Reflection on the development of an e-learning course for registrars

This module was special in various ways, not the least because of the wrong impression I had of e-learning. Thinking back, I probably thought of e-learning as Webstudies making your life easier and perhaps of nice little video programs which someone else developed to facilitate learning (but never exactly what you are looking for).
There were many stimulating new experiences. Participating in the blog discussions was exciting and often thought provoking. The continuous input of the lecturers throughout the course was of great value. But, apart from the content, one also became aware of the potential of these discussions in an organisation such as an Obstetrics and Gynaecology department where some members are always on call or post-call and therefore often cannot attend academic discussions. I followed all references to webpages, became adventurous and found a couple “of my own” on Powerpoint and becoming an e-learner site developer, joined several blogsites and exhausted my Vodacom internet account.
The emphasis on the learning (and not the “e”) in e-learning was important. This module tied the different modules in the MPhil course together, forcing me back to my notes on learning, curriculum development, leadership, facilitating learning and also assessment. I was surprised about the few references to the ADDIE approach in the medical literature – has no obstetrician ever used it before? I was sometimes uncertain how to interpret different articles on ADDIE, as it sometimes seemed as if there were too much overlap between phases and also repetition of work done in a previous phase. Till I saw that there were more than 100 variations on the theme and realised that one has to adjust the approach to your own needs to some extent.
There is a real need for registrars to be better teachers. It took some thinking to decide where in the current MMed course this could be fitted in and how much content should included. It was a nice challenge to build this course around the principles of adult learning – registrars differ from undergraduates in many ways and I once again wondered if (all) undergraduates are really adult learners. I was convinced, after reading a couple of publications especially from the field of nursing, that the constructivist approach was ideally suited for the development of e-learning courses for adults. Till I heard about connectivism. I found Siemens’s original (and subsequent) work and have little doubt that this is the one publication which I encountered during the module which I have to highlight. Normally I would have probably chosen a scientific article with clearly described methods, but Siemens’s persuasive arguments for a learning theory addressing the challenges of the 21st century convinced me. (Siemens G. Connectivism: A learning theory for the Digital Age. International Journal of Instructional Technology and Distance Learning 2005; 2: 3 – 9). He emphasises several points. One is the change in knowledge, which is expanding at a rate unknown previously – available knowledge is doubling every 18 months. Informal learning has developed in importance to such an extent that formal education is no longer the most important way of learning. The importance of technology is highlighted throughout the article and the limitations of behaviourism, cognitivism and constructivism are discussed in detail. These learning theories deal mainly with the belief that learning occurs within a person. In the digital age learning can reside outside a person. The questions posed by technology to existing learning theories require revision to such an extent that an entirely new approach is required. The result is a new theory combining components of existing learning theories, social structures and technology. The principles of connectivism are as follows:

* Learning and knowledge rests in diversity of opinions.
* Learning is a process of connecting specialized nodes or information sources.
* Learning may reside in non-human appliances.
* Capacity to know more is more critical than what is currently known
* Nurturing and maintaining connections is needed to facilitate continual learning.
* Ability to see connections between fields, ideas, and concepts is a core skill.
* Currency (accurate, up-to-date knowledge) is the intent of all connectivist learning activities.
* Decision-making is itself a learning process.

One cannot fault any of these principles. However, the readiness of the individual will determine the success of its implementation. I still cannot knit, but that is due to lack of trying. Perhaps our approach to teaching of registrars is to blame. We cannot deny that, even at the postgraduate level, there is still a degree of “spoon feeding” necessitate by students’ lack of readiness to use the technology, the often present inability to distinguish between what is really important, and of course, the implications of selecting wrong information in a discipline where an estimated 9000 babies died between 2005 and 2006 because of wrong decisions taken by health care workers. We clearly have much to do.
A bit of good news to end off. Our head of department is very enthusiastic about e-learning and has arranged that I will have one week per month set aside to work exclusively on the development of e-learning within our department. How’s that?

