Medical Teacher

ISSN: 0142-159X (Print) 1466-187X (Online) Journal homepage: http://www.tandfonline.com/loi/imte20

FAIRness and clinical teaching

Philip Chan

To cite this article: Philip Chan (2013) FAIRness and clinical teaching, Medical Teacher, 35:9,
779-781, DOI: 10.3109/0142159X.2013.799639

To link to this article: https://doi.org/10.3109/0142159X.2013.799639

Published online: 19 Jun 2013.

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 2013; 35: 779–781

PERSONAL VIEW

FAIRness and clinical teaching

PHILIP CHAN
University of Sheffield, UK

Abstract
Reflection on my long experience in medical student education has led me to conclude that the standard model of the clinical
placement is not fit for purpose. The encounters between teacher and student are generally brief, superficial, and teacher-centred.
Assessment of student progress is a particular problem. The model has come under pressure from increasing numbers of medical
students on each placement and shorter placements.
I have proposed a new model of the clinical placement, emphasising generic skills over specialist knowledge, based on Harden’s
principles of Feedback, Activity, Relevance and Individualisation (FAIRness). The model’s cardinal feature is review of students’
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own work to accurately assess their progress and to give meaningful and regular feedback. Every student receives individual
feedback, as well as exploring common problems in whole class sessions, where students can compare their standard to others’
work. This model emphasises improvement over time, rather than snapshots of student ability.

Content & style of clinical teaching. Practice points

Like most clinicians, I have always been satisfied with my
clinical teaching, but afterwards. I would see students failing at
the very things that I knew I had taught them. And always the
familiar student refrain ‘‘No-one’s ever taught us that . . .’’
I became troubled: I was teaching to the best of my ability,
but clearly some students were not learning.
What was I supposed to be teaching clinical students?
Taking the first clinical year as an example, their educational
needs are not difficult to appreciate. Students are in full-time
clinical attendance for the first time. They wish to learn the
clinical method; how to gain medical information from patients
that lead to diagnosis; that guide and inform management; that
can have prognostic importance. The traditional method is
history and physical examination, supplemented by diagnostic
testing. So surely, students need instruction on how to take
better histories, perform better physical examinations, and
understand tests better.
 Was I teaching this?
Unfortunately not.
 Had I or any of my senior colleagues seen each of our
. Teaching on the standard clinical placement is strongly
teacher centred, does not meet the needs of learners and
is not fit for purpose.
. FAIRness is a useful basic template for reform of clinical
teaching.
. Complex feedback, encompassing private individual
feedback, and exposure to the standard of other
students’ work as well as hearing criticism of one’s
own work is possible, and not difficult. Safety can be
promoted by anonymisation of work in class sessions.
. Review of students’ work allows improvement over time
to be honestly assessed. The end of placement assess-
ment becomes self-evident.
. This approach can be adapted to many clinical settings,
as long as the placement is long enough to allow
improvement.
this glaring disconnect? Possible reasons might be
13

students taking a history?

No. (1) Not my job. There may not be a particular item relating
20

 Even one of our students?
Not something that would pass for a complete history.
 Perform a physical exam?
Except the most abbreviated demonstration, no.
 Do I know with any degree of confidence the level of my
students’ clinical skills?
Except using the most peremptory and unfair judge-
ments, again, no.
In summary, it appears that I know what my students need,
but it does not figure in my teaching. What is responsible for
to student teaching in a doctor’s job plan, but the duty
to teach is clearly present, by custom and tradition, but
also by legal contract.
(2) No guidance or training. This is partially true. Although
the handbooks and papers surrounding each phase of
the students’ course specify their learning objectives,
this is not obvious to the teacher. Certainly the ways
and means of achieving these objectives is not
explained to the teacher, nor is there any method of
inspection or training to back up the teachers.

