Medical Education 1991, 25, 471-474
Complementary value of traditional bedside teaching and structured clinical teaching in introductory surgical studies D. A. HILL & R. S. A . LORD School of Surgery, University of New South Wales and St Vincent’s Hospital, Sydney
Summary. A prospective randomized trial was conducted to see if student performance in a combined multiple choice and objective structured clinical examination was better following a period of structured clinical teaching compared with traditional bedside teaching. Student groups were crossed over in a second phase of the experiment to allow the two teaching techniques to be compared sequentially in the same group. There was no significant difference between the two teaching techniques as measured by performance in a criterion-referenced examination. The results ofthe study led to modification of the curriculum for third-year introductory surgical studies to incorporate both teaching strategies, which are regarded as complementary in value. Key words: *education, medical, undergraduate; teaching/*methods; surgery/*methods; clinical competence; educational measurement; curriculum; prospective studies; random allocation; Australia
Introduction ‘Clinical teaching is concerned with the acquisition of the skills of clinical competence’ (McLeod & Harden 1985). These skills include those of information-gathering and informationgiving (Carney et al. 1985). The hospital wards have been the traditional venue for students to develop these competencies. The past decade has been one of curriculum reform at the University of New South Wales
Medical School (Ewan 1985). There have been variations in course length from 6 years to 5 years and now back to 6 years. Non-teaching hospitalbased studies in community medicine and general practice have been introduced. The teaching of clinical medicine and surgery, however, is still principally based at teaching hospitals. The teaching hospitals are generally tertiary referral centres and as such often lack the broad range of patients necessary for comprehensive undergraduate teaching. The problem is further compounded by a shortage of suitable clinical teachers because of increasing clinical subspecialization. Various strategies have been developed to address these problems. One is the utilization of peripheral hospitals to broaden students’ clinical exposure. Another is the development of alternative teaching techniques. The academic surgical unit at this hospital introduced structured clinical teaching of surgery to third-year medical students on an experimental basis in 1988. This was done to broaden student clinical exposure and to make more effective use of available teaching staff. A prospective, randomized controlled trial was conducted to evaluate the effectiveness of this new teaching strategy. The examination performance of a student group undergoing structured clinical teaching was compared with that of a group taught in the traditional manner.
Materials and methods The 1988 cohort of third-year medical students commencing introductory clinical studies were used in this experiment. This course was the
Correspondence: Dr David Hill, Surgical Professorial Unit, St Vincent’s Hospital, Sydney, New South Wales 2010, Australia.
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D. A. Hill G R . S . A . Lord
students’ first exposure to teaching in clinical surgery. The 66 medical students were randomized into an experimental group and a control group. The experiment was conducted over two 12-week sessions. Each session consisted of 11 2-hour teaching sessions with an assessment being carried out in the 12th week. The experimental group underwent a course of structured clinical teaching during the first session while the control group was taught in the traditional manner. The groups were crossed over for the second teaching session whereby the experimental group became the control and vice versa. All tutors and students were given a syllabus at the start of each 12-week session. This syllabus listed 11 surgical topics to be covered at the level of history-taking and physical examination. Neither tutors nor students knew an experiment was being performed. Structured clinical teaching involving delivering a set syllabus in a series of lecture demonstrations at which students, teachers and patients were assembled in a defined geographical area. A teaching session commenced with a 30-minute didactic lecture to the whole group to give an ox erview of the scheduled topic. Following this the .%.udent body were divided into six subgroups. These smaller groups were rotated through a series of teaching stations, spending about 15 minutes at each before moving on to the next. The resource material at each station was carefully preselected by the course coordinator to facilitate acquisition of clinical skills and allow correlation with basic pathology. A session on inguino-scrota1 disorders would, for example, include stations with pathology bottles, a patient for history-taking and patients demonstrating inguinal hernia, femoral hernia and various scrotal swellings. Each station was supervised by a tutor specially selected for the occasion from the clinical academic and surgical staff. Many of the patients used were drawn from an out-patient register and were paid to come to the teaching session. Traditional bedside teaching was carried out on the wards using in-patients that were immediately available. A wide mix of patient was always on hand, drawn from the gastrointestinal surgical unit, the head and neck/oncology unit, the
