Competencies Comprising the Role Doctor as Educator

The goal of the Bridging Project is to enhance the vertical integration of medical education and training in Australia and New Zealand with respect to the learning of competencies generic to the practice of medicine. Doctor as Educator is the first generic medical competency role addressed by the Bridging Project.

Preface to the Competency Statements for Doctor as Educator

Background

Practice in any medical specialty requires discipline specific knowledge and competencies. In addition, specialties require a repertoire of common, generic competencies which provide the foundation for all doctors to function effectively in roles such as communicator, advocate, manager, professional, scholar and educator. The project titled 'The Bridging Project' was established in 2006 to define these generic competencies as they would be expected to be acquired and exhibited at each level of education, training and practice in Australia. The term 'Bridging' was selected to characterize the project as a collaboration of medical schools, prevocational programs and vocational programs. The project's goal was to define a 'vertically integrated' (bridged) set of competencies across the levels of education and training. The generic role selected as the initial focus of Bridging Project was Doctor as Educator.

Conceptual Framework for the Role Doctor as Educator

In defining the competencies underlying the role Doctor as Educator, the Bridging Project employed a framework consisting of seven educational sub-roles:

1. Planner
2. Developer
3. Teacher
4. Clinical Supervisor
5. Mentor
6. Assessor
7. Evaluator

Competencies in each of these domains were defined for four stages in the continuum of medical education and training:

1. Medical student
2. Prevocational trainee
3. Vocational trainee
4. Independent practitioner

The competencies defined at each stage describe the knowledge and skills which could be assumed to exist in a doctor moving from one stage to the next and in the last stage, in an experienced independent practitioner. The descriptions of competencies for each stage of education and training depict increasing levels of depth and breadth of knowledge and skills, broader responsibility, and increasingly challenging teaching and learning situations as related to self and others. These statements of progressively higher levels of competencies can serve as an initial basis for logically sequencing (vertically integrating) the training of doctors to be 'educators', and for assessing their skills at each level.

The following diagram depicts the framework developed for Doctor as Educator, and illustrates that the competencies to be acquired at each successive level of education and training in general subsume those that were acquired in the earlier levels:

The educational roles of medical trainees and doctors focus to varying degrees on their personal education, and on the education of medical students, junior colleagues, peers, other health professionals, patients and community groups. Whereas medical students are mainly involved in their own learning and that of their peers and more junior students, independent practitioners are involved in their own continuing self education or professional development, as well as the education of all levels and types of learners.

Description of Doctor as Educator Roles

The following descriptions of the seven roles comprising Doctor as Educator guided the development of the competencies listed for each role.

Planner Educational planning is a prerequisite to effective teaching and learning. The competencies pertaining to this role focus on planning for formal and informal sessions, for clinical attachments, for educational materials that support programs, and for educational strategies and resources that support ones own education. Competencies for planning related to the roles of assessor and evaluator are not included under the role 'planner', but are listed under these respective educational roles.

Developer To facilitate effective learning, the development of educational resources may be required. Competencies pertaining to this role focus on developing written, diagrammatic, electronic, on-line, simulation or virtual reality resources for formal and informal sessions, for clinical attachments, or to support ones own education. Competencies for development related to the roles of assessor and evaluator are not included under the role 'developer', but are listed under these respective educational roles.

Teacher The 'teacher' role encompasses educational interactions with learners in a variety of formal and informal settings in classroom and clinical contexts, as presenters of information, and as facilitators of small group or individual instruction. Additionally it includes self-learning. The role of teacher encompasses competencies required to support learning across the full spectrum of basic science and clinical knowledge, clinical skills, communication and professional behaviours. The Doctor as Educator framework separates the role 'clinical supervisor' from that of 'teacher', to highlight the importance and uniqueness of these roles.

Clinical Supervisor Clinical supervision occurs in the context of caring for patients and usually includes teaching and assessment in addition to supervising clinical work. The competencies comprising effective clinical supervision are required to ensure safe and quality care for patients, good communication with patients, and a safe and supportive learning environment for medical students, prevocational and vocational trainees. While the clinical supervisor role is a subset of the teacher role, it is considered separately given its dual purpose of student/trainee learning and patient care, and given its importance for clinical learning.

Mentor A competent mentor is someone who can confidentially discuss difficult issues and guide and encourage mentees in their career and on personal matters, usually over a long period, drawing on their advanced knowledge and experience in medicine. Ideally a mentor is chosen by the mentee (but is often allocated), and is not involved directly in supervision or assessment, the latter allowing him or her to stand aside and provide support. However, the mentor role frequently overlaps with roles of clinical supervisor and teacher, and informal mentoring for the duration of an attachment may occur.

Assessor Trainees and practitioners, particularly in clinical settings, are frequently involved in formative assessment (for the purpose of guiding and supporting learning) and summative assessment (for the purpose of judging competence). Competencies for this role pertain to judging one's personal competence and the competence of others against defined criteria, giving and receiving constructive feedback (especially in the clinical setting), and in general developing and using a variety of assessment systems and methods.

Evaluator Trainees and practitioners are frequently involved in the evaluation of educational programs, courses, and instructional materials, for both formative purposes (to identify strengths and weaknesses and guide improvements) and summative purposes (to make judgments about quality and effectiveness) reasons. Competencies for this role pertain to designing qualitative and quantitative evaluative strategies; receiving, analysing and acting on evaluations of teaching, materials or programs; and providing evaluations to others on their teaching, materials or programs.

The seven roles described above provide a useful framework for defining competencies for 'Doctor as Education'. These roles however are not mutually exclusive. The competencies listed under each role overlap with those listed under other roles in varying degrees.

Using the Doctor as Educator Competency Statements

The competencies described for each role at each level of education and training are designed to be descriptive, measurable and complete. The principal aims in developing this comprehensive statement of staged competencies were to develop a consensus among stakeholder groups of learners and educational providers on what these competencies are at each level of education and training, and to encourage vertical integration of educational programs addressing these competencies across these levels. A number of uses are envisaged for the competencies presented:

• As a guide to individual students/postgraduate trainees/doctors on their learning and development as an 'educator'
• As a guide to medical educators to assist in them in planning and developing programs, curricula, staff development activities, and learning materials which address the acquisition of the competencies at each stage
• As a basis for collaboration across (and within) levels of education and training to plan vertically integrated programs
• As a guide to the development of materials and strategies for assessing the 'educational' competencies expected of each level of trainee and of practitioners.
• As a reference for accreditation standards on educational competencies at each stage
• As a framework for further research into medical education practice.

It is hoped that medical schools, postgraduate medical education councils, and specialty colleges will review these competencies in light of the statements of educational competencies they already possess for their trainees, and as appropriate incorporate these competencies into their statements. It is further hoped that these groups will develop strategies to help their trainees acquire each competency, and will work with their teachers to ensure that the competencies are assessed. It is expected that individual programs may add additional competencies appropriate for their particular area, and may tailor the wording of some competencies to better suit their programs.

Instructions for Accessing the Competency Statements for Doctor as Educator

The competency statements for Doctor as Educator are presented in a hyperlinked format. The competencies differ for each level of education and trainees, and in large part the competencies stated for earlier levels are embedded in each higher level. In referencing this document, you can select the level or levels of education or training, and the educational role or roles of interest to you. You can also indicate whether you wish to be presented immediately with all of hyperlinked detail related to each competency statement, or with only the outline form of the statements. If the latter is selected, it is possible to access the detail for any one competency statement by clicking on the highlighted words in that statement. While the outline version of a competency statement might appear the same across different levels of education and training, the material hyperlinked to that statement may differ, reflecting different expectations. Many hyperlinked statements also possess numbered footnotes to references, most of which are immediately accessible on-line by clicking on the number of the reference, and the on the web address of the reference.

The statements of the competencies are prefaced by the following sentence. "As a medical student, prevocational trainee, vocational trainee, or independent practitioner, you should be able to:"

	All	1. Planner	2. Developer	3. Teacher	4. Clinical Supervisor	5. Mentor	6. Assessor	7. Evaluator
All
1. Medical Student
2. Prevocational Trainee
3. Vocational Trainee
4. Independent Practitioner

1.1 Planner - Medical Student

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Self Education

1. Develop a personal Learning Plan
   • Develop a written 'learning plan' for each component of your medical school program, based upon the outcomes expected of you in your program, and your strengths and gaps in performance identified from self- and external assessment.
2. Identify appropriate educational resources
   • Identify the learning resources and methods available to assist your learning, and for each identify its relevance, and its relative strengths and weaknesses in terms of your learning needs and learning style, and in terms of what is known about effective learning strategies in medicine.

Teaching Others

1. Define clearly stated objectives
   • Clearly state objectives/outcomes (what you want learned) for a session, including outcomes for formal group sessions (case based discussion, problem based learning) and one-on-one or group sessions with or without patients, taking into account the incoming knowledge and skills of the learners, how the session fits into the overall program, and your own personal level of competence related to these outcomes. Objectives should describe observable behaviours, using verbs such as identify, describe, interpret, and diagnose, and avoid verbs such as know, understand and appreciate. ^{1, 2}
2. Employ a 'set/body/closure' format for your sessions
   • Plan both formal and informal educational sessions using a structure of set (introduction, objectives, importance, ...), body (e.g. presenting content, demonstrating skills, analysing cases) and closure (summary, key issues). This format can be effectively applied to any length of session, from brief 2-5 minute spontaneous sessions in a clinical context, to longer seminar, rounds, and workshop sessions. For didactic sessions, the spirit of the 'set/body/closure' format is captured in the commonly stated guideline, 'tell them what you are going to tell them, tell them, and tell them what you have told them'. Longer sessions are most effective if they employ several set/body/closure components. ^{3, 4, 23}
3. Select appropriate methods and materials for your teaching
   • Select methods for teaching and learning (interactive or non-interactive, patient based, electronic) on the basis of the relative advantages and disadvantages of each.
   • Select or plan educational materials needed for your teaching sessions, including pre-reading, or other student preparation material, handouts, written evaluation forms, and if relevant, inform learners prior to the session about what, if any, preparation is required by them.
4. Select suitable teaching venues and teaching aids
   • Select and organize the most appropriate teaching venues (e.g., seminar rooms, clinics) and teaching aids (e.g., projectors, models) relative to your objectives and the number of learners in your group.
5. Rehearse your sessions
   • A 'dry run' or rehearsal of your session will identify and address problems related to content, presentation and time. Rehearsing your session, especially if it entails a presentation by you, is a key to its effectiveness.

Patient Education

1. Effectively respond to common questions from patients
   • Respond to common questions from patients by ensuring that you are familiar with their common diseases, investigations or treatments, by reviewing the literature and reporting back to them, or by referring the question onto a clinician more familiar with their problems.
   • Enable effective communication with and understanding by patients using language at a lay level and avoiding medical terminology. ^{9, 10}

2.1 Developer - Medical Student

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Self Education

1. Develop a bank of resources to facilitate your personal learning.
   • Create a means of storing a bank of resources (text books, handouts, study clubs, web-based sites, ...) to facilitate your personal learning, and establish a system, including by electronic means, to easily and effectively access these resources.

Teaching Others

1. Prepare effective teaching materials and resources.
   • Prepare teaching materials and resources including written handouts and web-based resources (e.g., PDF files) that clearly assist learners to achieve the learning objectives of a teaching session. ²³
   • Build questions and cases into your materials to stimulate active learning and challenge understanding through self-assessment. ²⁷
   • Liaise with your learners to identify their desired learning outcomes and preferred styles of learning to guide the development of learning opportunities/resources and teaching materials
   • Prepare information for presentation in teaching sessions (e.g., whiteboard notes, overhead transparencies, electronic presentations) according to sound instructional design principles including clarity of purpose, logical order, readability, conciseness, and use of examples, diagrams and pictures.

