexistinglevel ofknowledgeorexperienceof participants•yourpreexistinglevelofknowledgeorexperiencePkkpk•onethatlends itselftodiscussion•nottoostraightforward•groupmusthavesomepriorknowledgeSLah&•“CAP”-Cognitive,Affective,orPsychomotor?•Don’ttrytoget toomanypointsacrossShMarL•Determinethebestsessioncharacteristicsforyourneeds(seenextpage)CQnIh•Determinewhat mixofdiscussiontechniquestouse•Questioning•Brainstorming•CasebasedreasoningGroupdynamics•Familiarizeyourselfwithmanaginggroupdynamicsbeforethesession(seethispage)— VI.— 2.— 3.—4.—--—7.—. 8.—9.—Io.—::—-—-I—I—.-------> 0 0:‘-—------>0 0---.------.------>---------------.> 0®0.0> G®0:00:0--—-----------.>.000 0000 00 0, -‘V)0 0r0:000 000 0000000:0:0 ©I®0:© @j®0:000000:0:0000.00 0.000- _,000C’cV, i).0:00cc®00;000C’.C’ C’:0:00:0443EVALUATION OF CLINICAL TEACHINGInstructor’s Name:__________________________— n... ,, i.., .,. Instructions: Please read the criteria for each set— 0 ‘‘ 000000 coo . ,.. of statements and rate each statement by filling—in the appropriate bubble. Note also the write-in— c C. 0000000000•0 sections reserved for general comments on the—o oocoooooooo back of the form.——CCC DZOCCJ :CC. CZCJ Disagree Strongly— C0ODCCOCCCCDCCZCC—Nf’ C’(VC’C’.C’ NC’ Disagree Somewhat—___0000COOCZCCCC —____________ _______-—Equivocal C—GENERAL PURPOSE DATA SHEET IIform no 70921 Agree Somewhat____Agree Strongly —IS CLEAR AND ORGANIZED(stresses important concepts)IS ENTHUSIASTIC AND STIMULATING(enjoys teaching and profession, is dynamic and energetic)ESTABLISHES RAPPORT (sho respect andpersonal interest in students, listens and is supportive)ACTIVELY INVOLVES STUDEWIS (stimulatesUlought, asks chaflengmg questiods, answers questions precisely.IS KNOWLEDGEABLE AND ANALYTICAL(in regaxd to breadth, analysis and synthesis of ideas)DEMONSTRATES CLINICAL SKILLSPROVIDES DIRECTION AND FEEDBACK ON WORKIS PROFESSIONAL IN MANNER (is se1fassured, opento opinions of others, responsible and respectful)ADDRESSES THE DESIGNATED INSTRUCTIONALOBJECTIVES OF THE COURSEIS OVERALL AN EFFECTIVE INSTRUCTOR VPlease write your general comments in Write-in Areas 1. 2, and 3on the back of this form.;II444445APPENDIX FITEM STATISTICS- FINAL INSTRUMENTSUBTEST 1 TEACHING EFFICACY SUBSCALEITEM NUMBER 1MEAN S.D. ITEM CORRELATION3.400 0.821 0.358ITEM NUMBER 2MEAN S.D. ITEM CORRELATION4.800 0.410 0.372ITEM NUMBER 3MEAN S.D. ITEM CORRELATION4.750 0.550 0.286ITEM NUMBER 4MEAN S.D. ITEM CORRELATION3.200 0.768 0.427ITEM NUMBER 5MEAN S.D. ITEM CORRELATION3.100 0.912 0.434ITEM NUMBER 6MEAN S.D. ITEM CORRELATION4.400 0.503 0.236SUBTEST STATISTICSNUMBER OF INDIVIDUALS = 20.00 NUMBER OF ITEMS = 6.00MEAN = 23.65 HIGHEST SCORE = 27.00STANDARD DEVIATION = 2.39 LOWEST SCORE = 17.00HOYT ESTIMATE OF RELIABILITY = 0.61STANDARD ERROR OF MEASUREMENT = 1.37446SUBTEST 2 TEACHING SELF-EFFICACY SUBSCALEITEM NUMBER 1MEAN S.D. ITEM CORRELATION3.800 0.696 0.803ITEM NUMBER 2MEAN S.D. ITEM CORRELATION4.350 0.671 0.600ITEM NUMBER 3MEAN S.D. ITEM CORRELATION3.600 0.940 0.621ITEM NUMBER 4MEAN S.D. ITEM CORRELATION4.100 0.308 0.344ITEM NUMBER 5MEAN S.D. ITEM CORRELATION3.800 0.696 0.717ITEM NUMBER 6MEAN S.D. ITEM CORRELATION3.350 0.813 0.427ITEM NUMBER 7MEAN S.D. ITEM CORRELATION4.050 0.510 0.468ITEM NUMBER 8MEAN S.D. ITEM CORRELATION4.300 0.733 0.747ITEM NUMBER 9MEAN S.D. ITEM CORRELATION4.050 0.759 0.678ITEM NUMBER 10MEAN S.D. ITEM CORRELATION3.450 0.605 0.703ITEM NUMBER 11MEAN S.D. ITEM CORRELATION3.350 0.671 0.384ITEM NUMBER 12MEAN S.D. ITEM CORRELATION4.600 0.598 0.461SUBTEST STATISTICSNUMBER OF INDIVIDUALS 20.00 NUMBER OF ITEMS = 12.00MEAN = 46.80 HIGHEST SCORE = 57.00STANDARD DEVIATION = 5.38 LOWEST SCORE = 33.00447HOYT ESTIMATE OF RELIABILITY = 0.88STANDARD ERROR OF MEASUREMENT = 1.79SUBTEST 3 SELF REPORTED BEHAVIORS SCALEITEM NUMBER 1MEAN S.D. ITEM CORRELATION3.550 0.887 0.711ITEM NUMBER 23.850 0.813 