Regards

Wilhelm

Outcomes and a few Storyboard pages

I have finished the planning for the "Registrars as Teachers" course but find myself continuously making changes, especially in the fine print. I also have to finalise the sources I intend recommending to the registrars - I am trying to restrict each topic to one or two references given their very busy clinical program, as well as other examinations they have to prepare for. The course (currently) consists of six themes, each in turn consisting of one or two sessions. I have uploaded this document on Google Docs and the link is http://docs.google.com/fileview?id=0B_lUh2NOX0GRZGUwZWY2ODgtOTEzZS00N2ZkLWE4OGEtZTU2ODVjMTJmY2Rl&hl=en. The document can be read by copying and pasting the address into the web address space. I will appreciate comments - remember that the sources are incomplete. It may also be difficult to make total sense from the activities in the abbreviated format, but it will be clearer in the "ADDIE documents". I also prepared a storyboard which I created for myself. I also attach three pages which I have prepared for the Theme 1 Session 1. The link is http://docs.google.com/fileview?id=0B_lUh2NOX0GRZDYwNzhkMmEtYjMxNy00YWU4LWJhZDEtNzllY2VmYzBhZWMx&hl=en, but it seems a bit temperamental, sometimes loading easily, other times giving error messages. The pages makes sense to me and it helped me to develop the pages which the students will see. I do it in Powerpoint, including using the sound function. I have downloaded the program to convert the PTT-file to I am thinking to include video's of simulated situations for my cases, but do not know whether there will be time to do that. I do not do so well using my own voice for the sound files - will definitely haev to find someone better.

Hoping to hear from you soon.

Wilhelm

Student-Student interaction - What is best?

Different learning theories can contribute to the development of online programs. Behaviourist approaches can support teaching of facts (what), cognitivist strategies the attitudes and procedures (how), and constructivist strategies the real-life and individual applications and contextual learning. Connectivism addresses the learning skills and tasks needed for learners to do well in a digital era. It recognizes that learning is no longer an internal, individualistic activity.

Registrars are adult, postgraduate students aspiring to become medical specialists.

When developing an e-learning course to equip them as teachers, the available technologies should be used to develop a program based on adult learning principles. Some may reason that this includes registrar involvement in the planning and development of the module, but I would argue against that at this point. Data obtained from student interns’ questionnaires indicate inexperience, uncertainty and possibly an unwillingness to teach amongst registrars. However, based on Knowles’s original work, the educator should not have complete control once the course is developed. The program should allow for student autonomy and should recognize registrar’s life experiences, including professional knowledge, on which they can build new knowledge. Goal-orientation may be somewhat of a problem, as not all registrars may see teaching as essential to qualifying as an obstetrician. However, this may be countered if some other characteristics of adult learning as defined by Knowles are taken into account. Adult learners need relevancy, but they are practical. The learning has to relate to their work, which include supervision of students. Registrars are actually currently assessed on their teaching of undergraduates every three months, but it is not specified what the consequences are of persistently performing unsatisfactorily in this evaluation. All consultants should assist in improving the status of teaching by directly attending to the registrar’s teaching skills on combined ward rounds and other clinical areas. If registrars see that learning something about teaching applies to their work or other responsibilities, they will value it more. It is important for them to understand the usefulness of a lesson.

However, I do not really want to write about the application of adult learning principles to e-learning. That could be a topic for another day. I am specifically thinking about the place of student-student interaction in adult learning. This is a central consideration in modern constructivist theory which assists students in developing multiple perspectives. There are several (evidence-based) advantages associated with collaborative learning. Without exhausting the literature, I came across improved development of important social and interpersonal skills, gains in knowledge and increased completion rates of courses as well as improved investigation of implicit knowledge (shared by group members) in addition to the formal curriculum.

So I have decided that interactive discussion is an essential component. However, I am uncertain as to which format of discussion is best. I am only familiar with the WebStudies discussion board, as well as the “blog system”. Both will fit the purpose, as I only foresee asynchronous discussions. I tried a mobisite approach to set up a discussion group for student interns, but several of the students did not have cell phones with which they could access the site. Will a blog work? I specifically like the advantage of being informed of new postings by the use of RSS, which prevents "unnecessary log-ons". I also think that the organisation of comments under the posting makes following the discussions easy. Or is the advantage that messages can be threaded in traditional discussion boards enough to rather use them?

Perhaps I can summarise my (current) thinking on my first theme, which consist of two sessions.

THEME 1: THE UNDERGRADUATE STUDENT IN OBSTETRICS

SESSION 1: YOUR OWN DAYS AS UNDERGRADUATE STUDENT

GOALS OF SESSION: TO REFLECT ON YOUR DAYS AS FINAL YEAR UNDERGRADUATE STUDENT IN OBSTETRICS

ACTIVITIES: 1. COMPLETE THE QUESTIONNAIRE ON THE WEBPAGE. 2. WRITE SHORT NOTES ON HOW YOU REMEMBER YOUR OWN ROTATION AS UNDERGRADUATE STUDENT IN OBSTETRICS ACCORDING TO THE REQUIREMENTS AS STATED. PUBLISH THEM ON THE BLOGSITE AND COMMENT ON THOSE OF YOUR PEERS.

OUTCOMES: 1. LIST THREE POSITIVE MEMORIES OF YOUR OWN UNDERGRADUATE ROTATION THROUGH OBSTETRICS 2. LIST THREE NEGATIVE MEMORIES OF YOUR OWN UNDERGRADUATE ROTATION THROUGH OBSTETRICS. 3. DEFINE YOUR OPINION OF WHAT LEARNING DURING AN UNDERGRADUATE ROTATION THROUGH OBSTETRICS ENTAILS.


SESSION 2: UNDERGRADUATE TEACHING AT THE FACULTY OF HEALTH SCIENCES

GOALS OF SESSION: TO FAMILIARIZE YOURSELF WITH THE CONTENT AND PHILOSOPHY OF UNDERGRADUATE TEACHING AT STELLENBOSCH UNIVERSITY.

ACTIVITIES: 1. PARTICIPATE IN THE DISCUSSION ON THE BLOGSITE ON THE ORGANIZATION OF THE MBCHB COURSE AT SU. 2. PARTICIPATE IN THE DISCUSSION ON THE BLOGSITE ON THE ORGANIZATION OF THE OBSTETRICS AND GYNAECOLOGY COURSE AT SU. 3. PARTICIPATE IN THE DISCUSSION ON THE BLOGSITE ON THE “PROFILE OF THE STELLENBOSCH DOCTOR” ACCORDING TO THE REQUIREMENTS AS STATED. 4. PARTICIPATE IN THE DISCUSSION ON THE BLOGSITE ON THE OF STUDENT INTERNS’ EXPECTATIONS OF THIS ROTATION.

OUTCOMES: 1. EXPLAIN THE STRUCTURE OF THE MBCHB COURSE AT SU. 2. EXPLAIN THE COMPONENTS OF THE OBSTETRICS AND GYNAECOLOGY TEACHING AT SU. 3. SUMMARISE THE CORE CHARACTERISTICS (AS IDENTIFIED BY YOU AND YOUR COLLEAGUES) OF THE PHILOSOPHY TOWARDS UNDERGRADUATE TEACHING AT SU. 4. EXPLAIN HOW STUDENT INTERNS ARE ASSESSED DURING THEIR ROTATION THROUGH OBSTETRICS AND GYNAECOLOGY. 5.EXPLAIN THE FIVE MOST COMMON EXPECTATIONS OF STUDENT INTERNS FROM THIS ROTATION.

SOURCES: 1. SHORT INTERVIEWS WITH AT LEAST TWO CONSULTANTS, TWO STUDENT INTERNS AND ONE COLLEAGUE WHO TRAINED AT SU AS UNDERGRADUATE STUDENT.2. YEARBOOK OF SU. 3. PROFILE OF THE STELLENBOSCH DOCTOR. 4. GUIDELINES FOR UNDERGRADUATE STUDENTS (URO-GENITAL SYSTEM, REPRODUCTIVE SYSTEM AND LATE CLINICAL ROTATION (OBSTETRICS AND GYNAECOLOGY.)


I thought a blog could work well and can also serve as a way to encourage students' reflective learning and communication. Will it work? Please help.

Regards

Wilhelm

Connectivism and Teaching to teach Obstetrics

The concept of connectivism is new to me, but after JP’s remarks I attempted find out a bit more. Siemens is credited as the person who developed this theory of learning which accommodates the needs of the new century, allowing for changes in thoughts about learning, technological developments and the rapid expansion of knowledge. He argues that many of the processes previously handled by established learning theories such as behaviourism, cognitivism, and constructivism can now be supported by technology. These theories do not adequately deal with learning that is stored and manipulated by technology or how learning happens within organizations.
In connectivism, the fundamental thought is that learning starts with students linking with each other and not with a fixed body of content. The teacher functions as mediator.
Siemens listed eight key principles which summarise the essence of this learning theory. I have reservations about some of these as far as the development of a successful e-learning course on teaching for registrars in obstetrics at the present time is concerned. I am specifically uncertain about the statement that learning and knowledge rests in diversity of opinions. I think that, before applying this norm in the design of a new instructional setting, we have to consider prior knowledge of the target group. If knowledge is poor, individuals’ diverse opinions may not necessarily lead to useful knowledge in a discipline such as medicine (or for that matter medical education). I cannot knit. I think you need two needles and some wool to start knitting a jersey. I have several friends who cannot knit either. We will not produce any jerseys if we were to use our “diversity of opinions” as basis of learning and knowledge.
Furthermore, while Siemens states that decision making is considered as a learning process in itself, optimal decision making ability may take some time to master. However, we need the registrar to be able to teach student interns from very early in their careers.
Kala concluded that the use of learning theories can play a role in creating outstanding e-learning courses by providing a basis for the development and completion of suitable teaching–learning activities. There is ample evidence of the successful use of constructivism, based on Vygotski’s and Piaget’s contributions, in this regard in the literature. The educator can contribute in three ways: by encouraging active learning, by facilitating social interaction and by providing quality learning materials. I am almost through with a table which I use to sort out the outcomes of my proposed course, along with the expected skills and knowledge as well as the learning objectives. I try to follow the (social) constructivist approach. This may not be so bad from a connectivist point of view, as the latter seems to have developed from social constructivism.