peripheral vascular unit and the urology and orthopaedic wards. Four tutors were selected from the visiting general surgical staff. Each tutor had the same group of eight students for the full 11 weeks. Other than being provided with a syllabus to be covered, no further information was given to the tutors and teaching strategies were left to the individual discretion of the tutors. Students underwent an assessment in the 12th week of each of the two teaching sessions. This was an internal examination not formally required by the university. Each assessment consisted of a multiple choice question (MCQ) examination, which contributed half the marks, and an objective structured clinical examination (OSCE), which contributed the other half. Examination content was restricted to subjects on the syllabus. The 24 MCQs were designed to test cognitive skills while five OSCE stations were designed to test skills in history-taking and physical examination. The examination was discussed and marked immediately on completion by the students under the direction of the course supervisor. The comparative examination results between control and experimental groups and individual group performance in the first and second examinations were analysed statistically by Student’s t-test. Results
The results are summarized in Table 1. There was no significant difference ( P = 0.23) in the first examination results between the experimental group that underwent 11 weeks’ structured clinical teaching and the control group that underwent a similar period of traditional bedside teaching. Similarly, there was no significant difference ( P = 0.69) in the results between the crossed-over groups in the second examination. Both student groups improved their performance in the second examination when compared with the first. One group’s results increased from a mean of 55.7% to 60.5% ( P = 0.001). The other group’s result increased from a mean of 534% to 61.3 Yo ( P = 0.0008). Discussion This research was carried out because of per-
473
Structured vs traditional bedside teaching Table 1. Examination marks (YO)
First examination
Mean SD n
Second examination
Mean SD n
ceived problems in teaching introductory surgical studies to third-year medical students in a tertiary referral hospital. It was felt that students would not see a wide enough range of common surgical conditions in a hospital largely specializing in the surgery of arterial disease, cancer and organ transplantation. The hypothesis was developed that this teaching problem could be solved by implementation of the structured clinical teaching programme described above. It was felt that by bringing selected patients into the teaching environment on an out-patients basis, it would solve the problem of suitable patient availability. It was also felt that, in a structured clinical teaching environment, organized by the academic staff, learning the skills of clinical competence would be more effective than in the traditional ward environment. A prospective randomized clinical trial was thought to be an appropriate way to test this hypothesis. A similar educational research format has been successfully used in the past (Leinster & Rogers 1982). Randomization of students into two study groups created no ethical problem as each group was sequentially exposed to both teaching methods in the course of the experiment. Anecdotal discussions with student representatives indicated that the student body enjoyed the exposure of two different teaching modalities. This student perception of a favourable educational environment is, in itself, a stimulus to effective learning in the clinical years (Clarke et al. 1984). Factors concerned with the implementation of the two teaching modalities deserve further comment.
Experimental group
Control group
55.7 5.6 30 61.3 8.8 31
53.4 9.4 34 60.5 6.4 29
Perceived advantages of the structured clinical teaching format include comprehensive patient exposure, control of the educational objectives by virtue of tutor control and completeness in syllabus delivery. Observed disadvantages were principally the problems of overcrowding and noise control with about 50 people in one geographical area. It was also felt that the assembly line type situation was an inappropriate model for the development of interpersonal skills. Mention should be made of the considerable organizational and logistic effort to stage a lecture demonstration. The advantages of the time-honoured technique of traditional bedside teaching with a small student group in a ward environment include quietness and less time pressure. Such an environment is more conducive to developing an integrated approach to patient assessment. The success of this teaching strategy is dependent on the commitment and experience of the teacher. The role model portrayed by the teacher is probably an important factor in the education of students by this technique (McLeod & Harden 1985). The instrument used to measure learning in the two student groups was in the form of a criterion-referenced examination. Half the marks were allocated to the testing of cognitive skills. The M C Q examination was used for the purpose. Testing of psychomotor and attitudinal skills by an OSCE contributed the other half of the marks. These tests are regarded as valid and reliable for the purpose. Continuous assessment by a criterion-referenced examination is a valuable strategy to both motivate students and provide feedback to students and staff. Immediate marking of the examination by the