3.1 Teacher - Medical Student

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Self Education

1. Identify your personal learning needs.
   • Your personal learning needs should be defined relative to your program and course objectives, patient care roles, and career aspirations.
2. Independently use suitable learning materials.
   • Identify and independently use suitable learning materials, resources and strategies to address your personal learning needs.
3. Accurately self-assess when your personal learning needs have been fulfilled.
   • In addition to strategies such as study questions you can employ personally, engage your peers, senior trainees and medical faculty in challenging you to demonstrate your knowledge and skills, and more importantly to apply them in a clinical context.
   • Note that 'knowing' or 'knowing how' are but prerequisites to the primary goal of medical education which is to effectively apply knowledge and skills in a clinical context. Your ability to apply your knowledge and skills should be the ultimate focus of your self-assessment.

Teaching Others

1. Implement teaching sessions that are guided by the principles of effective teaching and learning.
   • Principles of effective teaching and learning for developing and implementing teaching sessions are:
     1. set clear objectives at a correct level (see discussion of objectives under 'planner'), ^{1, 2}
     2. employ a 'set/body/closure' format in all of your sessions (see discussion of set/body/closure under 'planner'), ^{3, 4, 23}
     3. provide a supportive, non-threatening learning environment,
     4. provide feedback (see #4 below), ^{8, 30}
     5. encourage learner self-reflection/self assessment,
     6. intellectually engage and interact with the learners,
        This guideline encourages you to use 'active' educational methods that include intellectual (reasoning, making clinical decisions, answering questions) and "hands on" engagement and that challenge learners. The more intellectually engaged learners are in a learning activity, the more effective it is. 'Listening' (as in a didactic lecture) is next only to sleeping as an intellectually passive activity, and as such is the least effective way to learn. Observing a demonstration is also a relatively intellectually passive activity. Reading is more intellectually active, but activities such as engaging learners in discussing, answering questions, demonstrating, and teaching others are much more effective at helping them acquire, understand, and retain their knowledge and skills. While listening and observing remain essential elements of the learning process, lectures in which students are passive listeners are often over-used in medical education.
     7. vary your instructional activities in a session, in recognition of the fact that the attention span of an adult is 10-15 minutes.
        The average adult has an attention span of 10-15 minutes during any one activity. Your sessions should therefore provide a mix of activities. For example, you can present information for 10 minutes, then ask a question, or ask if there are questions, or present a case as an illustration or challenge your learners to apply their understanding of the information you have presented, or summarize, or ...
2. Conduct one-to-one and small group sessions that are key instructional formats in medical student education.
   • As a medical student you should be particularly confident in conducting the following types of teaching sessions:
     1. one-on-one and small group sessions in a clinical setting, ²²
     2. leading patient/case reviews, ²⁴
     3. demonstrating clinical findings, and
     4. small group sessions in a classroom setting – tutoring a PBL group, or leading a case-based discussion. ⁵
3. Conduct teaching sessions that address a broad range of medical competencies.
   • Competencies of key relevance to medical students are: ¹¹
     1. basic sciences and clinical knowledge and its application to clinical problems,
     2. clinical skills,
     3. communication skills, and
     4. professional behaviours.
4. Provide constructive feedback to your learners.
   • The role of constructive feedback is to help learners learn, and to help them develop the skills of self-assessing their own learning. ^{7, 8, 30} This is best accomplished by feedback that:
     1. is a dialogue – begins for example by eliciting the learner's views on their strengths and weaknesses,
     2. is balanced -- identifies what is done well, identifies what needs to be improved,
     3. is specific,
     4. is timely (immediate is best),
     5. is descriptive (not judgmental),
     6. encourages and guides the development of plans to solve problems, and
     7. is honest.
        An immediate goal of constructive feedback is to assist the learner identify their strengths and weaknesses, and develop a plan to address the weaknesses. The long term goal of constructive feedback is to assist the learner develop the skills of effective self-assessment. Your constructive feedback session with learners should therefore challenge them to self-assess under your supervision, since like any other skill, self-assessment is learned via practice under supervision.
5. Use paper and electronic educational resources.
   • Use paper and electronic visual aids and other resources in your teaching that enhance the effectiveness of your session (i.e., to increase learning), and which exhibit sound instructional design principles including clarity of purpose, logical order, readability, conciseness, and use of examples, diagrams and pictures.

Patient Education

1. Effectively respond to common questions from patients.
   • Respond to common questions from patients about common diseases, investigations or treatments, or if appropriate refer the question to a clinician more familiar with their problems.
   • Enable effective communication with and understanding by patients using language at a lay level and avoiding medical terminology.

4.1 Clinical Supervisor - Medical Student

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1. Identify the learning needs of junior colleagues.
   • Relative to the knowledge, skills and professional attributes objectives of the area you are supervising, use questioning and observation of performance to determine the personal learning needs of your junior colleagues.
2. Identify learning opportunities for junior colleagues.
   • Identify and create learning opportunities that enable junior colleagues to interact with patients and practice skills under your supervision. ²⁴
3. Provide constructive feedback.
   • Provide clear and honest constructive feedback which is based upon your observation and assessment of junior colleagues' performance, and which through individual dialogue encourages self assessment and identifies what was performed well and what requires improvement (see the discussion on constructive feedback under the role 'teacher'). ^{6, 7, 8, 30}
4. Provide personal and professional guidance.
   • Provide guidance to your junior colleagues on who to contact if they require support on clinical or personal matters.

5.1 Mentor - Medical Student

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1. Establish a mutually beneficial mentoring relationship with one or more junior colleagues
   • Establish a supportive mentoring relationship with a junior colleague based upon mutual respect, trust, encouragement, openness, and interest with the goal of sharing knowledge, experiences, and insights to assist their personal and career development. ^{13, 14}
2. Provide advice and guidance
   • Provide advice and guidance with respect to issues such as:
     1. Strengths and areas requiring improvement
     2. Short term learning issues and creating learning opportunities
     3. Personal matters (e.g., housing, financial support, contacts)

6.1 Assessor - Medical Student
(See assessment terminology glossary ³⁵)

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Demonstrate effective self-assessment skills

1. Assess your own learning needs.
   • Develop and use strategies for accurately assessing your own learning needs (what you do not know and should know, what you can not do and should be able to do) relative to your course and program objectives, to the care of patients for whom you have responsibility, and to gaps in your knowledge and performance identified from previous self- and external assessments.
2. Assess your achievement.
   • By reflecting on external feedback that you have received, accurately self-assess when you have acquired the knowledge and skills required in your program and when you have fulfilled your personal learning needs.
3. Seek and effectively respond to constructive feedback
   • Actively seek and effectively respond to constructive feedback on your performance (i.e., identify and pursue strategies to improve your performance) from medical faculty, clinical supervisors, senior trainees, and peers.

Effectively assess, where relevant, your junior colleagues and peers, in classroom and clinical settings.

1. Provide constructive feedback.
   • Provide constructive feedback to support and guide the learning of your peers and junior colleagues (see discussion of constructive feedback under 'Planner'). ^{6, 7, 8, 30}
   • Use questioning and direct observation of clinical performance and practical skills as bases for your feedback. ²⁷
   • Ensure that your feedback:
     1. identifies strengths and areas of needed improvement,
     2. relates to expected learning,
     3. is timely (immediate is best), specific, descriptive, detailed (uses examples),
     4. is honest, and
     5. includes guidance in developing plans to address problems.
2. Employ questioning techniques.
   • Use of open ended questions to ask learners to identify areas they do not understand.
   • Use direct questions to assess what has been learned or not learned.
   • Employ questions that focus on the learner's ability to apply their knowledge in contrast to its recall. "Application' questions typically focus on the learner's ability to reason or make clinical decisions about individual patients. ²⁷

7.1 Evaluator - Medical Student

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Provide evaluations to others

1. Identify factors influencing instructional effectiveness.
   • Identify the factors contributing to or detracting from the effectiveness of teaching and learning sessions, educational materials, courses and programs in which you and your peers participate as learners.
2. Recommend changes contributing to effectiveness.
   • Recommend specific and realistic changes that would contribute to the effectiveness of teaching and learning sessions, materials, courses and programs in which you and your peers participate as learners, and effectively convey these recommendations via constructive feedback to teachers and supervisors.

Elicit, receive and act on evaluations

1. Evaluate your teaching.
   • For educational sessions you have conducted, use a number of simple methods of evaluation (e.g., self reflection, verbal and written feedback from learners) that identify what went well and what aspects could be improved (e.g., content, instructional plan, instructional materials, structure of the session) and act on the evaluation results as necessary.
2. Audit your clinical performance.
   • Participate in and use the results of clinical practice audits of cases in which you had a clinical role, as a basis for identifying steps leading to improvements in your clinical performance.

1.2 Planner - Prevocational Trainee

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Self Education

1. Develop a personal Learning Plan
   • Develop a written 'learning plan' for each component of your prevocational program, based upon the outcomes expected of you in your program, and your strengths and gaps in performance identified from self- and external assessment.
2. Identify appropriate educational resources
   • Identify the learning resources and methods available to assist your learning, and for each identify its relevance, and its relative strengths and weaknesses in terms of your learning needs and learning style, and in terms of what is known about effective learning strategies in medicine.
3. Develop strategies and set aside time for incorporating learning into your working day.

Teaching Others

1. Define clearly stated objectives
   • Clearly state outcomes (what you want learned) for a session, including outcomes for formal group sessions (case based discussion, problem based learning, lecture), one-on-one or group sessions with or without patients, and clinical attachments over weeks to months, taking into account the incoming knowledge and skills of the learners, how the session fits into the overall program, and your own personal level of competence related to these outcomes. Objectives should describe observable behaviours, using verbs such as identify, describe, interpret, and diagnose, and avoid verbs such as know, understand and appreciate. ^{1, 2}
2. Employ a 'set/body/closure' format for your sessions
   • Plan both formal and informal educational sessions using a structure of set (introduction, objectives, importance, ...), body (e.g. presenting content, demonstrating skills, analysing cases) and closure (summary, key issues). This format can be effectively applied to any length of session, from brief 2-5 minute spontaneous sessions in a clinical context, to longer seminar, rounds, and workshop sessions. For didactic sessions, the spirit of the 'set/body/closure' format is captured in the commonly stated guideline, 'tell them what you are going to tell them, tell them, and tell them what you have told them'. Longer sessions are most effective if they employ several set/body/closure components. ^{3, 4, 23}
3. Select appropriate methods and materials for your teaching
   • Select methods for teaching and learning (interactive or non-interactive, patient based, electronic, simulation, virtual reality) on the basis of the relative advantages and disadvantages of each.
   • Select or plan educational materials needed for your teaching sessions, including pre-reading, or other student preparation material, handouts, written evaluation forms, and if relevant, inform learners prior to the session about what, if any, preparation is required by them.
4. Select suitable teaching venues and teaching aids
   • Select and organize the most appropriate teaching venues (e.g., seminar rooms, clinics) and teaching aids (e.g., projectors, models) relative to your objectives and the number of learners in your group.
   • Ensure that patients are informed and prepared.
5. Ensure the content of your teaching is appropriate.
   • Review the content of your teaching to ensure that it is up to date, based on evidence and current literature, and where appropriate includes basic science and clinical knowledge, clinical skills, communication skills, professional behaviours and patient perspectives.
6. Rehearse your sessions
   • A 'dry run' or rehearsal of your session will identify and address problems related to content, presentation and time. Rehearsing your session, especially if it entails a presentation by you, is a key to its effectiveness.