Correspondence: Philip Chan, Academic Unit of Medical Education, Medical School, University of Sheffield, Sheffield S10 2RX, UK. Tel: 0114
2714709; email: p.chan@shef.ac.uk
ISSN 0142–159X print/ISSN 1466–187X online/13/90779–3 ß 2013 Informa UK Ltd. 779
DOI: 10.3109/0142159X.2013.799639
 P. Chan
(3) Students will pick up skills on the unit, as long as their
assessment focuses on these skills. However, the
current state of assessment is still dependent on
stereotypical simulations in time-limited OSCEs, such
as a 5-min history with such a plethora of ‘‘typical’’
diagnostic features that the average viewer of medical
soap opera could tick enough boxes to pass. These
assessments are not appropriate to the complex hos-
pital and community environments in which the
students are learning. To some extent, clinical teaching
is charged with making up the deficits in assessment
methods, rather than vice versa.
(4) Haven’t got the time. Partially true. Coaching better
techniques of history taking and examination is very
labour intensive. Medical student numbers have
become very large, and often their clerkship time
very brief. Given these limitations, how could I improve
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my clinical teaching?
FAIR
Harden (Harden & Laidlaw 2012) enunciated four principles of
effective face to face student teaching from quite a wide
evidence base, but also largely based on his own vast
experience and humanistic outlook. They are:
Feedback
Activity
Individualisation
Relevance
Feedback
Many studies have emphasised the powerful role of feedback
in student learning. (Hattie & Timperley 2007) The traditional
clinical placement supplies mainly indirect feedback, through
the relative ability of students to give quick answers to oral
questions during ward rounds. Attitude, attendance and
diligence are sometimes partially assessed, but rather sporad-
ically, and rarely formatively.
How could we incorporate better feedback into clinical
teaching? Feedback is most relevant when it is timely. I tried an
end of placement interview for individual students, but found
that it was difficult to remember actual examples of student
behaviour and action that led me to my opinion. This form of
feedback tended to be anodyne, particularly with the
increasing numbers of students, and shortened time on the
placement made it difficult to distinguish anything about
anyone. I decided that overall performance assessment and
feedback had to be based on actual evidence; but more
feedback needed to be delivered in a timely fashion.
I decided to use a system of weekly written clerkings.
I demanded two cases per week per student, written or typed
up. I would mark them, with written comments on each
particular good or bad point, as well as general comments.
I adopted a robustly critical attitude to the students’ work in
order to distinguish good from bad, and to set a standard for
students to aspire to. I indicated to the students that the end of
placement assessment would be based on these clerkings; that
my comments would allow each student to self-assess their
780
progress. Up to this time, I have never disagreed with any
student’s self-assessment.
Activity
Students on clinical placements are traditionally rather passive.
Although set work in the form of written clerkings did put
some onus on activity back on the student, I still felt that this
was not active enough. I therefore modified my weekly
session with the students, to focus on their clinical method,
rather than an instructional lecture.
Each week, the session used the previous week’s clerkings.
I identified common errors and grouped them into themes.
These include
. lack of timeline in the history of presenting complaint,
. lack of relevant detail of the presenting complaint,
. lack of ‘‘associated features’’ that could be diagnostically
helpful,
. artificial and unhelpful separation of a history between
presenting complaint and past medical history when it is all
part of the same medical problem
. incongruity in the account due to missing information,
. lack of understanding of the role of social history,
. over-brief or over-detailed physical examination,
. failure to examine relevant features as they don’t fit easily
into a ‘‘system’’
Each week, I transcribed a few examples of students’ work
into a document, usually illustrative of a single theme. The
examples are projected, or photocopies distributed to each
student. Students work in small groups to evaluate each
example for good and bad points. The examples are genuine,
but anonymised. The work is authentic, and readily identified
with by the group, which is a real advantage over worked
model examples.
This activity creates a complex feedback environment;
students are trying to feed back on others’ work, while
inevitably comparing to their own work. The honesty engen-
dered in the non-threatening class environment is an important
contributor to this. Most students readily admit ownership of
the anonymised work, especially if it is faulty. Students
conversely derive private satisfaction if their work avoids the
faults shown, and this could be regarded as an effective,
objective substitute for direct praise from the teacher.
Individualisation
Different students get different benefits from this class. The
public part of criticism and improvement of students’ work
allows the most able to serve as an example to the class, and to
set a high standard. The less able are able to see their faults
discussed in the class, with positive suggestions for improve-
ment. Some students will notice that their development is
behind the general level of the class; this will normally impel
them to seek special help.
However, each student receives additional individual
feedback in private, in the form of written comments on
their work. The students take these comments seriously, as
they form the basis of their final assessment on the placement.
This weekly feedback allows individuals to draw their own

conclusions, to improve specific aspects of their performance,
or to reinforce their good practice.
The placement becomes a programmed exercise for each
individual, based on learning from mistakes and demanding
longitudinal improvement.
Relevance
Students need to learn about the illnesses of their patients,
which will differ according to specialty placement. However,
students in every placement also need to learn the clinical
method; obtaining, ordering and processing clinical informa-
tion in the style appropriate to the specialty. And this method is
traditionally neither taught nor assessed.
The overwhelming advantage of this teaching is its
relevance to students. Junior students undergo a programme
of introduction to patient encounter; they self criticize their
early, often fumbling work, but generally improve rapidly and
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are encouraged by the obvious evidence for this. Senior
students undergo another programme, concentrating on inte-
gration and synthesis of information, and develop useful skills
in summarizing and oral presentation of patient stories in an
effective style. The relevance of this is very clear to students,
and encourages engagement.
FAIRness and clinical teaching
Summary
This programme is FAIR to students in many ways. I would like
to offer it to the public domain as a model for clinical teaching;
particularly relevant to medical and surgical speciality units, in
which the generic clinical education is of more relevance to
students than the particular specialist expertise of the unit.
Biographical notes
Philip Chan is Reader at the University of Sheffield and
consultant vascular surgeon in Sheffield Teaching Hospitals.
He is also Senior Fellow in the Academic Unit of Medical
Education.
Declaration of interest: The authors report no conflicts of
interest. The authors alone are responsible for the content and
writing of the article.
References
Harden RM, Laidlaw JM. 2012. Essential skills for a medical teacher.
London: Churchill Livingstone. pp 9–12.
Hattie JA, Timperley H. 2007. The power of feedback. Rev Educ Res
77(1):81–112.
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