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The Obstetrician & Gynaecologist 10.1576/toag.12.4.273.27620 [Link] 2010;12:273–280 Education

Education The teacher, the learner

and the method
Authors S J Duthie / A S Garden

Key content:
• The modern teacher of obstetrics and gynaecology provides knowledge, acts as
a role model, facilitates learning and plans assessments.
• Doctors training in obstetrics and gynaecology in the UK are adult learners who
work in the National Health Service and undergo training in the core curriculum
of the RCOG.
• There are various teaching methods that can be applied in different scenarios for
the maximum benefit of learners.

Learning objectives:
• To be aware of the attributes of good teachers and learners.
• To understand different methods of teaching and how they can be applied in the
specialty.

Ethical issues:
• What methods of teaching can be employed in the clinical learning environment
which would be of maximum benefit to learners while protecting the safety of
patients?
• What are the hallmarks of the model teacher and the model learner?
Keywords Certificate of Completion of Training / demonstration / evaluation /
feedback / workplace-based assessment
Please cite this article as: Duthie SJ, Garden AS. The teacher, the learner and the method. The Obstetrician & Gynaecologist 2010;12:273–280.

Author details
S J Duthie FRCOG A S Garden FRCOG FHEA FAcadMEd
Consultant Obstetrician and Gynaecologist Director of the Centre for Medical Education;
Blackpool Fylde and Wyre Hospitals NHS and Head of Division of Medicine
Foundation Trust, Whinney Heys Road, Lancaster University, Lancaster LA1 4YB, UK
Blackpool FY3 8NR, UK
Email: sjd757@[Link]
(corresponding author)

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Introduction • facilitator
Educit obstetrix, educat nutrix, instituit • assessor
pedagogus, docet magister. [The midwife • planner of curricula and courses
brings forth, the nurse brings up, the tutor • creator of resource materials.
trains and the master teaches.]
Marcus Terentius Varro, 116–27 BC The teacher as an information provider is the role
with which we are all familiar and comfortable.
Teaching in obstetrics and gynaecology to trainees at It is important that we have clear objectives for our
all levels and in different clinical environments is a teaching sessions and that these objectives fit in
continuing challenge. Obstetrics and gynaecology is with the overall curriculum of our trainee. For the
a varied and complex subject. There are relevant postgraduate trainee, they are laid out in the
issues in recruitment, retention and training. RCOG’s Training Portfolio, knowledge of which is
Current trainees may be practising in the specialty essential for anyone undertaking postgraduate
during the 2040s and possibly beyond. Using the new training. Equally, establishing a trainee’s prior
curriculum of the RCOG, we have the opportunity understanding is crucial, partly to avoid wasting
to equip our trainees for a lifelong career. In the time, partly to ensure that teaching is carried out at
current climate, with increasing demands and the appropriate level, but also to encourage learning
strictures on clinicians’ time and reduced juniors’ in context and to improve the quality of learning.4
hours, it is essential that the time we spend on
teaching is effective for both trainer and trainee. We often forget as teachers that our actions speak
To do this, it is helpful to consider the varying roles louder than our words and that we are role models
and types of teacher, student and method. for our trainees. Although most teachers are
remembered as very positive role models, the values
we teach are not always evident in our practice.5
The teacher A good role model has been identified as one of the
The contemporary teacher must be able to use elements associated with error reduction and an
knowledge and different methods of teaching, improvement in the performance of healthcare
assess the needs and level of knowledge of the teams.6
learners and conduct teaching in accordance
with the curriculum. Common problems with The role of the facilitator is fulfilled in many ways,
clinical teaching include: not least in ensuring that teaching and training
time is protected and not eroded by the pressures
• pitching it at the wrong level so that it is not of clinical service and other activities.7
congruent with the curriculum
• a lack of clear objectives and explanations Increased emphasis on the role of the teacher as
• insufficient participation by the learners themselves. 1
assessor has occurred with the use of log book and
workplace-based assessment in clinical training
Knowledge is the single best determinant of for the MRCOG and beyond. Formative assessment
expertise in a subject.2 However, a practising giving feedback about what a trainee has done well,
obstetrician and gynaecologist also requires skills in addition to identifying areas for improvement,
in communication, organisational ability, technical enhances the trainee’s learning. Clearly, not all
ability and teaching skills, as well as displaying the clinical teachers need to be course planners or
right attitude to make them a good role model. The creators of resources, although opportunities
attributes of the model clinical teacher in obstetrics abound for those willing to try something new!
and gynaecology are summarised in Box 1.
Teachers can face problems (Box 2). It is essential to
Harden and Crosby3 list the roles of a teacher as: maintain the professional relationship between
teacher, learner and, above all, the patient in a busy
• information provider and rapidly changing clinical situation. Teachers
• role model must use opportunities to update themselves in
modern assessment techniques. Individual teachers
Box 1 • Enthusiasm for teaching
Attributes of a good clinical often face the challenge of training a learner and
• Understanding of the learner’s specific needs
teacher then losing continuity with them as a result of rotas,
• Understanding of the educational targets and mandates
from national organisations
leave, different assignments and attendance at
• Clinical and surgical competence
educational activities. The record of training is an
• Possession of knowledge
essential tool in minimising the disruption caused
• Organisational ability
by lack of continuity. Both teacher and learner must
• Good time management
understand how a specific post fits within the
• Ability to use different teaching methods appropriately
overall curriculum. The General Medical Council
• Ability to guarantee patients’ privacy, dignity and safety
stated that there is a need for an educational
supervisor to discuss the educational framework