Patient Education

1. Effectively respond to common questions from patients
   • Respond to common questions from patients by ensuring that you are familiar with common diseases, investigations or treatments, by reviewing the literature and reporting back to them, or by referring the question onto a clinician more familiar with their problems.
   • Enable effective communication with and understanding by patients using language at a lay level and avoiding medical terminology.
2. Plan patient education on the basis of sound principles of patient counseling
   • Base plans for patient counseling and communication on a sound knowledge of effective methods to inform patients or change their behaviour. ^{9, 10}
   • Define the outcomes (knowledge, skills, attitudes, behaviours) you would expect a patient to exhibit at the end of a group or one-on-one session. The outcomes you are aspiring to achieve with patients should be stated using 'active verbs' that describe what you want the patients to be able to 'do' – avoid verbs such as know, understand and appreciate.
   • Plan the session to meet the individual needs of the patient in terms of their:
     1. current knowledge level,
     2. health needs,
     3. motivation and capacity to learn, and
     4. social, cultural and economic background.

2.2 Developer - Prevocational Trainee

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Self Education

1. Develop a bank of resources to facilitate your personal learning.
   • Develop and maintain a system (including by electronic means) for recording, storing, and readily accessing personal learning resources (text books, handouts, study clubs, web-based sites, ...).

Teaching Others

1. Prepare effective teaching materials and resources.
   • Prepare teaching materials and resources including written handouts and web-based resources (e.g., PDF files) that clearly assist learners to achieve the learning objectives of a teaching session ²³
   • Build questions and cases into your materials to stimulate active learning and challenge understanding through self-assessment. ²⁷
   • Liaise with your learners to identify their desired learning outcomes and preferred styles of learning to guide the development of learning opportunities/resources and teaching materials
   • Prepare information for presentation in teaching sessions (e.g., whiteboard notes, overhead transparencies, electronic presentations) according to sound instructional design principles including clarity of purpose, logical order, readability, conciseness, and use of examples, diagrams and pictures.

3.2 Teacher - Prevocational Trainee

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Self Education

1. Identify your personal learning needs.
   • Your personal learning needs should be defined relative to your program and course objectives, patient care roles, and career aspirations.
2. Independently use suitable learning materials.
   • Identify and independently use suitable learning materials, resources and strategies to address your personal learning needs.
3. Accurately self-assess when your personal learning needs have been fulfilled.
   • In addition to strategies such as study questions you can employ personally, engage your peers, senior trainees and clinical supervisors in observing and challenging you to demonstrate your knowledge and skills, and more importantly to apply them in a clinical context.
   • Note that 'knowing' or 'knowing how' are but prerequisites to the primary goal of medical training which is to effectively apply knowledge and skills in a clinical context. Your ability to apply your knowledge and skills, and not simply 'knowing' for example, should be the ultimate focus of your self-assessment.
4. Develop investigative and therapeutic procedural skills.
   • Your investigative and therapeutic procedural skills can be developed and refined through deliberate programs of practice under the supervision of experts. You should seek out opportunities to observe and then practice these skills under the eye of senior trainees and clinical supervisors
5. Refine your clinical reasoning and decision-making skills.
   • Use up-to-date knowledge of clinical reasoning and clinical decision-making processes, how these processes evolve through education and training, and the errors clinicians make in these processes, to guide your personal development of these skills. ¹²

Teaching Others

1. Implement teaching sessions that are guided by the principles of effective teaching and learning.
   • Principles of effective teaching and learning for developing and implementing teaching sessions are:
     1. set clear objectives at a correct level (see discussion of objectives under 'planner'), ^{1, 2}
     2. employ a 'set/body/closure' format in all of your sessions (see discussion of set/body/closure under 'planner'), ^{2, 4, 23}
     3. provide a supportive, non-threatening learning environment,
     4. provide feedback (see #4 below), ^{8, 30}
     5. encourage learner self-reflection/self assessment
     6. intellectually engage and interact with the learners,
        This guideline encourages you to use 'active' educational methods that include intellectual (reasoning, making clinical decisions, answering questions) and "hands on" engagement and that challenge learners. The more intellectually engaged learners are in a learning activity, the more effective it is. 'Listening' (as in a didactic lecture) is next only to sleeping as an intellectually passive activity, and as such is the least effective way to learn. Observing a demonstration is also a relatively intellectually passive activity. Reading is more intellectually active, but activities such as engaging learners in discussing, answering questions, demonstrating, and teaching others are much more effective at helping them acquire, understand, and retain their knowledge and skills. While listening and observing remain essential elements of the learning process, lectures in which students are passive listeners are often over-used in medical education.
     7. vary your instructional activities in a session, in recognition of the fact that the attention span of an adult is 10-15 minutes.
        The average adult has an attention span of 10-15 minutes during any one activity. Your sessions should therefore provide a mix of activities. For example, you can present information for 10 minutes, then ask a question, or ask if there are questions, or present a case as an illustration or challenge your learners to apply their understanding of the information you have presented, or summarize, or ...
2. Conduct one-to-one and small and large group sessions that are the key instructional formats in medical student education and prevocational training.
   • As a prevocational trainee you should be particularly confident in conducting the following types of teaching sessions:
     1. one-on-one and small group sessions in a clinical setting, ²²
     2. leading patient/case reviews, ²⁴
     3. demonstrating clinical findings,
     4. demonstrating investigative techniques,
     5. small group sessions in a classroom setting – tutoring a PBL group, or leading a case-based discussion, ⁵ and
     6. large group lecture or plenary sessions. ^{3, 4}
3. Conduct teaching sessions that address a broad range of medical competencies.
   • Competencies of key relevance to trainees are ¹¹:
     1. basic sciences and clinical knowledge and its application to clinical problems,
     2. clinical skills,
     3. communication skills, and
     4. Professional behaviours.
4. Provide constructive feedback to your learners
   • The role of constructive feedback is to help learners learn, and to help them develop the skills of self-assessing their own learning. ^{7, 8, 30} This is best accomplished by feedback that:
     1. is a dialogue – for example, begins by eliciting the learner's views on their strengths and weaknesses,
     2. is balanced -- identifies what is done well, identifies what needs to be improved,
     3. is specific,
     4. is timely (immediate is best),
     5. is descriptive (not judgmental),
     6. encourages and guides the development of plans to solve problems, and
     7. is honest.
     An immediate goal of constructive feedback is to assist the learner identify their strengths and weaknesses, and develop a plan to address the weaknesses. The long term goal of constructive feedback is to assist the learner develop the skills of effective self-assessment. Your constructive feedback session with learners should therefore challenge them to self-assess under your supervision, since like any other skill, self-assessment is learned via practice under supervision.
5. Use paper and electronic educational resources.
   • Use paper and electronic visual aids and other resources in your teaching that enhance the effectiveness of your session (i.e., to increase learning), and which exhibit sound instructional design principles including clarity of purpose, logical order, readability, conciseness, and use of examples, diagrams and pictures.
6. Use questions effectively.
   • Questioning your learners is an extremely effective strategy for: ²⁷
     1. Identifying their knowledge and knowledge deficiencies (i.e., as a basis for constructive feedback), and
     2. Engaging and intellectually challenging your learners to apply their knowledge to understanding and resolving clinical problems.
   • Questions which assess the recall of knowledge versus its application are of limited value in that knowing something is a necessary but not sufficient precondition to the understanding and effective application of knowledge, the latter being the ultimate goal of medical training.

Patient Education

1. Effectively respond to common questions from patients
   • Respond to questions from patients regarding common diseases, investigations or treatments, by reviewing the literature and reporting back to them, or by referring the question onto a clinician more familiar with their problems.
   • Enable effective communication with and understanding by patients by using language at a lay level and avoiding medical terminology.
2. Plan patient education on the basis of sound principles of patient counseling
   • Base your patient counseling and communication strategies on a sound knowledge of effective methods of patient counseling and instruction whose goals are to inform patients or change their behaviours. ^{9, 10}
   • Define the outcomes (knowledge, skills, attitudes, behaviours) you would expect a patient to exhibit at the end of a group or one-on-one session. The outcomes you are aspiring to achieve with patients should be stated using 'active verbs' that describe what you want the patients to be able to 'do' – avoid verbs such as 'understand' and 'appreciate' or 'know'.
   • Tailor the session to meet the individual needs of the patient in terms of their:
     1. current knowledge level,
     2. health needs,
     3. motivation and capacity to learn, and
     4. social, cultural and economic background.

4.2 Clinical Supervisor - Prevocational Trainee

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1. Organize and provide time for supervision.
   • The effective clinical supervision of juniors, which calls upon all of the competencies listed below, takes time. Such time should be deliberately scheduled. Effective supervision requires that you get to 'know' the juniors, provide them with an orientation, determine their previous experience, observe their performance, provide feedback, etc.
2. Provide a clear orientation for your junior colleagues.
   • Provide a clear orientation to your junior colleagues that includes a description of the clinical areas in which they will be functioning, and their roles and responsibilities in these areas.
3. Identify the incoming confidence and competence, and learning needs of junior colleagues.
   • Relative to the knowledge, skills and professional attributes objectives of the clinical area you are supervising, use questioning and observation of performance to determine the levels of incoming confidence and competence, and personal learning needs of your junior colleagues in providing clinical care and carrying out clinical procedures.
4. Serve as a role model for the attributes of a junior doctor.
   • Provide opportunities for your junior colleagues to see you role model excellence in clinical practice, teaching, mentoring and achieving a balanced life. For example, your junior colleagues should be provided with opportunities to see how you talk with patients and staff, or how you respond when you or someone else does not know or cannot do something, or how you respond to conflicts in professional and personal demands on your time.
5. Identify learning opportunities for junior colleagues.
   • Identify and create learning opportunities that enable junior colleagues to interact with patients and practice skills under your supervision.
6. Provide constructive feedback.
   • Directly observe and assess your junior colleagues' performance
   • Provide clear and honest constructive feedback on performance through individual dialogue, which encourages self assessment and identifies what was performed well and what requires improvement (see the discussion on constructive feedback under the role 'teacher'). ^{6, 7, 8, 30}
7. Provide personal and professional guidance and support.
   • Provide guidance to your junior colleagues on who to contact if they require support on clinical or personal matters. ^{13, 14}
   • Personally provide, or organize senior colleagues to provide clinical support to your learners as needed, to ensure appropriate patient care.
   • Identify who to contact when you detect major performance problems in a junior colleague that are beyond your scope to address and that require formal attention from their training program. ¹³
8. Challenge your learners' clinical reasoning and decision-making.
   • Challenge your learners to actively engage in and defend their clinical reasoning and decision-making through questioning and discussion of relevant issues. "Why" questions are most effective at identifying the learner's thinking (reasoning) underlying decisions they make about tests to order, diagnoses, treatment options, advice to give, or about their interpretations of clinical data. ²⁷
   • Challenge learners to identify alternate solutions, research findings and current developments in relation to their clinical decisions.
9. Pre-empt errors.
   • Pre-empt errors by being aware of common errors, looking out for them and educating medical students and junior colleagues about them. ³³

5.2 Mentor - Prevocational Trainee

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1. Establish effective mutually beneficial mentoring relationships with your junior colleagues
   • Establish a supportive mentoring relationship with junior colleagues based upon mutual respect, trust, encouragement, openness, and interest with the goal of sharing knowledge, experiences, and insights with these colleagues to assist their personal and career development. ^{13, 14}
2. Provide advice and guidance
   • Provide advice and guidance regarding issues such as:
     1. Strengths and areas requiring improvement
     2. Short term learning issues and creating learning opportunities
     3. Long term career goals (benefits and challenges, strategies to achieve goals,
     4. contacts)
     5. Personal matters (e.g., housing, financial support, contacts)
     6. What it is like to be a prevocational trainee
3. Consciously develop your mentoring strategy.
   • Consciously develop your mentoring strategy, including setting aside time for mentoring ^{13, 14}.

