Medical Teacher, Vol. 14, No. 2/3, 1992
215
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Learning objectives in training residents in general surgey in Kuwait
I. G. PREMADASA & FIKRI M. ABU ZIDAN, Faculty of Medicine, Kuwait University and Mubarak Al-Kabeer Teaching Hospital, Kuwait
SUMMARY An opinion survey of a five-year postgraduate training programme in general surgery was conducted using a questionnaire. The residents who responded indicated that the use of learning objectives needed to be given greater emphasis. They felt that learning objectives should be more clearly defined and be communicated with the learners and the instructors at an early stage in the programme. While the opportunity for learning theoretical concepts in surgey was rated as a strong feature of the programme, learning practical skills, it was pointed out, needed augmenting.
Introduction Curriculum review on a systematic basis is accepted as an important consideration in improving educational programmes. Medical schools and associated programmes, too, have been subjected to critical review, though the exercise itself or implementation of findings needs to clear a number of difficulties (Abrahamson, 1978; Williams, 1980). Models of medical curricula and plans for curriculum evaluation often accept the existence of disparities between the intentions of policy makers, results of curriculum planning activities and the experiences of the learner (Coles & Gale, 1985). Periodic review of training programmes, therefore, is an aspect that needs the attention of both the policy makers and the curriculum designers. A wide array of sources is used to collect data on educational programmes. Students undergoing training and graduates of training programmes constitute a useful source for obtaining feedback and student evaluations of faculty are widely used and well accepted (Association of American Medical Colleges, 1977). Though some limitations had been observed, student ratings have been found to provide reliable information for use in programme modification (Irby & Rakestraw, 1981). A point of considerable argument is the role of learning objectives in health professions training at undergraduate and graduate levels (Williams & Osborne, 1982). Training an auxiliary health worker, it is often suggested, allows for the listing of a set
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
216
I. G. Premadasa & Fikri M. Abu Zidan
of specific outcomes with relative ease. On the other hand, identifying appropriate role models of practising physicians, detecting the crucial elements of performance and the ease of writing objectives for trivial aims have been cited as major problems in using objectives in medical education (Simpson, 1980). While the utility or the feasibility of defining specific behavioural objectives for an entire course could be debated, it is generally felt that clarification of educational intentions is highly desirable. One may wonder whether graduate medical training programmes offer in fact a more appropriate level for defining clearer objectives than has been done hitherto: the in-depth study in a narrow field of content may by itself facilitate the delineation of expected outcomes. The Surgery Residency Training Programme in Kuwait, organized by the Faculty of Surgery, Kuwait Institute of Medical Specialization (KIMS), has been in existence since 1983. The programme aims to produce a surgeon who is able to assume responsibility for the assessment, management, critical decisions and accept responsibility for the outcome of the actions based on his clinical judgment. The trainees are “required to acquire (a) an understanding of basic sciences, (b) clinical application of these areas to surgery with emphasis on functional recovery and (c) appropriate basic technical skills”. Medical graduates of varying periods of post-qualification experience and serving under the Ministry of Public Health, State of Kuwait enrol in the programme. A total of 72 candidates entered the training programme, with 21 dropping out. Ten trainees have already completed the course. Instruction in the course is provided by consultant staff at the major hospitals and the academic staff of the Faculty of Medicine, Kuwait University. Additional instructional support is provided by KIMS in the form of seminars and conferences on special topics.
Aims of study The investigation reported here was conducted to ascertain (1) the extent of definition and use of learning objectives in the training programme, (2) the competencies acquired in relevant areas in surgery with the opportunities that were available, and (3) the effectiveness of the different learning opportunities in reaching the overall aims. It was hoped that the data collected would prove useful to the planners of the course in re-orienting the course so that appropriate emphasis could be given in selecting content and organising learning opportunities.
