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12• case-didactic teaching (learning cases are limited to minimum, in the forefront - lectures according to the topics included in the cases),
• case-iterative teaching (deep learning of complicated clinical cases "step-by-step").
The majority of students consider the case-method a useful thing to be applied. It improves their studies, and the instructors admit the case-method inspires and motivates students to study.
Therefore, interactive learning has gradually involved more and more supporters in practical work of both general and professional education, since it makes the educational process more motivated, productive, emotionally rich, personality-developing and of higher quality.
References
1. Marukhno V.M. Distance learning in medicine // International Journal of Experimental Education. - 2012. - № 4-2. - P. 154-156. MapyxHO B.M. ^Hcra-
нционное образование в медицине // Международный журнал экспериментального образования. -2012. - № 4-2. - С. 154-156;
2. Solovykh G.M., Kanunikova Y.A., Fabarisova L.G., Tikhomirova G.M., Nefedova Y.M., Osinkina T.V., Khodiachikh I.N. Experience of Implementation of Distance Learning on the Block of Natural-Scientific Disciplines at Medical Higher Educational Institutions // Modern Issues of Science and Education. - 2016. -№ 6. Соловых Г.Н., Кануникова Е.А., Фабарисова Л.Г., Тихомирова Г.М., Нефёдова Е.М., Осинкина Т.В., Ходячих И.Н. Опыт внедрения дистанционных форм обучения по блоку естественно-научных дисциплш в медицинских ВУЗах // Современные проблемы науки и образования. - 2016. - № 6.;
3. Kholopov M.V. Distance Learning in Medicine. http://www.mma.ru /article/id299005/from1 -[electronic resources]. Холопов М.В. Дистанционное обучение в медицине. http://www.mma.ru /article/id299005/from1 - [электронный ресурс].
LECTURING IN CLINICAL MEDICAL EDUCATION
Vasylieva N.
MD, PhD
HSEEU "Bukovinian State Medical University", Chernivtsi Department of Nervous Diseases, Psychiatry and Medical Psychology
ABSTRACT
During supervised clinical training, medical students are expected to develop their professional competence and attitudes. The present study investigates how teaching (lecturing) is carried out during medical students' clinical training. This article explores the types of narratives lecturers use, the attitudes of lecturers and students to the use of narratives in teaching, and the aspects of learning that narratives may facilitate.
Keywords: teaching, lecturing, medical students, narrative.
The literature declares that clinical medical education adheres to a master-apprenticeship system of learning and the fundamental condition for such teaching is that an expert is teaching a novice [1]. On the other hand clinical teaching is a complex learning situation influenced by the learning content, the setting and the participants' actions and interactions. Consequently, in such a system of knowledge acquisition, the clinical teachers play a crucial role as a teacher. But the master-apprenticeship model focuses the students' ability to handle clinical praxis in accordance with what the clinical teachers believe is correct and what tradition allows [2].
The master-apprenticeship structure and theory of teaching [3] are, however, not sufficient to meet modern academic educational demands. All formal education and academic teaching is aimed towards students gaining new knowledge and skills consistent with what is intended and necessary according to the curriculum. In medical education, as a consequence, everyday knowledge is expected to be left behind in exchange for scientifically-based knowledge or for knowledge based on professional experiential knowledge, useful in professional practice. Students' knowledge acquisition is, from this perspective, understood as a qualitative change from a previous kind of understanding. This means there are qualitative differences in how medical
or clinical information is understood. Furthermore, such qualitatively different kinds of student understanding of subject matter may also be found among the students exposed to clinical teaching in a clinical situation. Consequently, we might expect qualitative differences in how something is understood among students. This stresses the need for clinical teachers to identify and take advantage of the students' qualitative differences in what they learn, understand and what they remember of what is studied [4].
Consequently, the way clinical teaching is carried out will have consequences on students' abilities to study and understand. Three generic ways teachers can understand their role, each of which is related to how students are expected to learn [5]. There are:
- teaching as telling or transmission of knowledge;
- teaching as organizing student activity;
- teaching as making understanding possible.
These three methods highlight important qualitative differences in how clinical teachers could consider teaching and student learning.
The effective and excellent clinical teacher is described as an: excellent role model; effective supervisor; and dynamic and supportive educator. Kilminster and Jolly claimed that the essential aspects of clinical teaching are that it should ensure patient/client safety
and promote professional development, and that clinical teaching has three main functions: educational; supportive; and managerial or administrative [6]. Kernan acknowledged that excellent clinical teaching is multifactorial, transcends ordinary teaching, and is characterized by teachers inspiring, supporting, actively involving and communicating with the student [7]. A number of studies emphasise communicative and supportive competence with the clinical teacher and its importance for effective learning.
The literature demonstrates a vast number of pedagogical techniques used in clinical teaching [5, 6, 8], but there seems to be a lack of studies describing how such technique as lecturing is applied and used.
There are strong pedagogical and theoretical arguments for the benefits of narrative learning (learning through narratives, or stories) in medical education— particularly in the areas of meaning-making ("making sense") [9], the development of identity, enhancing memory, promoting empathy, reflection on practice, and the development of clinical reasoning through what are known as illness scripts [10, 11, 12]. All these areas are pertinent to training doctors, which suggests that using narratives as a teaching tool may be a powerful approach in medical education. Although most undergraduate medical courses around the world still use the traditional lecture format extensively within their curricula [11], there is very little information about the extent to which lecturers use narratives, how they use them and what impact this may have on student learning.
Narrative learning is based on the premise that an effective way to convey educational messages is via these constructions: learners connect new knowledge with lived experience and weave it into existing narratives of meaning. Stories have been proposed as potentially powerful educational tools because they are believable (often making the unfamiliar familiar), memorable, and engaging. Narratives demand that listeners become involved in creating meaning which can promote memory, and characters and their motivations encourage an emotional response that facts alone cannot. There is evidence that stories are used widely outside the lecture theatre in medical training. Formal case histories (professional narratives about clinical cases) are used widely, for example on ward rounds or in meetings, and observational studies have confirmed that more informal "anecdotes" (which Hunter describes as "informal stories of clinical cases, solved and unsolved") are used widely in educational settings in hospitals [13].
However, research is lacking on the use of narratives in basic medical science lectures—where perhaps the more formal and traditional setting encourages a more didactic teaching style. Although lectures may be as effective as any other teaching method for delivering information, there is little evidence that they have any role in modifying behaviors or values or inspiring interest, and there is a danger that learners can be overwhelmed by a large volume of information for which they have no context. Educational theory suggests that tactics such as setting memorable context, or encouraging the development of relevant connections or anchors
may help students to get the most from their lectures. Stories could be an effective way to promote understanding and embed new ideas in the narrative component of the listener's long-term memory.
The study used a mix of purposive and convenience-based sampling. It was important to observe basic neurological lectures which were likely to be rich in narratives or stories, as those were the focus of the observations. On this basis, we observed two lectures:
1. Lecture 1. The Motor System (pyramidal, extrapyramidal, cerebellar), symptoms of lesion (to 130 4th-year medical students of Bukovinian State Medical University).
2. Lecture 2. Multiple sclerosis: pathogenesis, clinical features, management (to 145 4th-year medical students of Bukovinian State Medical University).
Students often talked about narratives and stories improving understanding and helping students to make sense of the material. Two particular themes emerged from the interviews: engagement with the material, and providing a relevant context for the audience. The themes of engagement and providing relevant context for learning applied particularly to "story" narratives, driven by characters and struggles and goals; they were less often raised by students and lecturers in discussions of other narrative genres. These learning themes also seemed to appear more often in relation to narrative categories which provided particular relevance for the students - real world narratives that resonated with their existing experiences and narratives related to clinical cases, both real and hypothetical.
Another prominent narrative theme which emerged from interviews was around professional identity. The sub-themes here were about professionalism (particularly professional attitudes), authenticity and trust. All these themes have resonance with narrative learning theory in terms of using narratives to develop identity (in this case as a professional doctor), and in social terms (in terms of accepted professional behaviors, and the social enterprise of medical science).
Memory was a strong theme which emerged from students. Students felt that narratives - again particularly the "story" genre - helped them remember information better. They often mentioned that stories helped them remember because they were engaging, but also that they were often specific examples relating to a particular person. In conclusion, if you can remember a patient it's always easiest, and you remember what the patient went through, and you can actually find that you remember a lot of the symptoms, the signs, the diagnosis, how the doctor diagnosed it, the treatment, and things like that. Just by relating it to this one, like person, and what happened to them. I remember all these little details that if you're just remembering lists, actually it's a lot harder to remember that.
Several narratives—especially in the real world experience and clinical case categories - drew comments about empathy and compassion. Some lecturers particularly, told several narratives which seemed to be promoting the patient's point of view, encouraging students to step inside a patient's shoes. A story in Lecture 2 about a patient with multiple sclerosis with severe in-
tention tremor, urinal dysfunction, pyramidal insufficiency triggered some strong reactions in some students.
The promotion of empathy and compassion is a strong theoretical benefit of narrative pedagogy - these findings suggest that even in basic science lectures, this aspect of narrative learning is indeed at work. Students and lecturers both acknowledged that the value in many of the narratives used was in promoting a patient perspective.
Although not a formal element of the lectures, reflection did come up in discussions. For example, lecturers talked about using narratives as punctuation marks in lectures, to give the students a rest, and time to reflect on what's gone on before.
Students, on the whole, were very receptive to the idea of lecturers using narratives or stories in their science lectures, particularly given their view of medicine as a distinctly human endeavor. Students also seemed to distinguish between the (legitimate) use of narratives to aid student learning for a clinical context, and the (discouraged) use of stories in formal scientific discourse.
On the other hand, a minority of students had negative comments to make about the use of narratives in lectures. The three main themes here were that narratives/anecdotes may be more to do with entertainment than learning, that they are too often irrelevant asides (and particularly not focussed on passing exams).
From the findings presented, it appears that lecturers are using many narratives in their both neurological lectures - even when they don't think they are. The typology describes a variety of narrative themes, from clinical cases (both real and hypothetical) to narratives about patient experience or their own professional careers.
Whilst students felt that narratives or stories would not be appropriate to use in a formal scientific research paper, they were mostly receptive to the idea of using narratives for learning in lectures. A minority of students though, felt that narratives could be an irrelevant distraction, particularly if not related to learning objectives to be tested in exams. This may reflect different learning style preferences in different students. It is interesting that lecturers often underestimated the number and range of narratives or stories they were telling; this in itself might reflect a reluctance to consider them as useful learning tools. Most students (but not all) felt that narratives can be a valuable learning tool. A key step for medical learners - is to create meaning from what they experience; to make it make sense. Meaning-making is very closely linked to comprehension or understanding - a learner must comprehend before he or she can create meaning. There have been many studies of patient's illness narratives which add empirical weight to the theoretical centrality of narrative in meaning-making.
The findings support existing literature in this area which suggests that narratives may be a useful tool for learning in medicine e.g. in Neurology. This study suggests that narratives tap into several key learning processes including providing a relevant context for understanding, engaging learners, and promoting memory.
For medical students in theoretical lectures, narratives or stories may be particularly relevant in promoting the more humanistic aspects of medicine, including professional identity, and empathy.
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