6.2 Assessor - Prevocational Trainee

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Demonstrate effective self-assessment skills:

1. Assess your own learning needs.
   • Develop and use strategies for accurately assessing your own learning needs (what you do not know and should know, what you can not do and should be able to do) relative to your course and program objectives, to the care of patients for whom you have responsibility, and to gaps in your knowledge and performance identified from previous self- and external assessments.
2. Assess your achievement.
   • By reflecting on external feedback that you have received, accurately self-assess when you have acquired the knowledge and skills required in your program and when you have fulfilled your personal learning needs.
3. Seek and effectively respond to constructive feedback.
   • Actively seek and effectively respond to constructive feedback on your performance (i.e., identify and pursue strategies to improve your performance) from medical faculty, clinical supervisors, senior trainees, and peers.
4. Evaluate self-assessment methods.
   • Review the different methods and strategies available to you for self-assessing your competence, and relative to the advantages and limitations of each, select those that best suit your situation. ^{15 18}

Effectively assess, where relevant, your junior colleagues and peers, in classroom and clinical settings.

1. Provide constructive feedback.
   • Provide constructive feedback to support and guide the learning of your peers and junior colleagues (see discussion of feedback under 'Planner'). ^{6, 7, 8, 30}
   • Use questioning and direct observation of clinical performance and practical skills as bases for your feedback. ²⁷
   • Ensure that your feedback:
     1. identifies strengths and areas of needed improvement,
     2. relates to expected learning,
     3. is timely (immediate is best), specific, descriptive, detailed (uses examples),
     4. is honest, and
     5. includes guidance in developing plans to address problems.
2. Employ questioning techniques,
   • Use of open ended questions to ask learners to identify areas they do not understand.
   • Use direct questions to assess what has been learned or not learned.
   • Employ questions that focus on the learner's ability to apply their knowledge in contrast to its recall. "Application' questions typically focus on the learner's ability to reason or make clinical decisions about individual patients. ²⁷
3. Assess clinical reasoning and decision-making
   • Employ a sound knowledge of the clinical reasoning and decision-making, and the common errors in these processes to guide your assessment of peers and junior colleagues. ¹²
4. Make defensible assessments.
   • Defend your judgments of a junior trainee's or peer's performance with reference to program objectives, your observation of their performance (descriptively referencing what you saw them do or not do), and the desired levels of performance for their stage of training.
5. Evaluate the relative usefulness of different assessment methods and strategies.
   • Select, develop and use specific methods and strategies for assessing junior colleagues and peers on the basis of their relative utility. "Utility' is a function of their validity, reliability, acceptance, feasibility, educational impact, and cost as measures of different aspects of clinical competence, including clinical knowledge, clinical reasoning and decision-making skills, and communication, professional and procedural skills. ^{16, 15, 17, 18 20}

7.2 Evaluator - Prevocational Trainee

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Provide evaluations to others

1. Identify factors influencing instructional effectiveness.
   • Identify the factors contributing to or detracting from the effectiveness of teaching and learning sessions, educational materials, courses and programs in which you and your peers participate as learners.
2. Recommend changes contributing to effectiveness.
   • Recommend specific and realistic changes that would contribute to the effectiveness of teaching and learning sessions, materials, courses and programs in which you and your peers participate as learners, and effectively convey these recommendations via constructive feedback to teachers and supervisors.
   • Evaluate the relevance of the content of educational activities and materials to clinical practice and recommend how this content could more effectively address key knowledge and skills.

Elicit, receive and act on evaluations

1. Evaluate your instruction.
   • For your educational sessions, use a variety of simple methods of evaluation (e.g., self reflection, verbal and written feedback from learners) that identify what went well and what aspects could be improved (e.g., content, instructional plan, instructional materials, structure of the session) and act on the evaluation results as necessary.
2. Audit your clinical performance.
   • Participate in and use the results of clinical practice audits of cases in which you had a clinical role, as a basis for identifying steps leading to improvements in your clinical performance.

1.3 Planner - Vocational Trainee

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Self Education

1. Develop a personal learning plan.
   • Develop a written 'learning plan' for each component of your vocational program, based upon the outcomes expected of you in your program, and your strengths and gaps in performance identified from self- and external assessment.
2. Identify appropriate educational resources.
   • Identify the learning resources and methods available to assist your learning, and for each identify its relevance, and its relative strengths and weaknesses in terms of your learning needs and learning style, and in terms of what is known about effective learning strategies in medicine.
   • Identify the professional groups, conferences and professional journals to which you will subscribe.
3. Develop strategies and set aside time for incorporating learning into your working day.

Teaching Others

1. Define clearly stated objectives.
   • Clearly state outcomes (what you want learned) for a session, including outcomes for formal group sessions (case based discussion, problem based learning, lecture), one-on-one or group sessions with or without patients, and clinical attachments over weeks to months, taking into account the incoming knowledge and skills of the learners, how the session fits into the overall program, and your own personal level of competence related to these outcomes. Objectives should describe observable behaviours, using verbs such as identify, describe, interpret, and diagnose, and avoid verbs such as know, understand and appreciate. ^{1, 2}
2. Employ a 'set/body/closure' format for your sessions.
   • Plan both formal and informal educational sessions using a structure of set (introduction, objectives, importance, ...), body (e.g. presenting content, demonstrating skills, analysing cases) and closure (summary, key issues). This format can be effectively applied to any length of session, from brief 2-5 minute spontaneous sessions in a clinical context, to longer seminar, rounds, and workshop sessions. For didactic sessions, the spirit of the 'set/body/closure' format is captured in the commonly stated guideline, 'tell them what you are going to tell them, tell them, and tell them what you have told them'. Longer sessions are most effective if they employ several set/body/closure components. ^{3, 4, 23}
3. Select appropriate methods and materials for your teaching.
   • Select methods for teaching and learning (interactive or non-interactive, patient based, electronic, simulation, virtual reality) on the basis of the relative advantages and disadvantages of each.
   • Select or plan educational materials needed for your teaching sessions, including pre-reading, or other student preparation material, handouts, written evaluation forms, and if relevant, inform learners prior to the session about what, if any, preparation is required by them.
   • Develop plans for a medical student's and junior colleague's clinical attachments that include an orientation, scheduled learning opportunities and sessions, and involvement in supervised patient care.
   • Select 'active' educational methods that intellectually challenge learners (to reason, make clinical decisions, answer questions) and/or demand "hands on" engagement. The more intellectually engaged learners are in a learning activity, the more effective it is. 'Listening' (e.g., in a didactic lecture) is an intellectually passive activity, and as such is the least effective way to learn. Observing a demonstration is also a relatively passive activity. Reading is more intellectually challenging, but activities such as engaging the learner in discussing, answering questions, demonstrating, and teaching others are much more effective at helping learners acquire, understand, and retain their knowledge and skills. Listening and observing are important learning methods in medicine, but are often overused.
   • Plan a variety of teaching and learning activities for your sessions which take into account that the average attention span of an adult in any one activity is 10-15 minutes. Your learners should not therefore be required to listen, or to watch for more than 10-15 minutes at one time. Your sessions should provide a mix of activities. For example, you can present information for 10 minutes, then ask a question, or ask if there are questions, or present a case to challenge your learners to apply (test their understanding of) the information you have presented, or summarize, or ...
4. Select suitable teaching venues and teaching aids.
   • Select and organize the most appropriate teaching venues (e.g., seminar rooms, clinics) and teaching aids (e.g., projectors, models) relative to your objectives and the number of learners in your group.
   • Ensure that other teachers and patients are informed and prepared.
5. Ensure the content of your teaching is appropriate.
   • Review the content of your teaching to ensure that it is up to date, based on evidence and current literature, and where appropriate includes basic science and clinical knowledge, clinical skills, communication skills, professional behaviours and patient perspectives.
6. Rehearse your session.
   • A 'dry run' or rehearsal of your session will identify and address problems related to content, presentation and time. Rehearsing your session, especially if it entails a presentation by you, is a key to its effectiveness.

Patient Education

1. Effectively respond to common questions from patients.
   • Respond to common questions from patients by ensuring that you are familiar with common diseases, investigations or treatments, by reviewing the literature and reporting back to them, or by referring the question onto a clinician more familiar with their problems.
   • Enable effective communication with and understanding by patients using language at a lay level and avoiding medical terminology.
2. Plan patient education on the basis of sound principles of patient counselling.
   • Base plans for patient counseling and communication on a sound knowledge of effective methods of patient counseling and instruction whose goals are to inform patients or change their behaviour. ^{9, 10}
   • Define the outcomes (knowledge, skills and attitudes) you would expect a patient to have at the end of a group or one-on-one session. The outcomes you are aspiring to achieve with patients should be defined using 'active verbs' that describe what you want the patients to be able to 'do' – avoid verbs such as know, understand and appreciate.
   • Tailor the session to meet the individual needs of the patient in terms of their:
     1. current knowledge level,
     2. health needs,
     3. motivation and capacity to learn, and
     4. social, cultural and economic background.

2.3 Developer - Vocational Trainee

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Self Education

1. Develop a bank of resources to facilitate your personal learning.
   • Develop and maintain a system (including by electronic means) for recording, storing, and readily accessing personal learning resources (text books, handouts, study clubs, web-based sites, ...).

Teaching Others

1. Prepare effective teaching materials and resources.
   • Prepare teaching materials and resources including written handouts and web-based resources (e.g., PDF files) that clearly assist learners to achieve the learning objectives of a teaching session or clinical attachment ²³
   • Build questions and cases into your materials to stimulate active learning and challenge understanding through self-assessment. ²⁷
   • Liaise with your learners to identify their desired learning outcomes and preferred styles of learning to guide the development of learning opportunities/resources and teaching materials
   • Prepare information for presentation in teaching sessions (e.g., whiteboard notes, overhead transparencies, electronic presentations) according to sound instructional design principles including clarity of purpose, logical order, readability, conciseness, and use of examples, diagrams and pictures.

Patient Education

1. Prepare clear and effective patient education materials.
   • Access, draw or develop information sheets and handouts for patients on common problems or investigations, using clear diagrams, illustrations and charts and concise, simple and appropriate language, that ensures patients understand and are informed.

3.3 Teacher - Vocational Trainee

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Self Education

1. Identify your personal learning needs.
   • Your personal learning needs should be defined relative to your program and course objectives, patient care roles, and career aspirations.
2. Independently use suitable learning materials.
   • Identify and independently use suitable learning materials, resources and strategies to address your personal learning needs.
3. Accurately self-assess when your personal learning needs have been fulfilled.
   • In addition to strategies such as study questions you can employ personally, engage your peers, senior trainees and clinical supervisors in observing and challenging you to demonstrate your knowledge and skills, and more importantly to apply them in a clinical context.
   • Note that 'knowing' or 'knowing how' are but prerequisites to the primary goal of medical training which is to effectively apply knowledge and skills in a clinical context. Your ability to apply your knowledge and skills, and not simply 'knowing' for example, should be the ultimate focus of your self-assessment.
4. Develop investigative and therapeutic procedural skills.
   • Your investigative and therapeutic procedural skills can be developed and refined through deliberate programs of practice under the supervision of experts. You should seek out opportunities to observe and then practice these skills under the eye of senior trainees and clinical supervisors. ²⁵
5.  Refine your clinical reasoning and decision-making skills.
   • Use up-to-date knowledge of clinical reasoning and clinical decision-making processes, how these processes evolve through education and training, and the errors clinicians make in these processes, to guide your personal development of these skills. ¹²
6.  Conduct self-audits.
   • Through processes of self-reflection and personal practice audit, document and evaluate the efficacy of changes you make in your practice performance and patient care.