The perceptions of attending doctors of the role of residents as teachers of undergraduate clinical students.

Busari and colleagues reported the results of their questionnaire survey of 76 obstetricians and pediatricians at two big academic units in the Netherlands. (Medical Education 2003; 37: 241 - 247). The respondents thought that teaching by registrars was beneficial for students and registrars alike.

Most of the participating consutants felt that departments should emphasise the importance of teaching; that registrars’ teaching ability should be evaluated as part of their clinical evaluation, that teaching is a part of being a registrar and registrars would benefit from prior training in how to teach.

In another study, Ogburn and colleagues mention some statistics related to registrars as teachers. (Obstetrics and gynecology residents as teachers of medical students: Predictors of excellence; American Journal of Obstetrics and Gynecology (2005) 193, 1831–4).

They mention that 25% of registrars’ activities involve supervising, instructing, and evaluating medical students. American undergraduate students reckon that a third of their knowledge derives from registrar teaching and that 50% of teaching during obstetrics and gynecology rotations are done by registrars. The authors are surprised by the fact that teaching ability is not considered as acriterion used to select new registrars. They found in, in a retrospective study, that the most significant predictors of being identified as an excellent teacher by medical students were work experience, age, and male gender. They suggest that these may be considered in the selection of registrars. (Seriously  the older male!)

How many outcomes?

I thought it would be a good idea to think about some aspects which may influence the outcomes for my proposed course to equip registrars as teachers of undergraduate medical students. I re-read some of the articles I had previously downloaded to help me in this regard, obviously taking our own context and resources into consideration. I thought of the following themes, in no specific order of importance.
Undergraduate teaching at SU: Registrars, especially those who been trained elsewhere, need to be introduced to the philosophy of learning and teaching locally. Three aspects immediately spring to mind: the expected outcome of undergraduate teaching as stated in the “Profile of the Stellenbosch Doctor”, the function of the student intern in the firm and the role of the registrar in teaching student interns.
Teaching opportunities for registrars: We should concentrate on the four activities which occur significantly more often than others. They are bedside teaching, teaching of skills, teaching in the setting of a case presentation and giving of “mini-lectures”. This could be presented as a theme with four sessions with explicit outcomes for each of the sessions.
Knowledge of Obstetrics as a subject: Our registrars come from more different universities than before. The approach to specific clinical problems may therefore differ, as was found in the registrars’ marks in the OSCE examination to which I referred before. It is important that we expose all our undergraduate students to the same basic information. To express this as a specific outcome is not that easy. However, the students spend a maximum of three weeks with each registrar. It would therefore be reasonable to identify six important topics. The registrars will have to be aware of the outcomes for these topics and be able to present “mini-lectures”, which will really mean facilitating student intern discussion of the previously announced topic.
The educational content : This is an aspect where I will appreciate advice. It will possibly be counter-productive to overload the module with theoretical aspects concerning learning. However, it is clear that not all students learn in the same way. I think exposure to some concepts will not only enhance registrars’ experience of teaching, but may assist in them better understanding themselves as learners. The following needs to be considered for inclusion: Adult learning, learning styles, approach to learning (surface, deep and strategic approaches) and perhaps an introduction to learning theories. I have already referred to educational approaches to the four main activities the registrars are involved in. This will also include outcomes related to teaching small groups.
There is much more which can be included. What about leadership? The registrar is clearly a leader in his / her own right. Other authors have included communication skills, time management and self-assessment. Perhaps the above-mentioned is sufficient for the time being – we have to leave some time for obstetrics as well. Or have I forgotten something important?