474
D . A.Hill G R . S . A.Lord
students themselves is, in itself, a beneficial teaching technique (Black & Harden 1986). N o measurable difference was detected in the examination results between student groups exposed to different teaching techniques. Various sequences in the experimental design have been evaluated from problem identification, hypothesis, randomization, intervention, measurement and statistical evaluation. It was felt that possible design deficiencies included too small sample size and too few questions in assessment. Not withstanding these possible deficiencies in experimental design, it was felt that the conclusions drawn from the study were sufficiently valid to modify the curriculum for teaching introductory surgical studies at this university teaching hospital in 1989-1990. Both teaching strategies were formally introduced into the course during the 2 years following the experiment. Students now spend the first half of the year undergoing traditional bedside teaching in small groups as it is felt that this is the most appropriate way to teach the communication and attitudinal skills. The second half of the year is spent in a structured clinical teaching format as it
is felt that this is an effective way to teach clinical psychomotor skills. References Black N.M. & Harden R.M. (1986) Providing feedback to students on clinical skills by using the objective structured clinical examination. Medical Education 20, 48-52. Carney S.L., Mitchell K.R., Brinsmead M.W., Sanson-Fisher R.W. & Floate D.A. (1985) The way we teach medical students professional skills. Medical Teacher 7 , 37-44. Clarke R.M., Feletti G.I. & Engel C.E. (1984) Student perceptions of the learning environment in a new medical school. Medical Education 18,321-5. Ewan C . (1985) Curriculum reform: Has it missed its mark? Medical Education 19, 266-75. Harden R.M. (1979) How to assess students: an overview. Medical Teacher 1, 65-70. Leinster S.J. &Rogers K. (1982) Is new always better? A comparison of an established teaching method with a new teaching method in a surgical course. Medical Education 16,208-1 1. McLeod P.J. & Harden R.M. (1985) Clinical teaching strategies for physicians. Medical Teacher 7 , 173-89.
Received 13 February 1991; editorial comments to authors 18 April 1991; accepted f o r publication 21 M a y 1991
Complementary value of traditional bedside teaching and structured clinical teaching in introductory surgical studies D. A. HILL & R. S. A . LORD School of Surgery, University of New South Wales and St Vincent’s Hospital, Sydney
Summary. A prospective randomized trial was conducted to see if student performance in a combined multiple choice and objective structured clinical examination was better following a period of structured clinical teaching compared with traditional bedside teaching. Student groups were crossed over in a second phase of the experiment to allow the two teaching techniques to be compared sequentially in the same group. There was no significant difference between the two teaching techniques as measured by performance in a criterion-referenced examination. The results ofthe study led to modification of the curriculum for third-year introductory surgical studies to incorporate both teaching strategies, which are regarded as complementary in value. Key words: *education, medical, undergraduate; teaching/*methods; surgery/*methods; clinical competence; educational measurement; curriculum; prospective studies; random allocation; Australia
Introduction ‘Clinical teaching is concerned with the acquisition of the skills of clinical competence’ (McLeod & Harden 1985). These skills include those of information-gathering and informationgiving (Carney et al. 1985). The hospital wards have been the traditional venue for students to develop these competencies. The past decade has been one of curriculum reform at the University of New South Wales
Medical School (Ewan 1985). There have been variations in course length from 6 years to 5 years and now back to 6 years. Non-teaching hospitalbased studies in community medicine and general practice have been introduced. The teaching of clinical medicine and surgery, however, is still principally based at teaching hospitals. The teaching hospitals are generally tertiary referral centres and as such often lack the broad range of patients necessary for comprehensive undergraduate teaching. The problem is further compounded by a shortage of suitable clinical teachers because of increasing clinical subspecialization. Various strategies have been developed to address these problems. One is the utilization of peripheral hospitals to broaden students’ clinical exposure. Another is the development of alternative teaching techniques. The academic surgical unit at this hospital introduced structured clinical teaching of surgery to third-year medical students on an experimental basis in 1988. This was done to broaden student clinical exposure and to make more effective use of available teaching staff. A prospective, randomized controlled trial was conducted to evaluate the effectiveness of this new teaching strategy. The examination performance of a student group undergoing structured clinical teaching was compared with that of a group taught in the traditional manner.