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and support systems in a post at the time of • Lack of time Box 2

departmental induction.8 The respective Inhibitory factors for teachers
• Lack of interest
responsibilities of teacher and learner must be • Lack of knowledge of the curriculum
identified. • Poor level of familiarity with different methods of teaching
• Lack of familiarity with the learner

The learner • Lack of continuity with the learner

Androgogy is the term applied to the principles of

adult learning.9 In this learner-centred approach
the content of study is dictated by the needs of the • Lack of time Box 3
learner, there are clearly defined goals, there is a Potential pressures faced by
• Failure to grasp the aims of the curriculum learners
requirement for active and voluntary involvement, • Feeling undervalued
feedback is a key feature and self-reflection takes • Facing competition
place. • Bullying
• Lack of understanding of assessment documentation
Who are the learners in obstetrics and gynaecology • Concerns over proficiency in communication skills
and what are their needs? Our learners come from • Quality-of-life issues
widely differing backgrounds and teaching takes
place at undergraduate, pre-MRCOG,
post-MRCOG and subspecialist levels. the commitment of the trainee, no progress will be
made.
Many graduates of British medical schools will
enter the specialty for training having been exposed What are the hallmarks of a good learner?
to some form of self-directed learning. This may
not be the case for all trainees. In many areas, the • Motivation. The learner must genuinely desire
format for teaching still relies on didactic lectures progression in the specialty.
and examinations that still rely heavily on the recall • Good communication skills and language
of facts. This is not meant to be an unfavourable proficiency. The ability to communicate with
comparison but merely to make the point that patients, teachers and multidisciplinary team
learners have different experiences and members is vital to function in any healthcare
expectations; the needs of the learner must system.
be understood by the teacher. • The ability to understand and apply learning.
A good trainee is able to apply lessons from one
The RCOG has stated unequivocally that area to another and from one patient to another.
attainment of the Certificate of Completion of • The ability to retain facts. Although there is less
Training (CCT) equates to capability to practise emphasis on factual recall in modern
general obstetrics and gynaecology safely and examinations there are core pieces of
independently.10 There is a 7-year programme information, such as the anatomical
of training and it is essential for teachers to relationships of the ureter, which just have to be
understand where their trainees are in the remembered!
programme. The nomenclature for defining the • Good time management. Demands on time are
curriculum is as follows: increasing in the modern workplace. The learner
needs to be able take this into account and be
• basic training equates to years 1 and 2 punctual, plan ahead for assessments and use
• intermediate training to years 3, 4 and 5 resources constructively.
• advanced training to years 6 and 7. • Self-reflection. This is important in the
development of a trainee, allowing the trainee to
The requirements of the core curriculum underpin identify what went well in the day’s activities;
all 7 years of training and it is, therefore, the totality what needs to be learned from what happened;
of training that prepares an individual for what needs improvement, as well as areas that
independent practice following the attainment of went well; and why they did so.
the CCT.10 The seniority of trainees is important
in defining their needs. Doctors in year 1 of the Learners face certain pressures, some of which are
specialist training programme (ST1s) are focused summarised in Box 3. With these pressures in mind,
on the Part 1 MRCOG but need to be encouraged the RCOG has published recommendations to
not to neglect other educational objectives, whereas improve the clinical learning environment.11 The
year 5 trainees (ST5s) may need help in considering experiences of medical students in the specialty and
application to a subspecialist programme. of student midwives have been drawn on to analyse
relevant issues and make key recommendations.
Nevertheless, trainees are ultimately responsible for Although it is often overlooked, the environment
how they learn and develop: the teacher may be in which teaching takes place has a major effect on
good and the resources may be helpful, but without students.12