Method of investigation Data was collected using a questionnaire that was answered anonymously. The survey forms were handed over to all residents (39) who had completed the first year in the training programme, by a resident in training at present. A total of 26 questionnaires were received for analysis. The questionnaire consisted of six main sections. Except for the section on background data on the trainee, it had a series of Likert-type statements and room for open comments. The scale ranged from 1 (poor), through 2 (fair), 3 (good), and 4
General surgery training in Kuwait
217
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
(very good) to 5 (excellent). This approach to scaling to assess the views was used to minimize the possibility of a non-committal mid-position response and to allow for grouping of responses to quantify the worth of the programme to some extent. Though the different points in the response scale were identified with numerical figures, the values were treated only as nominal data. Therefore, the responses at any given point in the scale were only counted, with no attempt being made at summing or averaging. Thus, for a single respondent, counts of five points each would reflect excellence in all areas in a single section while five counts of one point indicated areas of concern. A similar approach of counting the corresponding values in the rating scale across respondents was used to get an assessment of the strengths and weaknesses of the overall programme.
Results Twenty six questionnaires were studied in the data analysis. Of these, three were from those who had already completed the training programme. The highest number of responses in a single year of training (12) was from the third year trainees.
Background of trainees Six residents were graduates of Kuwait University Medical School, while the rest had received their undergraduate training outside Kuwait. The year of graduation ranged from 1974 to 1985, with the average age at entry to the training programme being 28 years. Postgraduate qualifications obtained by the residents were the Primary FRCS and the Final FRCS Examinations. While 14 had passed the Primary FRCS before enrolling in the programme, two passed this examination during the training period. Twelve residents had obtained the Final FRCS qualification, while being in training. The residents had had an average of four years of postgraduate experience before joining the programme, while the specific experience in the field of surgery was 2 years.
Definition of objectives The questionnaire included five statements which dealt with the delineation and utilization of learning objectives in the training programme. Opinions on the extent to which general objectives of the programme had been clearly laid down were divided almost equally between the good or very good and the fair or poor categories. The two areas viz. the trainee’s knowledge of what was expected of him during each year of training and the feasibility of achieving the objectives within the available time too, received similar assessments with equal numbers of trainees responding in the two groups. The evaluation of the achievement of objectives at appropriate times was rated as fair or poor by nearly two thirds of the trainees while a third indicated that this aspect of the programme was good. The degree to which evaluation was related to achievement of objectives was assessed as fair or poor and good or very good by equal numbers, with five subjects not responding to this statement (Fig. 1). Additional observations that had been made by the trainees emphasized the need for defining the general objectives of the programme more clearly. Approximately a third
218
I. G. Premadasa &’ Fikri M . Abu Zidan
Aspects of objectives
Clearly specified
Expectations known
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Feasible to achieve
Matching evaluation
Evaluation timely
t
0
I
I
I
I
I
I
2
4
6
8
10
12
I 14
I
I
16
18
Number responding
FIG. 1. Objectives-definition and use (W good/very good;
poodfair).
of the respondents indicated their concern about the inadequacy of discussion of the objectives of the programme with the learners and the lack of awareness of tutors of the overall expectations. The latter factor was suggested as having led to some degree of disorganization of the activities.
Competencies acquired Learning factual knowledge (concepts and theories) in the field of surgery and developing clarity and precision in oral communication, such as presenting a surgical problem, received very high ratings (Fig. 2). The opportunities for acquiring skills in selecting special investigations for data collection and developing patient management plans were rated positively by most of the trainees. Developing desirable attitudes and values of a surgeon, learning to interpret the results of special investigations, acquiring skills in performing diagnostic and therapeutic procedures and developing abilities in written communication (e.g. writing surgical reports) were also assessed favourably as regards the opportunities that were available for their acquisition. The learning experiences for improving interpersonal relations with patient and family, though receiving a lower total, were still categorized as favourable by the majority. Learning relevant factual knowledge in basic sciences was rated the lowest with only ten responses in the good or very good categories. Sixteen trainees, in fact had indicated this aspect as either poor or fair.
General surgery training in Kuwait
-
219
Competencies ossessed os very good/gwd
Leorning focts
Orol cornmunicotion
Selecting tests
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Potient monogernent plons
Interpreting tests Doing procedures I nterpersonol ski1 Is
Basic sciences
I
0
I
I
1
1
I
5
10
15
20
25
I 30
Number responding
FIG.2. Acquiring surgical skills.