Materials and methods The 1988 cohort of third-year medical students commencing introductory clinical studies were used in this experiment. This course was the
Correspondence: Dr David Hill, Surgical Professorial Unit, St Vincent’s Hospital, Sydney, New South Wales 2010, Australia.
47 1
472
D. A. Hill G R . S . A . Lord
students’ first exposure to teaching in clinical surgery. The 66 medical students were randomized into an experimental group and a control group. The experiment was conducted over two 12-week sessions. Each session consisted of 11 2-hour teaching sessions with an assessment being carried out in the 12th week. The experimental group underwent a course of structured clinical teaching during the first session while the control group was taught in the traditional manner. The groups were crossed over for the second teaching session whereby the experimental group became the control and vice versa. All tutors and students were given a syllabus at the start of each 12-week session. This syllabus listed 11 surgical topics to be covered at the level of history-taking and physical examination. Neither tutors nor students knew an experiment was being performed. Structured clinical teaching involving delivering a set syllabus in a series of lecture demonstrations at which students, teachers and patients were assembled in a defined geographical area. A teaching session commenced with a 30-minute didactic lecture to the whole group to give an ox erview of the scheduled topic. Following this the .%.udent body were divided into six subgroups. These smaller groups were rotated through a series of teaching stations, spending about 15 minutes at each before moving on to the next. The resource material at each station was carefully preselected by the course coordinator to facilitate acquisition of clinical skills and allow correlation with basic pathology. A session on inguino-scrota1 disorders would, for example, include stations with pathology bottles, a patient for history-taking and patients demonstrating inguinal hernia, femoral hernia and various scrotal swellings. Each station was supervised by a tutor specially selected for the occasion from the clinical academic and surgical staff. Many of the patients used were drawn from an out-patient register and were paid to come to the teaching session. Traditional bedside teaching was carried out on the wards using in-patients that were immediately available. A wide mix of patient was always on hand, drawn from the gastrointestinal surgical unit, the head and neck/oncology unit, the
peripheral vascular unit and the urology and orthopaedic wards. Four tutors were selected from the visiting general surgical staff. Each tutor had the same group of eight students for the full 11 weeks. Other than being provided with a syllabus to be covered, no further information was given to the tutors and teaching strategies were left to the individual discretion of the tutors. Students underwent an assessment in the 12th week of each of the two teaching sessions. This was an internal examination not formally required by the university. Each assessment consisted of a multiple choice question (MCQ) examination, which contributed half the marks, and an objective structured clinical examination (OSCE), which contributed the other half. Examination content was restricted to subjects on the syllabus. The 24 MCQs were designed to test cognitive skills while five OSCE stations were designed to test skills in history-taking and physical examination. The examination was discussed and marked immediately on completion by the students under the direction of the course supervisor. The comparative examination results between control and experimental groups and individual group performance in the first and second examinations were analysed statistically by Student’s t-test. Results
The results are summarized in Table 1. There was no significant difference ( P = 0.23) in the first examination results between the experimental group that underwent 11 weeks’ structured clinical teaching and the control group that underwent a similar period of traditional bedside teaching. Similarly, there was no significant difference ( P = 0.69) in the results between the crossed-over groups in the second examination. Both student groups improved their performance in the second examination when compared with the first. One group’s results increased from a mean of 55.7% to 60.5% ( P = 0.001). The other group’s result increased from a mean of 534% to 61.3 Yo ( P = 0.0008). Discussion This research was carried out because of per-
473
Structured vs traditional bedside teaching Table 1. Examination marks (YO)
First examination
Mean SD n
Second examination
Mean SD n
ceived problems in teaching introductory surgical studies to third-year medical students in a tertiary referral hospital. It was felt that students would not see a wide enough range of common surgical conditions in a hospital largely specializing in the surgery of arterial disease, cancer and organ transplantation. The hypothesis was developed that this teaching problem could be solved by implementation of the structured clinical teaching programme described above. It was felt that by bringing selected patients into the teaching environment on an out-patients basis, it would solve the problem of suitable patient availability. It was also felt that, in a structured clinical teaching environment, organized by the academic staff, learning the skills of clinical competence would be more effective than in the traditional ward environment. A prospective randomized clinical trial was thought to be an appropriate way to test this hypothesis. A similar educational research format has been successfully used in the past (Leinster & Rogers 1982). Randomization of students into two study groups created no ethical problem as each group was sequentially exposed to both teaching methods in the course of the experiment. Anecdotal discussions with student representatives indicated that the student body enjoyed the exposure of two different teaching modalities. This student perception of a favourable educational environment is, in itself, a stimulus to effective learning in the clinical years (Clarke et al. 1984). Factors concerned with the implementation of the two teaching modalities deserve further comment.