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The method can be either the ward, the clinic, the labour ward or
How can good clinical teaching be developed? a departmental case presentation. The important
A model for the improvement of clinical teaching points to note are that the learner must have been
is the seven-category framework of analysis responsible for managing the patient and that
developed by the Stanford Faculty Development aspects of diagnosis, treatment, need to refer,
Center for Medical Teachers and described by awareness of professional limitations, record
Skeff.13 keeping, use of resources and emergency
management can be assessed. By contrast, the mini-
1. The teacher must set the stage for teaching and clinical evaluation exercise (mini-CEX) consists of
learning by promoting a climate in which a consultation between a patient and the learner
learners find stimulation and are able to identify which is observed and assessed by the teacher. The
and meet their needs. mini-CEX is a powerful tool for assessing
2. The teacher must take control of the session by doctor–patient communication, diagnostic
maintaining focus and using time efficiently. acumen and treatment planning. Neither the case-
3. The goals of the learners must be identified and based discussion nor the mini-CEX are easily used
expressed explicitly. for domains such as audit, probity or health.
4. There must be a meaningful interaction
between the learners and the subject material An important concept in assessment is
with the purpose of promoting understanding triangulation.4 Evidence of progress, attainment
and retaining of concepts and facts. or problems should be obtained from two or
5. The teacher must develop the ability to carry more assessors on more than one teacher–learner
out formative and summative evaluation encounter and if possible using more than one
against the identified goals. method of assessment.14
6. The teacher must have the ability to provide
timely feedback in addition to evaluation. Methods of teaching
Feedback is an ongoing process of informing A list of useful teaching methods is provided in Box 4.
the learner whether a goal has been met,
exceeded or not met. If a goal is unmet, Lectures
feedback informs the learner how close they This is an educational talk to an audience and is the
came to the goal and what requires to be done teaching method with which most clinicians are
to achieve the agreed standard. comfortable. There are many circumstances in
7. Promotion of self-directed learning. The which this is a suitable method of teaching.
teacher facilitates learning derived from the However, there are potential drawbacks.
learner’s needs with the objective of Participation by learners is minimal, there is a risk
encouraging lifelong learning. that the lecturer can appear patronising and
ulterior motives may be suspected. The lecture has
In addition to these general principles, there are been described as ‘a process by which the notes of
different teaching methods that can be applied in a teacher become the notes of the student without
different situations. While we all have our favourite passing through the minds of either’. In addition,
methods, good teaching develops a repertoire of it is recognised that students actually retain very
methods so that the one most appropriate to the little of the information imparted (Figure 1).
circumstances can be used.
On the other hand, a lecture is a useful method of
In a clinical discipline such as obstetrics and teaching learners when they are at a comparatively
gynaecology, it is of paramount importance to early stage in their career and when the lecturer is a
protect patients. A teacher must ensure that world authority on a subject with a limited amount of
patients’ privacy, dignity and safety are assured. time. Ideally, a lecture should stimulate the trainee,
provide a framework for the subject and encourage
Workplace-based assessments are important tools them to undertake further self-directed learning.
for constructing evidence-based reports on the
progress of a learner, for providing data to inform Tips to produce the best possible lecture include
‘high stakes’ judgements such as the annual review the following:
of competence progression (ARCP) and for the
identification of those in need of additional • Ensure that the topic is best learned by the trainee
support, preferably at an early stage.14 Again, it is through the lecture format and would not be
important that the teacher understands different better delivered by one of the techniques outlined
methods of workplace-based assessments and below.
how they are applied. For example, in a case- • Resist the temptation to put in ‘everything’ and
based discussion the teacher explores the clinical overfill the available time.
knowledge, judgement and reasoning of the learner • Ensure that it meets the trainees’learning objectives
using patient records and test results. The setting by making yourself aware of the curriculum.

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• Summarise before you finish. • Brainstorming Box 4