Eflectiveness of learning opportunities A variety of learning opportunities were made available to the trainees. While some of these sessions were conducted by the members of the faculty and visiting lecturers, the others were of the format of self-directed learning where the trainees took the overall responsibility for planning and implementing. The survey analysed the trainees’ views on the contribution of the different types of learning opportunities to achieving the overall aims of the programme. Nearly all the respondents rated the symposia arranged by special organizations such as the Kuwait Institute of Medical Specialization inviting external lecturers as good, very good or excellent (Fig. 3). Literature review sessions conducted by the residents and discussions of special topics were two other areas which received very high ratings. Other activities which were assessed very positively as regards their contribution to the overall aims of the programme were morbidity/mortality discussions and symposia and case discussions presented by the fifth year residents. Bedside teaching and learning surgical skills in the theatre received a relatively poor assessment. While the former area was rated as poor or fair by fifteen trainees, the latter was categorized in this fashion by half the respondents. Discussion
While it was not possible to draw definite conclusions from some of the early studies of the effects of learning objectives on achievement, the usefulness of employing clearly defined objectives in instruction was evident in the later studies (Duchastel & Merrill, 1973; Day, 1972; Engel, 1980; Varagunam, 1971). The need to employ
220
I. G. Premadasa & Fikri M. Abu Zidan
Learning opportunities assessed as very gaad/good
Symposia-KIMS
3
Literature review
Discussion of special topics
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Morbidity/mortality conference
Symposia by 5 t h yrs
Theatre sessions
Bedside teaching
I
0
I
I
I
I
I
5
10
15
20
25
I 30
Number responding
FIG.3. Learning opportunities.
schemes of instruction and assessment based on clearly defined objectives at graduate level of medical education as well has been pointed out (Iseri, Mulbert & Ansell, 1977; Kravath, 1977; Love & Stone, 1978). Writing learning objectives consisting of performance standards and conditions as was advocated widely in the 1960s (Mager, 1962) though, appears to have lost its appeal (Williams & Osborne, 1982; Popham, 1988). A point that the instructor needs to emphasize in using learning objectives is that they state the minimum competencies that all learners are expected to achieve. This implies that the capable student is in no way barred from going beyond the target level of achievement and the instructor is not compelled to operate within a straitjacket. The investigation reported here indicates that the learners felt that there was a need for the learning objectives of the programme to be defined more clearly than in the past. It is important that the expectations of the programme planners are communicated with the residents and the instructors, so that suitable learning situations could be organized. Approximately two thirds of the residents who answered the questionnaire pointed out the need for improving the evaluation system so that learner achievement would be assessed at appropriate times. As is bound to happen in most training programmes, the cognitive aspects of learning appear to have received considerable emphasis in the surgery residency programme. This is evident from the observations of almost all the respondents. A point of much value to the course planners is the useful role of sessions that contributed to the improvement of oral communication skills. Acquiring the skills of presenting surgical problems has been rated as one of the strengths of the programme by almost all trainees who responded. A matter of concern is the relatively poor assessment of bedside teaching and learning surgical skills in the operating theatre. Though it is commendable that the
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
General surgery training in Kuwait
221
programme has promoted, to a very high extent, the learning of concepts and theories relevant in surgical practice, the greater emphasis needs to be on content areas that can be mastered only during clinician-patient encounters. It is therefore important to identify the competencies for which bedside teaching and similar encounters with the patient can be best used, so that optimum use is made of the resources invested. The majority of the respondents felt that the sessions organized by the residents themselves were of considerable value. Similar opinions had been expressed on the utility of programmes arranged by specialized bodies such as KIMS. Though it may not have been obvious initially, this result need not be something unexpected. The average age of the resident at entry to the programme was 28 years, with a 4-year postgraduate experience in the practice of medicine. Being adult learners, the residents were therefore well equipped to take over the responsibility for their own learning and to get considerable benefit from non-formal learning activities. The programme planners could provide appropriate guidance to the resident by indicating the direction in which to proceed and the goals to be reached.
Conclusion This investigation on the role of learning objectives in the residency training programme showed that delineation and utilization of objectives needed to be given greater emphasis. Though it did not assess the competencies of the trainees, but only obtained their perceptions, the findings, however, suggest that providing clearly defined learning objectives in advance to the learners and the instructors is likely to be useful. An important benefit of such a step is that the relative importance of different content areas, as perceived by the planners, could be maintained during the implementation of the training programme. If learning objectives are to be of use to the learners, they need to be meaningful and relevant, clear to all concerned groups and achievable within the available resources. An additional aspect of the use of objectives is that they should be shared with the learners at an early stage in the programme. It was also seen that learning concepts and theories related to surgical topics was a major strength of the programme, while the area of acquiring practical skills needed to be augmented.