0.000ITEM NUMBER 3MEAN S.D. ITEM CORRELATION4.000 0.459 0.356ITEM NUMBER 4MEAN S.D. ITEM CORRELATION3.500 0.827 0.297ITEM NUMBER 5MEAN S.D. ITEM CORRELATIONITEM NUMBER 6MEAN S.D. ITEM CORRELATION3.500 0.688 0.441ITEM NUMBER 7MEAN S.D. ITEM CORRELATION4.050 0.510 0.491ITEM NUMBER 8MEAN S.D. ITEM CORRELATION3.400 0.883 0.481ITEM NUMBER 93.250 0.851 0.555ITEM NUMBER 10MEAN S.D. ITEM CORRELATION3.550 0.826 0.242ITEM NUMBER 11MEAN S.D. ITEM CORRELATION3.950 0.394 0.389ITEM NUMBER 12MEAN S.D. ITEM CORRELATION3.650 0.813 0.207ITEM NUMBER 13MEAN S.D. ITEM CORRELATION4483.800 0.616 0.584ITEM NUMBER 14MEAN S.D. ITEM CORRELATION4.050 0.605 0.415ITEM NUMBER 15MEAN S.D. ITEM CORRELATION3.400 1.046 0.723ITEM NUMBER 16MEAN S.D. ITEM CORRELATION4.200 0.616 0.303SUBTEST STATISTICSNUMBER OF INDIVIDUALS = 20.00 NUMBER OF ITEMS = 16.00MEAN = 58.85 HIGHEST SCORE = 69.00STANDARD DEVIATION = 5.98 LOWEST SCORE = 49.00HOYT ESTIMATE OF RELIABILITY = 0.81STANDARD ERROR OF MEASUREMENT = 2.55449APPENDIX FSCORES: RAW DATARaw Scores: Control PreI.D. TE TSE SRBC1A1O1 26.00 48.00 53.00C1B1O2 20.00 43.00 52.00C1C1O3 24.00 38.00 44.00C1D1O4 27.00 36.00 51.00C1A205 21.00 43.00 59.00C1B206 28.00 51.00 62.00C1C207 22.00 37.00 38.00C1D208 22.00 38.00 54.00450APPENDIX FRaw Scores: Control Post—I.D. TE TSE SRBC2A1O1 25.00 50.00 49.00C2B102 24.00 40.00 52.00C2C103 24.00 44.00 50.00C2D104 26.00 40.00 52.00C2A205 24.00 45.00 61.00C2B206 26.00 53.00 67.00C2C207 25.00 40.00 46.00C2D208 21.00 43.00 58.00451APPENDIX FRaw Scores: Treatment PreI.D. TE TSE SRBT1A1O9 20.00 37.00 42.00T1B11O 28.00 39.00 47.00T1C111 23.00 41.00 52.00T1D112 23.00 46.00 45.00T1A213 22.00 30.00 53.00T1B214 17.00 33.00 59.00T1C215 26.00 46.00 64.00T1D216 24.00 43.00 45.00T1B317 22.00 41.00 53.00T1C318 20.00 42.00 60.00T1D319 27.00 45.00 54.00452APPENDIX FRaw Scores: Treatment Post-I.D. TE TSE SRB SRB-retroT2A109 25.00 55.00 72.00 36.00T2B11O 28.00 46.00 65.00 46.00T2C111 28.00 45.00 63.00 47.00T2D112 25.00 45.00 59.00 41.00T2A213 22.00 38.00 58.00 44.00T2B214 18.00 39.00 59.00 64.00T2C215 20.00 45.00 67.00 61.00T2D216 18.00 46.00 60.00 50.00T2B317 23.00 42.00 58.00 44.00T2C318 21.00 44.00 64.00 45.00T2D319 27.00 53.00 68.00 48.00APPENDIX FStats: ControlTE TSE SRBPreMean 23.75 41.75 51.63S.D. 2.96 5.50 7.69PostMean 24.38 44.38 54.38S.D. 1.60 4.87 7.03453454APPENDIX FStats: TreatmentTE TSE SRBPreMean 22.91 40.27 52.18S.D. 3.27 5.20 6.97PostMean 23.18 45.27 63.00S.D. 3.71 5.10 4.67TE = Teaching EfficacyTSE = Teaching Self -EfficacySRB = Self-Reported Teaching Behaviours455APPENDIX GCONSENT FORMResident Teacher Training Program-Consent-Chief Investigator: Ric Arseneau, MD, FRCPC 682-2344Faculty Advisor: Kip Anastasiou, PhD 822-5316The “Resident Teacher Training Program” consists of a series of weekly, one hourworkshops on various aspects of clinical teaching (total 8 hours). This program isnot only an educational activity for residents, but also a research project for thechief investigator. The sessions will be audiotape recorded for data analysis.Participants will be required to complete a questionnaire at the beginning and at theend of the workshop. They may also be asked for their thoughts on various aspectsof the program by way of a short interview at the end of the program.The transcripts will be kept confidential, and no names will be included. Aftercompletion of the data gathering the tapes will be erased.Although your participation would be greatly appreciated, you are under noobligations to participate and can withdraw at any time without any consequences.Should you have any questions, feel free to discuss them with Dr. Arseneau (eitherin person or at the above number).I consent to participate in the “Resident Teacher Training Program”*, and havereceived a copy of this consent form.Signature Date

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