Teaching Others

1. Implement teaching sessions that are guided by principles of effective teaching and learning.
   • Principles of effective teaching and learning for developing and implementing teaching sessions are:
     1. set clear objectives at a correct level (see discussion of objectives under 'planner'), ^{1, 2}
     2. employ a 'set/body/closure' format in all of your sessions (see discussion of set/body/closure under 'planner'), ^{2, 4, 23}
     3. provide a supportive, non-threatening learning environment,
     4. provide feedback (see #4 below), ^{8, 30}
     5. encourage learner self-reflection/self assessment,
     6. intellectually engage and interact with the learners,
        This guideline encourages you to use 'active' educational methods that include intellectual (reasoning, making clinical decisions, answering questions) and "hands on" engagement and that challenge learners. The more intellectually engaged learners are in a learning activity, the more effective it is. 'Listening' (as in a didactic lecture) is next only to sleeping as an intellectually passive activity, and as such is a relatively ineffective way to learn. Observing a demonstration is also a relatively intellectually passive activity. Reading is more intellectually active, but activities such as engaging learners in discussing, answering questions, demonstrating, and teaching others are much more effective at helping them acquire, understand, and retain their knowledge and skills. While listening and observing remain essential elements of the learning process, lectures in which students are passive listeners are often over-used in medical education.
     7. vary your instructional activities in a session, in recognition of the fact that the attention span of an adult is 10-15 minutes.
        The average adult has an attention span of 10-15 minutes during any one activity. Your sessions should therefore provide a mix of activities. For example, you can present information for 10 minutes, then ask a question, or ask if there are questions, or present a case as an illustration or challenge your learners to apply their understanding of the information you have presented, or summarize, or ...
2. Conduct one-to-one and small and large group sessions that are the key instructional formats in medical student, prevocational and vocational training.
   • As a vocational trainee you should be confident in conducting the full range of teaching sessions, including:
     1. one-on-one and small group sessions in a clinical setting, ²²
     2. leading patient/case reviews, ²⁴
     3. demonstrating clinical findings,
     4. demonstrating investigative techniques,
     5. small group sessions in a classroom setting – tutoring a PBL group ⁵, leading a case-based discussion,
     6. flarge group lecture or plenary sessions. ^{3, 4}
3. Conduct teaching sessions that address a broad range of medical competencies.
   • Competencies of key relevance to trainees are: ¹¹
     1. basic sciences and clinical knowledge and its application to clinical problems
     2. clinical skills
     3. communication skills
     4. professional behaviours
4. Provide constructive feedback to your learners.
   • The role of constructive feedback is to help learners learn, and to help them develop the skills of self-assessing their own learning. ^{7, 8, 30} This is best accomplished by feedback that:
     1. is a dialogue – for example, begins by eliciting the learner's views on their strengths and weaknesses,
     2. is balanced -- identifies what is done well, identifies what needs to be improved,
     3. is specific,
     4. is timely (immediate is best),
     5. is descriptive (not judgmental),
     6. encourages and guides the development of plans to solve problems, and
     7. is honest.
        An immediate goal of constructive feedback is to assist the learner identify their strengths and weaknesses, and develop a plan to address the weaknesses. The long term goal of constructive feedback is to assist the learner develop the skills of effective self-assessment. Your constructive feedback session with learners should therefore challenge them to self-assess under your supervision, since like any other skill, self-assessment is learned via practice under supervision.
5. Use paper and electronic educational resources.
   • Use paper and electronic visual aids and other resources in your teaching that enhance the effectiveness of your session (i.e., to increase learning), and which exhibit sound instructional design principles including clarity of purpose, logical order, readability, conciseness, and use of examples, diagrams and pictures.
6. Use questions effectively.
   • Questioning your learners is an extremely effective strategy for: ²⁷
     1. a) Identifying their knowledge and knowledge deficiencies (i.e., as a basis for constructive feedback), and
     2. b) Engaging and intellectually challenging your learners to apply their knowledge to understanding and resolving clinical problems.
   • Questions which assess the recall of knowledge versus its application are of limited value in that knowing something is a necessary but not sufficient precondition to the understanding and effective application of knowledge, the latter being the ultimate goal of medical training.
7. Identify your learners' needs and preferences.
   • Identify your learner's needs, desired learning outcomes, and preferred learning styles collaboratively, through negotiation, and through a process of assessing their (clinical) performance.
8. Capitalize on 'teachable moments'.
   • Make effective use of the 'teachable moment' in clinical situations, when a learner's performance identifies a knowledge, skill or attitudinal deficiency. Learning that occurs 'in context' (the best context in medicine is a patient encounter) and in response to a documented need has a much greater chance of being understood and retained. ²⁴
9. Use a structured approach to teaching a skill.
   • The recommended and common sense approach to teaching a skill includes explanation, then demonstration, then observation of the student's/trainee/s performing the skill with feedback. ²⁵
10. Challenge learners to self-assess.
    • Through questioning and role modeling, challenge learners to develop the predisposition and skill of self-assessing their own performance as a basis for defining their learning needs. Many medical trainees, especially those with significant learning needs, are not effective at self-assessing their deficiencies. This skill, like all others is learned through a process of practice under (your) supervision, with feedback.

Patient Education

1. Effectively respond to common questions from patients.
   • Respond to questions from patients regarding their diseases, investigations or treatments, or refer the question onto a clinician more familiar with their problems.
   • Enable effective communication with and understanding by patients by using language at a lay level and avoiding medical terminology.
2. Provide patient education on the basis of sound principles of patient counseling.
   • Base patient counseling and communication strategies on a sound knowledge of effective methods of patient counseling and instruction with the goal of assisting patients understand their health problems, treatments, and their own role in resolving these problems and managing their health. ^{9, 10}
   • Define the outcomes (knowledge, skills, attitudes, behaviours) you would expect a patient to exhibit at the end of a group or one-on-one session. The outcomes you are aspiring to achieve with patients should be stated using 'active verbs' that describe what you want the patients to be able to 'do' – avoid verbs such as 'understand' and 'appreciate' or 'know'.
   • Tailor the session to meet the individual needs of the patient in terms of their:
     1. current knowledge level,
     2. health needs,
     3. motivation and capacity to learn, and
     4. social, cultural and economic background.
3. Prepare educational materials for patients.
   • Prepare educational materials on health and illness topics for patients, at a level of sophistication and using terminology that is understood by patient groups.

4.3 Clinical Supervisor - Vocational Trainee

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1. Organize and provide time for supervision.
   • The effective clinical supervision of juniors, which calls upon all of the competencies listed below, takes time. Such time should be deliberately scheduled. Effective supervision requires that you get to 'know' the juniors, provide them with an orientation, determine their previous experience, observe their performance, provide feedback, etc. ³³
2. Provide a clear orientation for your junior colleagues.
   • Provide a clear orientation to your junior colleagues that includes a description their roles and responsibilities; the support that is available to them; the policies, protocols and expectations in caring for patients; the organization and physical structure of the clinical placement; administrative procedures pertaining to learners; and educational opportunities.
   • Clarify how supervision will occur, and your responsibilities and those of the learners in the process, and allow learners' input into planning the supervision process.
3. Identify the incoming confidence and competence, and learning needs of junior colleagues.
   • Relative to the knowledge, skills and professional attributes objectives of the clinical area you are supervising, use questioning and observation of performance to determine the levels of incoming confidence and competence, and personal learning needs of your junior colleagues in providing clinical care and carrying out clinical procedures.
4. Serve as a role model for the attributes of a vocational trainee.
   • Provide opportunities for your junior colleagues to see you role model excellence in clinical practice, teaching, mentoring and achieving a balanced life. For example, your learners should be provided with opportunities to see how you talk with patients and staff, or how your respond when you or someone else does not know or cannot do something, or how you respond to conflicts in professional and personal demands on your time.
   • Demonstrate how new learning can be integrated into clinical practice.
5. Identify learning opportunities for junior colleagues.
   • Identify and create learning opportunities that enable junior colleagues to interact with patients and practice skills under your supervision.
6. Provide constructive feedback.
   • Directly observe and assess your junior colleagues' performance
   • Provide clear and honest constructive feedback on performance through individual dialogue, which encourages self assessment and identifies what was performed well and what requires improvement (see the discussion on constructive feedback under the role 'teacher'). ^{6 7, 8, 30}
7. Provide personal and professional guidance and support.
   • Provide guidance to your junior colleagues on who to contact if they require support on clinical or personal matters. ^{13, 14}
   • Personally provide, or organize senior colleagues to provide clinical support to your learners as needed, to ensure appropriate patient care.
   • Identify who you should contact when you detect major performance problems in a junior colleague that are beyond your scope to address and that require formal attention from their training program. ³¹
8. Challenge your junior colleagues' clinical reasoning and decision-making.
   • Challenge your junior colleagues to actively engage in and defend their clinical reasoning and decision-making through questioning and discussion of relevant issues. "Why" questions are most effective for identifying the learner's thinking (reasoning) underlying their decisions about tests to order, diagnoses, treatment options, advice to give, or about their interpretations of clinical data. ²⁷
   • Challenge junior colleagues to identify alternate solutions, research findings and current developments in relation to their clinical decisions.
9. Analyse and pre-empt errors.
   • Pre-empt errors by being aware of common errors, looking out for them and educating junior colleagues about them. ³¹
   • Analyse junior colleagues' errors, near misses or adverse events using root cause analyses, and ensure learning from such events occurs through discussion in a non punitive environment.
10. Ensure effective clinical team functioning.
    • Ensure the clinical team functions effectively as a team and that individual needs are being met, by asking team members for group and individual feedback on a regular basis.
    • Ensure that the workload of learners is appropriate in scope and in tasks assigned.
11. Reliably assess your junior colleagues' performance.
    • Reliably assess juniors when required, by ongoing and effective implementation of assigned assessment methods, observing performance, and recording honest and fair judgments of their performance. ^{28, 29}
12. Analyse and address performance problems.
    • Develop and implement suitable strategies for addressing junior colleagues' performance problems, whether arising from personal factors (e.g., lack of clinical or communication skills, personal or health problems), the supervision (e.g., unsupportive, provides no feedback) and/or system failings (e.g., excess workload, excess administrative work, long hours). ³¹
    • Accurately document performance and performance problems and inform relevant individuals and groups.

5.3 Mentor - Vocational Trainee

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1. Establish effective mutually beneficial mentoring relationships with your junior colleagues
   • Establish a supportive relationship with junior colleagues based upon mutual respect, trust, encouragement, openness, and interest with the goal of sharing knowledge, experiences, and insights with these colleagues to assist their personal and career development. ^{13, 14}
2. Provide advice and guidance.
   • Provide advice and guidance regarding issues such as:
     1. Strengths and areas requiring improvement
     2. Short term learning issues and creating learning opportunities
     3. Long term career goals (benefits and challenges, strategies to achieve goals,
     4. contacts)
     5. Personal matters (e.g., housing, financial support, contacts)
     6. What it is like to be a vocational trainee
3. Consciously develop your mentoring strategy.
   • Consciously develop your mentoring strategy, including setting aside time for mentoring. ^{13, 14}

6.3 Assessor - Vocational Trainee
(See assessment terminology glossary ³⁵)

Show/Hide all Details in Section 6.3

Demonstrate effective self-assessment skills:

1. Assess your own learning needs.
   • Develop and use strategies for accurately assessing your own learning needs (what you do not know and should know, what you can not do and should be able to do) relative to your course and program objectives, to the care of patients for whom you have responsibility, and to gaps in your knowledge and performance identified from previous self- and external assessments.
2. Assess your achievement.
   • By reflecting on external feedback that you have received, accurately self-assess when you have acquired the knowledge and skills required in your program and when you have fulfilled your personal learning needs.
3. Seek and effectively respond to constructive feedback.
   • Actively seek and effectively respond to constructive feedback on your performance (i.e., identify and pursue strategies to improve your performance) from medical faculty, clinical supervisors, senior trainees, peers and other members of a '360 degree team' (non-medical members of the health team, other staff, patients).
4. Evaluate self-assessment methods.
   • Review the different methods and strategies available to you for self-assessing your competence, and relative to the advantages and limitations of each, select those that best suit your situation. ^{15, 18}

Effectively assess, where relevant, your junior colleagues and peers, in classroom and clinical settings.

1. Provide constructive feedback.
   • Provide constructive feedback to support and guide the learning of your peers and junior colleagues (see discussion of feedback under 'Planner'). ^{6, 7, 8, 30}
   • Use questioning and direct observation of clinical performance and practical skills as bases for your feedback. ²⁷
   • Ensure that your feedback:
     1. identifies strengths and areas of needed improvement,
     2. relates to expected learning,
     3. is timely (immediate is best), specific, descriptive, detailed (uses examples),
     4. is honest, and
     5. includes guidance in developing plans to address problems.
   • Provide informal feedback to your junior colleagues on a regular (daily or weekly) basis.
2. Employ oral questioning techniques.
   • Use of open ended questions to ask learners to identify areas they do not understand.
   • Use direct questions to assess what has been learned or not learned.
   • Employ questions that focus on the learner's ability to apply their knowledge in contrast to its recall. 'Application' questions typically focus on the learner's ability to reason or make clinical decisions about individual patients. ²⁷
3. Assess clinical reasoning and decision-making
   • Employ a sound knowledge of the clinical reasoning and decision-making, and the common errors in these processes to guide your assessment of peers and junior colleagues. ¹²
4. Make defensible assessments.
   • Defend your judgments of a junior trainee's or peer's performance with reference to program objectives, your observation of their performance (descriptively referencing what you saw them do or not do), and the desired levels of performance for their stage of training.
5. Evaluate the relative usefulness of different assessment methods and strategies.
   • Select, develop and use specific methods and strategies for assessing junior colleagues and peers on the basis of their relative utility. "Utility' is a function of their validity, reliability, acceptance, feasibility, educational impact, and cost as measures of different aspects of clinical competence, including clinical knowledge, clinical reasoning and decision-making skills, communication, professional and procedural skills. ^{16, 15, 17, 18, 20}
6. Effectively implement assessment procedures
   • Effectively use assessment procedures (formative and summative) you have been asked to use, in particular with respect to your personal conduct in their implementation, and in their marking/grading and reporting/feedback strategies. ^{28, 29}
7. Guide your learners to self-reflect on their performance.
   • Through a process of role modeling and questioning, guide your peers and junior colleagues to practice ongoing reflection on their personal performance, as a basis for their life-long self-directed learning skills and independent professional development.
8. Implement '360 degree' assessments.
   • Take a leadership role in developing and nurturing a '360 degree team' (clinician colleagues, other members of the health team, staff, patients) strategy for the formative and summative assessment of yourself, your peers and junior colleagues.

7.3 Evaluator - Vocational Trainee

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Provide evaluations to others

1. Identify factors influencing instructional effectiveness.
   • Identify the factors contributing to or detracting from the effectiveness of teaching and learning sessions, educational materials, courses and programs in which you and your peers participate as learners.
2. Recommend changes contributing to effectiveness.
   • Recommend specific and realistic changes that would contribute to the effectiveness of teaching and learning sessions, materials, courses and programs in which you and your peers participate as learners, and effectively convey these recommendations via constructive feedback to teachers and supervisors.
   • Evaluate the relevance of the content of educational activities and materials to clinical practice and recommend how this content could more effectively address key knowledge and skills.

Elicit, receive and act on evaluations

1. Evaluate your instruction.
   • For your educational sessions, use a variety of simple methods of evaluation (e.g., self reflection, verbal and written feedback from learners) that identify what went well and what aspects could be improved (e.g., content, instructional plan, instructional materials, structure of the session) and act on the evaluation results as necessary.
2. Audit your clinical performance.
   • Participate in and use the results of clinical practice audits of cases in which you had a clinical role, as a basis for identifying steps leading to improvements in your clinical performance.
3. Select/develop evaluation methods.
   • Select, develop and use suitable qualitative methods (e.g., self-reflection, verbal feedback, focus groups) and quantitative methods (e.g., rating forms, checklists, trainee examination scores) of evaluation. For the broad spectrum of teaching, learning, and assessment activities experienced by the vocational and prevocational doctors with whom you work and for whom you are responsible, these methods should:
     1. Elicit both descriptive and judgmental data
     2. Identify what went well and what could be improved,
     3. Include a focus on both educational process and content, and
     4. Provide information that effectively guides improvements as necessary.
4. Use assessment results to evaluate instructional and program effectiveness.
   • Use informal (e.g., via questioning during sessions) and formal (e.g., examination scores) learner assessment results related to your teaching as an indicator of the effectiveness of your teaching.
   • Use group assessment data to identify program strengths and deficiencies and provide provide guidance on the need for additional learning interventions for that group.
5. Use statistical methods to analyse evaluation data.
   • Use descriptive and basic inferential statistics, and graphical techniques to analyse and interpret evaluation data.

1.4 Planner - Independent Practitioner

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Self Education

1. Develop a personal learning plan.
   • Develop a (written) 'learning plan' for each component of your professional development program, based upon the outcomes you expect to achieve in your program, and your strengths and gaps in performance identified from self- and external assessment.
2. Identify appropriate educational resources.
   • Identify the learning resources and methods available to assist your learning, and for each identify its relevance, and its relative strengths and weaknesses in terms of your learning needs and learning style, and in terms of what is known about effective learning strategies in medicine.
   • Identify the professional groups, conferences and professional journals to which you will subscribe.
3. Develop strategies and set aside time for incorporating learning into your working day.

Teaching Others

1. Define clearly stated objectives.
   • Clearly state outcomes (what you want learned) for a session, including outcomes for formal group sessions (case based discussion, problem based learning, lecture), one-on-one or group sessions with or without patients, and clinical attachments over weeks to months, taking into account the incoming knowledge and skills of the learners, how the session fits into the overall program, and your own personal level of competence related to these outcomes. Objectives should describe observable behaviours, using verbs such as identify, describe, interpret, and diagnose, and avoid verbs such as know, understand and appreciate. ^{1, 2}
2. Employ a 'set/body/closure' format for your sessions.
   • Plan both formal and informal educational sessions using a structure of 'set' (introduction, objectives, importance, ...), 'body' (e.g. presenting content, demonstrating skills, analysing cases, answering questions) and 'closure' (summary, key issues). This format can be effectively applied to any length of session, from brief 2-5 minute spontaneous sessions in a clinical context, to longer seminar, rounds, and workshop sessions. For didactic sessions, the spirit of the 'set/body/closure' format is captured in the commonly stated guideline, 'tell them what you are going to tell them, tell them, and tell them what you have told them'. Longer sessions are most effective if they employ several set/body/closure components. ^{3, 4, 23}
3. Select appropriate methods and materials for your teaching.
   • Select methods for teaching and learning (interactive or non-interactive, patient based, electronic, simulation, virtual reality) on the basis of the relative advantages and disadvantages of each.
   • Select or plan educational materials needed for your teaching sessions, including pre-reading, or other student preparation material, handouts, written evaluation forms, and if relevant, inform learners prior to the session about what, if any, preparation is required by them.
   • Develop plans for a medical student's and trainee's clinical attachments that include an orientation, scheduled learning opportunities and sessions, and involvement in supervised patient care.
   • Select 'active' educational methods that intellectually challenge learners (to reason, make clinical decisions, answer questions) and/or demand "hands on" engagement. The more intellectually engaged learners are in a learning activity, the more effective it is. 'Listening' (e.g., in a didactic lecture) is an intellectually passive activity, and as such is the least effective way to learn. Observing a demonstration is also a relatively passive activity. Reading is more intellectually challenging, but activities such as engaging the learner in discussing, answering questions, demonstrating, and teaching others are much more effective at helping learners acquire, understand, and retain their knowledge and skills. Listening and observing are important learning methods in medicine, but are often overused.
   • Plan a variety of teaching and learning activities for your sessions which take into account that the average attention span of an adult in any one activity is 10-15 minutes. Your learners should not therefore be required to listen, or to watch for more than 10-15 minutes at one time. Your sessions should provide a mix of activities. For example, you can present information for 10 minutes, then ask a question, or ask if there are questions, or present a case to challenge your learners to apply (test their understanding of) the information you have presented, or summarize, or ...
4. Select suitable teaching venues and teaching aids.
   • Select and organize the most appropriate teaching venues (e.g., seminar rooms, clinics) and teaching aids (e.g., projectors, models) relative to your objectives and the number of learners in your group.
   • Ensure that other teachers and patients are informed and prepared.
5. Ensure the content of your teaching is appropriate.
   • Review the content of your teaching to ensure that it is up to date, based on evidence and current literature, and where appropriate includes basic science and clinical knowledge, clinical skills, communication skills, professional behaviours and patient perspectives.
6. Rehearse your session.
   • A 'dry run' or rehearsal of your session will identify and address problems related to content, presentation and time. Rehearsing your session, especially if it entails a presentation by you, is a key to its effectiveness.

Patient Education

1. Effectively respond to common questions from patients.
   • Respond to common questions from patients by ensuring that you are familiar with common diseases, investigations or treatments, by reviewing the literature and reporting back to them, or by referring the question onto a clinician more familiar with their problems.
   • Enable effective communication with and understanding by patients using language at a lay level and avoiding medical terminology.
2. Plan patient education on the basis of sound principles of patient counseling.
   • Base plans for patient counseling and communication on a sound knowledge of effective methods of patient counseling and instruction whose goals are to inform patients or change their behaviour. ^{9, 10}
   • Define the outcomes (knowledge, skills and attitudes) you would expect a patient to have acquired at the end of a group or one-on-one session. The outcomes you are aspiring to achieve with patients should be defined using 'active verbs' that describe what you want the patients to be able to 'do' – avoid verbs such as know, understand and appreciate.
   • Tailor the session to meet the individual needs of patients in terms of their:
     1. a) current knowledge level,
     2. b) health needs,
     3. c) motivation and capacity to learn, and
     4. d) social, cultural and economic background.

2.4 Developer - Independent Practitioner

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Self Education

1. Develop a bank of resources to facilitate your personal learning.
   • Develop and maintain a system (including by electronic means) for recording, storing, and readily accessing personal learning resources (text books, handouts, study clubs, web-based sites, ...).

Teaching Others

1. Prepare effective teaching materials and resources.
   • Prepare teaching materials and resources including written handouts and web-based resources (e.g., PDF files) that clearly assist learners to achieve the learning objectives of a teaching session or clinical attachment. ²³
   • Build questions and cases into your materials to stimulate active learning and challenge understanding through self-assessment. ²⁷
   • Liaise with your learners to identify their desired learning outcomes and preferred styles of learning to guide the development of learning opportunities/resources and teaching materials
   • Prepare information for presentation in teaching sessions (e.g., whiteboard notes, overhead transparencies, electronic presentations) according to sound instructional design principles including clarity of purpose, logical order, readability, conciseness, and use of examples, diagrams and pictures.
2. Develop tools to identify learners' needs.
   • Develop strategies and tools (written, electronic or verbal) which identify learner's needs by using questions to assess their interests, skills and knowledge.

Patient Education

1. Prepare clear and effective patient education materials.
   • Access, draw or develop handouts for patients on common problems or investigations, using clear diagrams, illustrations and charts and concise, simple and appropriate language that ensures patients understand and are informed.