• Provide the students with some self-assessment • The Delphi technique
Types of teaching methods
questions to ensure their understanding. • Direct observation of procedures with feedback
• Provide some additional resources for those you • Lectures
hope you have stimulated to learn further! • The 1-minute preceptor
• Peer coaching
Problem-based learning • Problem-based learning
In this technique, learners are given a problem or • Schema activation
case to discuss. Using self-directed learning they • Schema refinement
are encouraged to identify and research their own • Simplified procedural hierarchy
learning objectives, incorporating scientific, • Complex procedural hierarchy
clinical, psychological, social, ethical, professional • Snowballing
and public health aspects. An example would be a
case involving the organisation of a
multiprofessional teaching session for a small incidence of common abnormalities, diagnosis of
group of midwives and medical students on the fetal abnormality, risks of the diagnostic methods,
subject of termination of pregnancy for fetal the importance of early diagnosis, breaking bad
abnormality. Over a 2-week period the learners news, principles of counselling, the legal
have three 1 or 2-hour sessions with a facilitator. framework of abortion for fetal abnormality,
The role of the teacher in this situation is to informed consent, methods of termination of
facilitate the trainees’ learning: to ensure everyone pregnancy, complications, management of future
takes part, to guide the discussion if important pregnancy and principles of minimising the risks
areas are being neglected and to keep the discussion of fetal abnormality.
focused. Resources such as clinics, ultrasound
sessions, the library and the internet are provided The 1-minute preceptor
for use in private study time. This is a five-step process that can be carried out
in minutes15 with the purpose of structuring
The learning objectives will vary depending on the teaching opportunities that arise in the clinical
experience of the trainees. In the aforementioned environment. This is an example of a teaching
example the learning experience would include: the method that demands a good rapport between the

Figure 1
The learning pyramid.
A comparison of different learning
methods and the retention
of material. Reproduced with
permission from the National
Training Laboratories, Bethel, ME

277
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teacher and the learner(s). The teacher must make The value of the method lies in the use of all five
the learner feel secure and allow the voicing of steps, not a ‘buffet’ selection of some of them.
opinions, whether they are correct or incorrect.
The five steps are: Directly observed procedures with feedback
The teacher observes the learner carrying out a task.
• commitment This could be the insertion of an indwelling urinary
• justification catheter, intrauterine contraceptive device or
• application vaginal pessary. If the learner fails, three steps are
• positive reinforcement integral to this method of teaching. First, the
• correction of mistakes. teacher must observe, preferably record the
findings, and make a judgement. The second step
An example could be that of a pregnant woman is to inform the learner of the opinion that has been
who has had very little antenatal care and has formed and to demonstrate how the procedure
been admitted to the labour ward with painless should have been done. In basic terms the learner
antepartum haemorrhage. The woman’s general must be told that the performance was either
condition appears to be good; there is a single adequate or inadequate. However, the method
fetus with a reassuring fetal heart rate tracing. of teaching is incomplete without the third step,
Application of the 1-minute preceptor model which is to advise the learner exactly where they
of teaching would involve asking a group of went wrong to the point of an inadequate score.
learners who have just seen the woman what The learner must be offered an analysis of the
would be the differential diagnosis. This is the mistake(s).
step of ‘commitment’ on the learners’ part. It is
important to note that the teacher does not Brainstorming
present his or her own views before the learners This is a spontaneous group discussion to produce
have an opportunity for expression. The second ideas and ways of solving a problem. The clinical
step, of justification, involves asking the learners teacher may use this method to promote clinical
to provide evidence from the woman’s history and critical thinking in trainees who are at a
and relevant examination findings to support the relatively early stage in their career. The teacher
differential diagnosis they have identified. As the may start by introducing an idea or clinical
learners present their evidence the clinical teacher question such as the measurement of cervical
must either affirm or reject what is said. Most length by transvaginal ultrasound as a valid
clinicians would find the first two steps screening tool for detecting women at risk of
straightforward. The third step involves preterm labour. Brainstorming would encompass
illustration of how the learning from the woman the pathophysiology of preterm labour; the
with antepartum haemorrhage can be applied to anatomy of the cervix; changes in the cervix prior
other women with obstetric haemorrhage. This to the onset of labour; the reliability of ultrasound
could include a discussion on how the volume and how it compares with vaginal examination in
of blood loss can be estimated or measured. The terms of accuracy, acceptability and feasibility; the
teacher could elaborate on how the blood loss concept of screening; how a simple study may be
in postpartum haemorrhage is usually revealed designed; and how preterm labour can be
unless there is a broad ligament haematoma, prevented if an at-risk group is defined.
whereas in antepartum haemorrhage due to
abruption there may be a large amount of Schema activation
concealed retroplacental blood loss. Another A schema is a representation of a plan in the form
fundamental point to cover would be the adage of a model. From a philosophical perspective a
that ‘painless antepartum haemorrhage is due to schema is a conception of what is common to
placenta praevia until proved otherwise’. This all members of a class. For instance, it is quite
particular woman may well have placenta praevia. reasonable for a clinical teacher to expect specialist
As the fetal heart rate tracing is reassuring, vasa trainees in year 1 to understand the anatomy of the
praevia is unlikely and the learners’ knowledge vagina and cervix. These learners would have been
of this can be probed. The discussion could be taught the basic anatomy in medical school. The
widened to include the differential diagnosis in teacher would activate recall of basic facts and
other situations such as whether cancer of the concepts prior to enhancing learning. An example
cervix could present with painless antepartum would be the task of providing a tutorial to
haemorrhage. specialist trainees in years 1 and 2 on the
management of genitourinary prolapse. The
The fourth step is to reinforce what the learners clinical teacher would initially apply schema
did correctly. This increases their confidence: an activation to revise the learners’ knowledge of
important consequence of learning. The fifth step pelvic floor anatomy which had been taught years
is the correction of mistakes, which should be before but the knowledge of which is essential to
specific and not vague. all the learners in the group.