Wilhelm

PS If the objectives for the program were more than only teaching skills, such as helping learners to develop as educators, a second course could be planned for senior registrars later in their career, or perhaps even better, a blog for continuous participation could be created.

Utilising registrars as teachers

We have a six year long undergraduate medical course at Stellenbosch University, after which the successful candidates receive the MBChB degree. The clinical teaching takes place from the third to the sixth year and is divided into the early, mid- and late clinical phases respectively. The latter phase, the student intern phase, consists of the last 15 weeks of the fifth year with another 45 weeks in the sixth year. During this period, each student intern will rotate through Obstetrics and Gynaecology for three weeks each. Individual students join one of five clinical service groups (a firm) for the period where they will work very closely with a registrar. A registrar is a qualified doctor who is currently specialising in Obstetrics and Gynaecology. They are registered as postgraduate students. Student interns spend more than half of their time during the rotation with the registrars, much more than with the consultants. Historically, registrars were very involved with clinical teaching student interns.

Over the last few months, I have been asking student interns to complete questionnaires about their experiences in labour ward during their student intern rotation. They are asked to comment on how much they learned from their registrars. The responses varied from very enthusiastic appreciation to much more reserved “not as much as one had hoped for” to a very blunt “nothing”. Some students, where registrars changed from firms during the student’s rotation, were very aware of how much teaching depended on the individual registrar. Students clearly value good teaching. They also offer possible explanations of why some registrars are less likely to be good teachers. These reasons include perceptions that some registrars are incapable of teaching because of lack of ability or of confidence, or both.

We have never formally assessed how capable our registrars are to teach undergraduate students. The readiness of registrars to fulfil their role as tutors to undergraduate students is crucial in meeting student interns’ expectations. Readiness is task specific and in this context refers to the extent to which the registrars have the ability and the willingness to act as tutors for student interns.

Ability to teach is a function of knowledge of teaching, experience of or related to teaching and skills in teaching. Knowledge and skills do not only refer to basic pedagogic principles, but also to knowledge of and skills in the field of obstetrics and gynaecology. Recently our registrars had to write the same WebCT test as the student interns had done earlier that day. One of the registrars failed while another four had grades below 60%. It is quite clear that not all registrars are adequately equipped to teach student interns. What is less clear, is whether registrars understand what is expected from them? Other skills required from lecturers, such as proficiencies in interpersonal relationships and conflict management are also essential. It would be safe to assume that teaching experience of most newly appointed registrars are low. Proven performance, not potential, is the only test of ability. Willingness to teach, on the other hand, relates to the effort put out by individuals and is a function of confidence, commitment and motivation.

There are several reports in the literature on registrars’ role in teaching, also specific to Obstetrics and Gynaecology. They allow the reader to make some conclusions. One is that the ability to teach is a required skill for all doctors. It is also clear that some form of teaching of the teachers is required – registrars will need some formal preparation for this task. Various models have been proposed, ranging from a three month rotation to a short half day course. There are several considerations which may influence the selection of a similar course Stellenbosch University. However, the sequence of rotations of the registrars through their own course is of importance. Registrars will normally begin their careers in labour ward, where they will be responsible for student interns from the first day. Any course aimed at improvement of teaching skills will therefore have to be done early in the registrar’s career. Furthermore, the working activities of junior registrars, specifically labour ward calls, make it almost impossible to bring them together for a formal course. Ideally, this module should be available for the registrars to complete in their own time, but within a set time frame.

I am planning a course for registrars to improve their teaching skills. Given the facts above, I think that a course on WebStudies or on DC-Rom will be the best option. Any comments? If not, I will return to ask new comments on my further suggestions.

Nice day.

Wihelm.

What is this all about?

I am a consultant at the Department of Obstetrics and Gynaecology at Stellenbosch University in the Western Cape with a special interest in Maternal-Fetal Medicine. I am also very enthusiastic about medical education. While quite involved in postgraduate activities, undergraduate teaching is something special. I enrolled in a MPhil course in Health Science Education last year, primarily because of questions I had about the validity and reliabilty of our methods of assessment, specifically our ability to correctly place the borderline student. However, continuous exposure to educational matters as we progressed from module to module were sufficient to convince me of various shortcomings as a lecturer, but also to enable me to at least attempt to address these. I will regularly attend to issues which I am unsure about and also often call for help when I am uncertain. Please join in.

Wilhelm