3.4 Teacher - Independent Practitioner

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Self Education

1. Identify your personal learning needs.
   • Define your general personal learning needs relative to your patient care roles and career aspirations.
   • Identify your specific learning needs relative to issues arising in the process of providing effective care to the patients for whom you are responsible, and through self assessment methods available through your specialty association.
2. Independently use suitable learning materials.
   • In general, identify and independently use suitable learning materials, resources and strategies to address your personal learning needs.
   • Access, interpret, and critically evaluate information pertaining to your learning needs from your specialty associations and colleagues, and specialty research journals, reference books, meetings, and electronic databases.
3. Accurately self-assess when your personal learning needs have been fulfilled.
   • In addition to strategies such as study questions you can employ personally, collaborate with your peers and colleagues in assessing your knowledge and skills, and their application in your clinical practice.
   • Note that 'knowing' or 'knowing how' are but prerequisites to the primary goal of effectively applying knowledge and skills in the care of your patients. Your ability to apply your knowledge and skills, and not simply 'knowing' for example, should be the ultimate focus of your self-assessment.
4. Develop investigative and therapeutic procedural skills.
   • Your investigative and therapeutic procedural skills can be further developed and refined through deliberate programs of practice under the supervision of experts. You should seek out opportunities to observe and then practice these skills under the eye of peers and senior colleagues. ²⁵
5. Refine your clinical reasoning and decision-making skills.
   • Use up-to-date knowledge of clinical reasoning and clinical decision-making processes, how these processes evolve through the life of a medical practitioner, and the errors clinicians make in these processes, to guide your personal development of these skills. ¹²
6. Conduct self-audits.
   • Through processes of self-reflection and personal practice audit, document and evaluate the efficacy of changes you make in your practice performance and patient care.

Teaching Others

1. Implement teaching sessions that are guided by the principles of effective teaching and learning.
   • Principles of effective teaching and learning for developing and implementing teaching sessions are:
     1. set clear objectives at a correct level (see discussion of objectives under 'planner'), ^{1, 2}
     2. employ a 'set/body/closure' format in all of your sessions (see discussion of set/body/closure under 'planner'), ^{2, 4, 23}
     3. provide a supportive, non-threatening learning environment,
     4. provide feedback (see #4 below), ^{8, 30}
     5. encourage learner self-reflection/self assessment,
     6. intellectually engage and interact with the learners,
        This guideline encourages you to use 'active' educational methods that include intellectual (reasoning, making clinical decisions, answering questions) and "hands on" engagement and that challenge learners. The more intellectually engaged learners are in a learning activity, the more effective it is. 'Listening' (as in a didactic lecture) is next only to sleeping as an intellectually passive activity, and as such is a relatively ineffective way to learn. Observing a demonstration is also a relatively intellectually passive activity. Reading is more intellectually active, but activities such as engaging learners in discussing, answering questions, demonstrating, and teaching others are much more effective at helping them acquire, understand, and retain their knowledge and skills. While listening and observing remain essential elements of the learning process, lectures in which students are passive listeners are often over-used in medical education.
     7. The average adult has an attention span of 10-15 minutes during any one activity. Your sessions should therefore provide a mix of activities. For example, you can present information for 10 minutes, then ask a question, or ask if there are questions, or present a case as an illustration or challenge your learners to apply their understanding of the information you have presented, or summarize, or ...
2. Conduct one-to-one and small and large group sessions that are the key instructional formats in medical student, prevocational and vocational training.
   • As an independent practitioner with responsibilities for the education and supervision of students and trainees, you should be confident in conducting the full range of teaching sessions, including:
     1. one-on-one and small group sessions in a clinical setting, ²²
     2. leading patient/case reviews, ²⁴
     3. demonstrating clinical findings,
     4. demonstrating investigative techniques,
     5. small group sessions in a classroom setting – tutoring a PBL group ⁵, leading a case-based discussion,
     6. large group lecture or plenary sessions ^{3, 4}
   • Integrate teaching and learning into your everyday clinical practice.
3. Conduct teaching sessions that address a broad range of medical competencies.
   • Competencies of key relevance to education and training are: ¹¹
     1. Basic sciences and clinical knowledge and its application to clinical problems
     2. Clinical skills
     3. Communication skills
     4. Professional behaviours
4. Provide constructive feedback to your learners.
   • The role of constructive feedback is to help learners learn, and to help them develop the skills of self-assessing their own learning. ^{7, 8, 30} This is best accomplished by feedback that:
     1. is a dialogue – for example, begins by eliciting the learner's views on their strengths and weaknesses,
     2. is balanced -- identifies what is done well, identifies what needs to be improved,
     3. is specific,
     4. is timely (immediate is best),
     5. is descriptive (not judgmental),
     6. encourages and guides the development of plans to solve problems, and
     7. is honest.
     The immediate goal of constructive feedback is to assist the learner identify their strengths and weaknesses, and develop a plan to address the weaknesses. The long term goal of constructive feedback is to assist the learner develop the skills of effective self-assessment. Your constructive feedback session with learners should therefore challenge them to self-assess under your supervision, since like any other skill, self-assessment skills are learned via practice under supervision.
5. Use paper and electronic educational resources.
   • Use paper and electronic visual aids and other resources in your teaching that enhance the effectiveness of your session (i.e., to increase learning), and which exhibit sound instructional design principles including clarity of purpose, logical order, readability, conciseness, and use of examples, diagrams and pictures.
   • Provide handouts to accompany presentations to learners (students, peers, other staff, and patients) that are clear, factually correct, up-to-date, relevant, and at a level appropriate for the learners.
6. Use questions effectively.
   • Questioning your learners is an extremely effective strategy for: ²⁷
     1. Identifying their knowledge and knowledge deficiencies (i.e., as a basis for constructive feedback), and
     2. Engaging and intellectually challenging your learners to apply their knowledge to understanding and resolving clinical problems.
   • Questions which assess the recall of knowledge versus its application are of limited value in that knowing something is a necessary but not sufficient precondition to the understanding and effective application of knowledge, the latter being the ultimate goal of medical training.
7. Identify your learners' needs and preferences.
   • Identify your learner's needs, desired learning outcomes, and preferred learning styles collaboratively, through negotiation, and through a process of assessing their (clinical) performance.
     Adapt your teaching methods to suit the preferred learning styles and motivation of individual learners.
8. Capitalize on 'teachable moments'.
   • Make effective use of the 'teachable moment' in clinical situations, when a learner's performance identifies a knowledge, skill or attitudinal deficiency. Learning that occurs 'in context' (the ideal context in medicine is a patient encounter) and in response to a documented need has a much greater chance of being understood and retained. ²⁴
9. Use a structured approach to teaching a skill.
   • The recommended and common sense approach to teaching a skill entails explanation, then demonstration, then observation of student's/trainee's performing the skill with feedback. ²⁵
10. Challenge learners to self-assess.
    • Through questioning and role modeling, challenge learners to develop the predisposition and skill of self-assessing their own performance as a basis for defining their learning needs and for identifying the learning opportunities inherent in everyday clinical practice. Many medical trainees, especially those with significant learning needs, are not effective at self-assessing their deficiencies. This skill, like all others is learned through a process of practice under (your) supervision, with feedback.
11. Participate in scholarly activities.
    • Prepare oral presentations and written papers on research findings or clinical matters, that are accepted by peer reviewed forums and journals.

Patient Education

1. Effectively respond to common questions from patients.
   • Respond to questions from patients regarding their diseases, investigations or treatments, or refer the question onto a clinician more familiar with their problems.
   • Enable effective communication with and understanding by patients by using language at a lay level and avoiding medical terminology.
2. Plan patient education on the basis of sound principles of patient counselling, with the goal of assisting patients understand their health problems, treatments, and their own role in resolving these problems and managing their health.
   • Base patient counseling and communication strategies on a sound knowledge of effective methods of patient counseling and instruction with the goal of assisting patients understand their health problems, treatments, and their own role in resolving these problems and managing their health. ^{9, 10}
   • Define the outcomes (knowledge, skills, attitudes, behaviours) you would expect a patient to exhibit at the end of a group or one-on-one session. The outcomes you are aspiring to achieve with patients should be stated using 'active verbs' that describe what you want the patients to be able to 'do' – avoid verbs such as 'understand' and 'appreciate' or 'know'.
   • Tailor the session to meet the individual needs of the patient in terms of their:
     1. current knowledge level,
     2. health needs,
     3. motivation and capacity to learn, and
     4. social, cultural and economic background.
3. Prepare educational materials for patients.
   • Prepare educational materials on health and illness topics for patients and community groups, at a level of sophistication and using terminology that is understood by such groups.

4.4 Clinical Supervisor - Independent Practitioner

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1. Organize and provide time for supervision.
   • The effective clinical supervision of students and trainees, which calls upon all of the competencies listed below, consumes time. Such time should be deliberately scheduled. Effective supervision requires that you get to 'know' your learners, provide them with an orientation, determine their previous experience, observe their performance, provide feedback, etc. ³³
2. Provide a clear orientation for your junior colleagues.
   • Provide an orientation to your junior colleagues that includes a description their roles and responsibilities; the support that is available to them; the policies, protocols and expectations in caring for patients; the organization and physical structure of the clinical placement; administrative procedures pertaining to learners; and educational opportunities.
   • Clarify how supervision will occur, and your responsibilities and those of the learners in the process, and allow learners' input into planning the supervision process.
3. Identify the incoming confidence and competence, and learning needs of your students and trainees.
   • Relative to the knowledge, skills and professional attributes objectives of the clinical area you are supervising, use questioning and observation of performance to determine the levels of incoming confidence and competence, and personal learning needs of your junior colleagues in providing clinical care and carrying out clinical procedures.
4. Serve as a role model for the attributes of an independent medical practitioner.
   • Provide opportunities for your junior colleagues to see you role model excellence in clinical practice, in teaching, in mentoring and in achieving a balanced life. For example, your junior colleagues should be provided with opportunities to see how you talk with patients and staff, or how your respond when you or someone else does not know or cannot do something, or how you respond to conflicts in professional and personal demands on your time.
   • Demonstrate how new learning can be integrated into clinical practice.
5. Identify learning opportunities for your junior colleagues.
   • Identify and create learning opportunities that enable junior colleagues to interact with patients and practice skills under your supervision.
6. Provide constructive feedback.
   • Directly observe and assess your junior colleagues' performance
   • Provide clear and honest constructive feedback on performance through individual dialogue, which encourages self assessment and identifies what was performed well and what requires improvement (see the discussion on constructive feedback under the role 'teacher'). ^{6 7, 8, 30}
7. Provide personal and professional guidance and support.
   • Provide guidance to your junior colleagues on who to contact if they require support on clinical or personal matters. ^{13, 14}
   • Personally provide, or organize other colleagues to provide clinical support to your junior colleagues as needed, to ensure appropriate patient care.
   • Identify whom you should contact when you detect major performance problems in a junior colleague that are beyond your scope to address and that require formal attention from their training program. ³¹
8. Challenge your junior colleagues' clinical reasoning and decision-making.
   • Challenge your junior colleagues to actively engage in and defend their clinical reasoning and decision-making through questioning and discussion of relevant issues. "Why" questions are most effective for identifying the thinking (reasoning) underlying decisions made about tests to order, diagnoses, treatment options, advice to give, or about their interpretations of clinical data. ²⁷
   • Challenge junior colleagues to identify alternate solutions, research findings and current developments in relation to their clinical decisions.
9. Analyse and pre-empt errors.
   • Pre-empt errors by being aware of common errors, looking out for them and educating junior colleagues about them. ³¹
   • Analyse junior colleagues' errors, near misses or adverse events using root cause analyses, and ensure learning from such events occurs through discussion in a non punitive environment.
10. Ensure effective clinical team functioning.
    • Ensure the clinical team functions effectively as a team and that individual needs are being met, by asking team members for group and individual feedback on a regular basis.
    • Ensure that the workload of learners is appropriate in scope and in tasks assigned.
11. Reliably assess your junior colleagues' performance.
    • Reliably assess junior colleagues when required, by ongoing and effective implementation of assigned assessment methods, observing performance, and recording honest and fair judgments of their performance. ^{28, 29}
12. Analyse and address performance problems.
    • Develop and implement suitable strategies for addressing junior colleagues' performance problems, whether arising from personal factors (e.g., lack of clinical or communication skills, personal or health problems), the supervision (e.g., unsupportive, provides no feedback) and/or system failings (e.g., excess workload, excess administrative work, long hours). ³¹
    • Accurately document performance and performance problems and inform relevant individuals and groups.