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• Interaction between teachers and learners in the clinical workplace is pivotal to medical education Box 5
Summary
• There are significant limits on time
• Demonstration to the learner and observation of the learner must be followed by both evaluation and feedback
• There are several different teaching methods for use in different circumstances
• Some teaching methods may be applied in a matter of minutes; others require application over several months
• The learners of today are the specialists who will care for women over the next 40 years

Schema refinement something. For example, a teacher has been asked

This is a useful method for teaching more advanced to instruct junior trainees on how to carry out
learners. In this technique the learners are diagnostic laparoscopy. The teacher initially shows
encouraged to apply basic concepts, clarify their the trainees how to assemble the laparoscopic
understanding and solve clinical problems. One equipment.
example would be the use of a tutorial on the
anatomy, physiology and endocrinology Complex procedural hierarchy
appropriate to amenorrhoea followed by a series In this technique a hierarchy is involved which
of clinical cases which could include post- develops over several encounters and over a
chemotherapy amenorrhoea, Turner syndrome, significant time span.
hyperprolactinaemia and complete androgen
insensitivity syndrome. The learners recall what In one example a consultant asks a trainee to assist
they have experienced in the tutorial and attempt to in the operation of total abdominal hysterectomy.
solve clinical problems. After several such operations, during which the
educational experience of the trainee consists of
Snowballing observing surgical techniques, there is a rapport
This is a useful technique to employ if the teacher is between the consultant and the trainee. The
unsure of the current level of knowledge or skills of consultant would then ask the trainee to describe
the learners. This is not an ideal situation but it the operation in order to ascertain that they have
could arise. grasped the steps, techniques and use of
instruments that are vital to a safely conducted
The discussion may be very basic and unstructured operation. The consultant then assists the trainee
at first. However, it soon becomes obvious that the in the procedure. After several operations with
knowledge base of the learners is high and the ongoing assessment, evaluation and feedback, the
discussion is allowed to snowball — increase in consultant and trainee would be in a position to
intensity and importance. judge progress. The safety of patients is of
paramount consideration. If the trainee is capable
One example would be the task of teaching ethics of carrying out uncomplicated abdominal
to a group of 12 embryologists for 2 hours. The hysterectomy independently, the next step is to task
teacher is unsure of their current understanding of the trainee to carry out the operation while assisted
the subject. They may start by getting the students, by another trainee. The consultant would be
in groups, to discuss the terms of the Abortion Act immediately available.
1967, basing further teaching on the knowledge
displayed by the students.
Conclusion
Some clinical teaching methods have been (See Box 5 for a summary of points in the article.)
employed by teachers throughout their clinical Both teacher and learner must be aware of the
lifetime without their being aware that they had limitations of supervised postgraduate training. This
a formal name! is one reason why it is important to encourage the
attitude of lifelong learning. The learner needs to
Simplified procedural hierarchy recognise that the reduced number of hours of
A hierarchy is a system in which members are training inevitably means that learning and
ranked according to relative authority. In medicine, experience will continue after completion of training.
the authority arises from the teacher’s recognised It has been estimated that it takes about 10 years of
knowledge of certain matters. In its most basic intensive involvement and 10 000 hours of practice
form, simplified procedural hierarchy is a to acquire an elite level of expertise or performance.16
demonstration by the teacher to the learner The time taken to achieve mastery of cognitive and
or learners. There is no demand for assessment, manual skills in order to practise surgery is estimated
evaluation or feedback. The technique is efficient to be 15 000–20 000 hours.16 The CCT may be a
and is used extensively in the National Health milestone but it is not the end of the journey.
Service (NHS). It is important to note that there
is no mechanism in itself for assessing or testing The challenges faced by the contemporary clinical
the learner. The learner is simply shown how to do teacher include the need to deliver a new

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Education 2010;12:273–280 The Obstetrician & Gynaecologist

curriculum, use modern methods of teaching department through formal teamwork training: evaluation results of the
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