Experimental group
Control group
55.7 5.6 30 61.3 8.8 31
53.4 9.4 34 60.5 6.4 29
Perceived advantages of the structured clinical teaching format include comprehensive patient exposure, control of the educational objectives by virtue of tutor control and completeness in syllabus delivery. Observed disadvantages were principally the problems of overcrowding and noise control with about 50 people in one geographical area. It was also felt that the assembly line type situation was an inappropriate model for the development of interpersonal skills. Mention should be made of the considerable organizational and logistic effort to stage a lecture demonstration. The advantages of the time-honoured technique of traditional bedside teaching with a small student group in a ward environment include quietness and less time pressure. Such an environment is more conducive to developing an integrated approach to patient assessment. The success of this teaching strategy is dependent on the commitment and experience of the teacher. The role model portrayed by the teacher is probably an important factor in the education of students by this technique (McLeod & Harden 1985). The instrument used to measure learning in the two student groups was in the form of a criterion-referenced examination. Half the marks were allocated to the testing of cognitive skills. The M C Q examination was used for the purpose. Testing of psychomotor and attitudinal skills by an OSCE contributed the other half of the marks. These tests are regarded as valid and reliable for the purpose. Continuous assessment by a criterion-referenced examination is a valuable strategy to both motivate students and provide feedback to students and staff. Immediate marking of the examination by the
474
D . A.Hill G R . S . A.Lord
students themselves is, in itself, a beneficial teaching technique (Black & Harden 1986). N o measurable difference was detected in the examination results between student groups exposed to different teaching techniques. Various sequences in the experimental design have been evaluated from problem identification, hypothesis, randomization, intervention, measurement and statistical evaluation. It was felt that possible design deficiencies included too small sample size and too few questions in assessment. Not withstanding these possible deficiencies in experimental design, it was felt that the conclusions drawn from the study were sufficiently valid to modify the curriculum for teaching introductory surgical studies at this university teaching hospital in 1989-1990. Both teaching strategies were formally introduced into the course during the 2 years following the experiment. Students now spend the first half of the year undergoing traditional bedside teaching in small groups as it is felt that this is the most appropriate way to teach the communication and attitudinal skills. The second half of the year is spent in a structured clinical teaching format as it
is felt that this is an effective way to teach clinical psychomotor skills. References Black N.M. & Harden R.M. (1986) Providing feedback to students on clinical skills by using the objective structured clinical examination. Medical Education 20, 48-52. Carney S.L., Mitchell K.R., Brinsmead M.W., Sanson-Fisher R.W. & Floate D.A. (1985) The way we teach medical students professional skills. Medical Teacher 7 , 37-44. Clarke R.M., Feletti G.I. & Engel C.E. (1984) Student perceptions of the learning environment in a new medical school. Medical Education 18,321-5. Ewan C . (1985) Curriculum reform: Has it missed its mark? Medical Education 19, 266-75. Harden R.M. (1979) How to assess students: an overview. Medical Teacher 1, 65-70. Leinster S.J. &Rogers K. (1982) Is new always better? A comparison of an established teaching method with a new teaching method in a surgical course. Medical Education 16,208-1 1. McLeod P.J. & Harden R.M. (1985) Clinical teaching strategies for physicians. Medical Teacher 7 , 173-89.
Received 13 February 1991; editorial comments to authors 18 April 1991; accepted f o r publication 21 M a y 1991