Correspondence:I. G . Premadasa, Centre for Medical Education, Faculty of Medicine, Kuwait University, PO Box 24923, Safat 13110, Kuwait. REFERENCES ABRAHAMSON, S. (1978) Diseases of the curriculum, Journal of Medical Education, 53, pp. 951-957. &SOCIATION OF &ERICAN ~’~EDICAL COLLEGES (1977) Preliminary Report of the faculty development survey, (Washington DC), pp. 112-119. Corn, C.R. & GALE,J.G. (1985) Curriculum evalution in medical and health care education, Medical Education, 19, pp. 403-422. DAY,J. (1972) Definition of objectives for teaching clinical medicine, Medical Teacher, December 1972, pp. 5-9. DUCHASTFJLL, P.C. & MERRILL,P.F. (1973) The effects of behavioural objectives on learning, Review of Educational Research, 43, pp. 53-69. ENGEL,C.E. (1980) For the use of objectives, Medical Teacher, 2, pp. 232-237. IRBY, D. & RAKBTRAW, P. (1981) Evaluating clinical teaching in medicine, Journal of Medical Education, 55, pp. 181-186.
222
I. G.Premadasa & Fikri M. Abu Zidan
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Ismu, M., MULBERT,L. & ANSELL,T. (1977) Educational objectives for residency tr-g Urology,I X , pp. 478-483.
in urology,
KRAVATH,R. (1977) Educational objectives for house staff in the paediavic intensive care unit, Critical Care Medicine, 5, pp. 159-160. LOW, R. & Smm, H. (1978) Instructional objectives for a teaching programme in cancer for primary care physicians, The Journal of Family Practice, 6, pp. 1253-1257. IMAGER, R.F. (1952) Reparing Instructional Objectives (Palo Alto, California, Fearon Publishers). POPHAM, J.W. (1981) Educational Evaluation (NJ, Englewood, Prentice-Hall). S&IPSON, M.A. (1980) Objections to objectives, Medical Teacher, 2, pp. 229-231. VARAGUNAM, T. (1971) Student awareness of behavioural objectives: the effect on learning, British Journal of Medical Education, 5 , p. 213-216. WILLIAMS, G. (1980) Western Reserve’s experiment in medical education and its outcome (New York, Oxford University Press). WILLUMS, R.G. & O ~ R N B C.E. , (1982) Medical teachers’ perspectives on development and use of objectives, Medical Education, 16, pp. 68-71.
215
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Learning objectives in training residents in general surgey in Kuwait
I. G. PREMADASA & FIKRI M. ABU ZIDAN, Faculty of Medicine, Kuwait University and Mubarak Al-Kabeer Teaching Hospital, Kuwait
SUMMARY An opinion survey of a five-year postgraduate training programme in general surgery was conducted using a questionnaire. The residents who responded indicated that the use of learning objectives needed to be given greater emphasis. They felt that learning objectives should be more clearly defined and be communicated with the learners and the instructors at an early stage in the programme. While the opportunity for learning theoretical concepts in surgey was rated as a strong feature of the programme, learning practical skills, it was pointed out, needed augmenting.
Introduction Curriculum review on a systematic basis is accepted as an important consideration in improving educational programmes. Medical schools and associated programmes, too, have been subjected to critical review, though the exercise itself or implementation of findings needs to clear a number of difficulties (Abrahamson, 1978; Williams, 1980). Models of medical curricula and plans for curriculum evaluation often accept the existence of disparities between the intentions of policy makers, results of curriculum planning activities and the experiences of the learner (Coles & Gale, 1985). Periodic review of training programmes, therefore, is an aspect that needs the attention of both the policy makers and the curriculum designers. A wide array of sources is used to collect data on educational programmes. Students undergoing training and graduates of training programmes constitute a useful source for obtaining feedback and student evaluations of faculty are widely used and well accepted (Association of American Medical Colleges, 1977). Though some limitations had been observed, student ratings have been found to provide reliable information for use in programme modification (Irby & Rakestraw, 1981). A point of considerable argument is the role of learning objectives in health professions training at undergraduate and graduate levels (Williams & Osborne, 1982). