Teaching Philosophy

How three years in this programme changed what I think teaching is.

I came into this programme believing that teaching was clinical expertise, generously shared. I now hold something narrower and more useful: expertise is necessary but not sufficient, and what separates a physician who knows a great deal from one who teaches well is deliberate design.

That conviction has a theoretical spine. My earliest formal thinking rested on Bandura’s social cognitive theory, and on triadic reciprocality, where learner, behaviour and environment continuously shape one another. In endoscopy this is not abstract: learning by consequence is unavailable to me, because a mishandled loop can lacerate a spleen and the patient bears that cost. What remains is modelling, graded practice, and goals set with attention to specificity, proximity and difficulty (Schunk, 2012). I still teach procedures this way.

I have also learned to say when theory and my own practice disagree. Revisiting a curriculum I had designed, I found its weekly open-book assessment better described by Vygotsky’s zone of proximal development than by the social cognitive frame I had claimed. A closed-book examination would have fit my stated theory more neatly. I kept the open-book policy, because trainee stress was the more pressing problem. I no longer treat that kind of inconsistency as a lapse in rigour. More than one theory can be true of the same room.

Design now carries as much weight as content. Building a fifteen-week course forced me to treat signalling, segmenting and redundancy (Mayer, 2009) as decisions rather than instincts, and they govern the e-learning modules I have built since. I now decide what a learner should see first, and in what order, before I write any of it.

I used to treat assessment as the audit that follows teaching. Blueprinting an examination across content domains and cognitive levels changed what I taught before anyone sat it, and the difficulty and discrimination indices afterwards told me more about my own items than about the trainees. The endoscopic skills rubric I wrote is anchored for repeated use across three years of fellowship and expects low first-year scores, so a fellow can see movement across three years rather than a single verdict.

The affective domain is the part I once neglected and now consider indispensable. Designing simulation-based teaching for paracentesis, I wrote an objective requiring a student to raise a guideline-based concern with a supervising physician — to speak up across the clinical hierarchy. Psychomotor competence can be built with a checklist in one session (Barsuk et al., 2012) and staged with Peyton’s four-step approach to manage cognitive load (Krautter et al., 2011). The willingness to advocate for a patient cannot; it has to be taught on purpose.

I ask trainees to reflect against a validated instrument rather than freely, using the REFLECT rubric’s progression from description to critical reflection (Wald et al., 2012), and hold myself to the same standard. My own performance anxiety during procedural training is something I disclose to learners, because a supervisor who appears never to have struggled is not a usable model. Having trained in Canada, Ireland and the United States, I have been the outsider each time, and I try to teach from a learner’s starting point rather than my own.

This is where the work is going. I founded a four-year medical school track in hepatology and transplantation because the discipline is barely visible in undergraduate medical education, and a workforce shortage is not solved at the fellowship level. My aim is to design, deliberately, the exposure I did not have.

References

Bandura, A. (1986). Social foundations of thought and action: A social cognitive theory. Prentice-Hall.

Barsuk, J. H., Cohen, E. R., Vozenilek, J. A., O’Connor, L. M., McGaghie, W. C., & Wayne, D. B. (2012). Simulation-based education with mastery learning improves paracentesis skills. Journal of Graduate Medical Education, 4(1), 23–27.

Krautter, M., Weyrich, P., Schultz, J.-H., Buss, S. J., Maatouk, I., Jünger, J., & Nikendei, C. (2011). Effects of Peyton’s four-step approach on objective performance measures in technical skills training: A controlled trial. Teaching and Learning in Medicine, 23(3), 244–250.

Mayer, R. E. (2009). Multimedia learning (2nd ed.). Cambridge University Press.

Schunk, D. H. (2012). Learning theories: An educational perspective (6th ed.). Pearson.

Vygotsky, L. S. (1978). Mind in society: The development of higher psychological processes. Harvard University Press.

Wald, H. S., Borkan, J. M., Taylor, J. S., Anthony, D., & Reis, S. P. (2012). Fostering and evaluating reflective capacity in medical education: Developing the REFLECT rubric for assessing reflective writing. Academic Medicine, 87(1), 41–50.