5.4 Mentor - Independent Practitioner

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1. Establish effective mutually beneficial mentoring relationships with your junior colleagues
   • Establish supportive relationships with junior colleagues based upon mutual respect, trust, encouragement, openness, and interest with the goal of sharing knowledge, experiences, and insights with these colleagues to assist their personal and career development. ^{13, 14}
2. Provide advice and guidance.
   • Provide advice and guidance regarding issues such as:
     1. Strengths and areas requiring improvement
     2. Short term learning issues and creating learning opportunities
     3. Long term career goals (benefits and challenges, strategies to achieve goals,
     4. contacts)
     5. Personal matters (e.g., housing, financial support, contacts)
     6. What it is like to be a practitioner in your specialty
3. Consciously develop your mentoring strategy.
   • Consciously develop your mentoring strategy, including setting aside time for mentoring. ^{13, 14}
   • Mutually agree on how the mentoring will occur and for what period.

6.4 Assessor - Independent Practitioner

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Demonstrate effective self-assessment skills:

1. Assess your own learning needs.
   • Develop and use strategies for accurately assessing your own learning needs (what you do not know and should know, what you can not do and should be able to do) relative to the care of patients for whom you have responsibility, and to gaps in your knowledge and performance identified from previous self- and external assessments.
2. Assess your achievement.
   • By reflecting on external feedback that you have received, accurately self-assess when you have acquired the knowledge and skills required in your clinical practice and when you have fulfilled your personal learning needs.
3. Seek and respond to constructive feedback.
   • Actively seek and effectively respond to constructive feedback on your performance from peers and other members of a '360 degree team' (non-medical members of the health team, other staff, patients).
4. Evaluate self-assessment programs and methods.
   • Review the different programs, methods, and strategies available to you for self-assessing your competence, and relative to the advantages and limitations of each, select those that best suit your situation.

Effectively assess, where relevant, your trainees and peers, in classroom and clinical settings.

1. Provide constructive feedback.
   • Provide constructive feedback to support and guide the learning of your trainees and peers (see discussion of feedback under 'Planner'). ^{6, 7, 8, 30}
   • Use questioning and direct observation of clinical performance and practical skills as bases for your feedback. ²⁷
   • Ensure that your feedback:
     1. a) identifies strengths and areas of needed improvement,
     2. b) relates to expected learning,
     3. c) is timely (immediate is best), specific, descriptive, detailed (uses examples),
     4. d) is honest, and
     5. e) includes guidance in developing plans to address problems.
   • Provide informal feedback to your trainees on a regular (daily or weekly) basis.
2. Employ oral questioning techniques.
   • Use of open ended questions to ask learners to identify areas they do not understand.
   • Use direct questions to assess what has been learned or not learned.
   • Employ questions that focus on the learner's ability to apply their knowledge in contrast to its recall. Such questions typically focus on the learner's ability to reason or make clinical decisions about individual patients. ²⁷
3. Assess clinical reasoning and decision-making
   • Employ a sound knowledge of the clinical reasoning and decision-making, and the common errors in these processes to guide your assessment of trainees and peers. ¹²
4. Make defensible assessments.
   • Defend your judgments of a trainee's or peer's performance with reference to program objectives, your observation of their performance (descriptively referencing what you saw them do or not do), and the desired levels of performance for their stage of training.
5. Evaluate the relative usefulness of different assessment methods and strategies.
   • Select, develop and use specific methods and strategies for assessing trainees and peers on the basis of their relative utility. "Utility" is a function of their validity, reliability, acceptance, feasibility, educational impact, and cost as measures of different aspects of clinical competence, including clinical knowledge, clinical reasoning and decision-making skills, communication, professional and procedural skills. ^{16, 15, 17 18, 20}
6. Effectively implement assessment procedures
   • Effectively use assessment procedures (formative and summative) you have been asked to use, in particular with respect to your personal conduct in their implementation, and in their marking/grading and reporting/feedback strategies. ^{28, 29}
7. Guide your learners to self-reflect on their performance.
   • Through a process of role modeling and questioning, guide your trainees and peers to practice ongoing reflection on their personal performance, as a basis for their life-long self-directed learning skills and independent professional development.
8. Implement '360 degree' assessments.
   • Take a leadership role in developing and nurturing a '360 degree team' (clinician colleagues, other members of the health team, staff, patients) strategy for the formative and summative assessment of yourself, your trainees and your peers.
9. Develop assessment questions and strategies.
   • Develop assessment materials using specific formats: ^{17 18, 19, 20}
     1. a) multiple-choice, extended matching, and modified essay questions which test knowledge application,
     2. b) Objective Structured Clinical Examination (OSCE) stations which test clinical skills,
     3. c) clinical performance rating forms or checklists (for use with case-based oral examinations, mini-CEX encounters, direct observation of procedural skills (DOPS), ...), and for term assessments
   • Adapt assessment methods and strategies to the unique characteristics of the practice environment in which the assessment is to occur, and to the formative or summative purpose of the assessment.
10. Use valid marking systems.
    • Use marking systems within clinically-based assessment processes that reflect the spectrum and relative importance of all aspects of clinical performance.
11. Create an assessment documentation system.
    • Develop, implement and manage an assessment record system which documents:
      1. a) assessment methods and instruments,
      2. b) records of learner performance,
      3. c) records of follow-up activities with learners, and
      4. d) mechanisms for and records of assessment appeals.

7.4 Evaluator - Independent Practitioner

Show/Hide all Details in Section 7.4

Provide evaluations to others

1. Identify factors influencing instructional effectiveness.
   • Identify the factors contributing to or detracting from the effectiveness of teaching and learning sessions, educational materials, courses and programs in which you and your peers participate as learners.
2. Recommend changes contributing to effectiveness
   • Recommend specific and realistic changes that would contribute to the effectiveness of teaching and learning sessions, materials, courses and programs in which you and your peers participate as learners, and effectively convey these recommendations via constructive feedback to teachers and supervisors.
   • Evaluate the relevance of the content of educational activities and materials to your clinical practice and that or your colleagues and recommend how this content could more effectively address key knowledge and skills.

Elicit, receive and act on evaluations

1. Evaluate your instruction.
   • For your educational sessions, use a variety of simple methods of evaluation (e.g., self reflection, verbal and written feedback from learners) that identify what went well and what aspects could be improved (e.g., content, instructional plan, instructional materials, structure of the session) and act on the evaluation results as necessary.
2. Audit your clinical performance.
   • Participate in and use the results of clinical practice audits of cases in which you had a clinical role, as a basis for identifying steps leading to improvements in your clinical performance.
3. Select/develop evaluation methods.
   • Select, develop and use suitable qualitative methods (e.g., self-reflection, verbal feedback, focus groups) and quantitative methods (e.g., rating forms, checklists, trainee examination scores) of evaluation. For the broad spectrum of teaching, learning, and assessment activities experienced by the vocational and prevocational doctors with whom you work and for whom you are responsible, these methods should:
     1. Elicit both descriptive and judgmental data
     2. Identify what went well and what could be improved,
     3. Include a focus on both educational process and content, and
     4. Provide information that effectively guides improvements as necessary.
4. Use assessment results to evaluate instructional and program effectiveness.
   • Use informal (e.g., via questioning during sessions) and formal (e.g., examination scores) learner assessment results related to your teaching as an indicator of the effectiveness of your teaching.
   • Use group assessment data to identify program strengths and deficiencies and provide guidance on the need for additional learning interventions for that group.
5. Use statistical methods to analyse evaluation data.
   • Use descriptive and basic inferential statistics, and graphical techniques to analyze and interpret evaluation data.
6. Routinely evaluate.
   • Routinely include plans for evaluation in your educational program planning and development activities.

Feedback

The developers of this document would welcome your feedback. Please convey your comments and suggestions:

Professor Gordon Page
Director, Bridging Project
Email: gpage@interchange.ubc.ca

Acknowledgement

This project was supported by a grant from General Practice Education and Training Ltd, a body funded by the Commonwealth Department of Health and Aging. Additional support was provided by the Victorian Metropolitan Alliance, a general practice training provider in Melbourne. The project team wishes to acknowledge the leadership and foresight demonstrated by both organisations in their support of the project. The materials in this document were prepared collaboratively by the Bridging Project staff and the volunteer representatives of the stakeholder groups who are members of the project's Governance Committee, and Development and Implementation Committee. The project team acknowledges and thanks each of these individuals for their significant commitment and contribution.

Project Staff

• Professor Gordon Page, Project Director
• Assoc Professor Neil Spike, Project Planner
• Dr Mark Rowe. Project Administrator
• Ms Shannon Campbell, Project Officer
• Dr Rod Wellard, Project Educational Consultant

Governance Committee

• Ms Teresa Cosgriff, former President, AMSA
• Mr Ian Frank, Executive Officer, AMC
• Professor Barry McGrath, Chair, CPMEC
• Professor Rick McLean, DHA
• Mr Rob Mitchell, former President, AMSA
• Mr. Michael Bonning, President, AMSA
• Dr Andrew Perry, AMA CDT
• Dr Andrew Singer, President, ACEM, representing CPMC
• Professor Lindon Wing, former Chair, Medical Deans Australia and New Zealand
• Professor Paul Worley, Medical Deans Australia and New Zealand

Development and Implementation Committee

• Ms Joan Burns, Head of Education & Accreditation, RANZCR
• Professor John Bushnell, Deputy Dean & Director of Teaching, University of Wollongong
• Ms Sandra Carr, Head of Education Centre, University of Western Australia
• Assoc Professor Tony Celenza, University of Western Australia
• Professor Rufus Clarke, Australian School of Advanced Medicine at Macquarie University
• Professor Jane Dahlstrom, RCPA
• Assoc Professor Kevin Forbes, University of Queensland
• Ms Karen Grace, PMCSA
• Dr Julie Gustavs, Manager Evaluation Systems, RANZCO
• Dr Wayne Hazell, Censor-in-Chief, ACEM
• Assoc Professor Fiona Lake, Medical Education, University of Western Australia
• Ms Debra Le Bhers, Accreditation Manager, PMCQ
• Dr Matthew McConnell, Lecturer in Medical Education, Adelaide University
• Dr Alex Markwell, AMA CDT
• Assoc Professor Jenepher Martin, RACS
• Assoc Professor Phillippa Poole, Assoc Dean of Medical Programme, University of Auckland
• Professor David Prideaux, Head, Department of Medical Education, Flinders University
• Dr Morton Rawlin, Director of Educational Services, RACGP
• Dr Catherine Reid, ACD
• Dr Gerard Ryan, Chair of Education Committee, PMCWA
• Dr Jagdishwar Singh, National Project Manager, PMCV
• Assoc Professor Tim Shaw, Director of Program Development, University of Sydney
• Ms Marie-Louise Stokes, Senior Medical Officer, NSW IMET
• Assoc Professor Merilyn Walton, Assoc Professor Medical Education, University of Sydney
• Dr Peter White, Chief Executive Officer, RANZCOG
• Dr Sally Whyte, Deputy Director Education, RANZCP
• Professor Ian Wilson, Medical Education, University of Western Sydney

The preparation of this document has also benefitted from consultations with and guidance from the following additional people.

• Professor John Campbell, President, NZ Medical Council
• Professor Michael Cousins, Chair, CPMC
• Dr Jo Flynn, Immediate Past President, AMC
• Dr. Jason Frank, Office of Education, Royal College of Physicians and Surgeons of Canada
• Professor Janet Grant, UK Postgraduate Medical Education Training Board (PMETB)
• Professor Dan Pratt, Faculty of Education, University of British Columbia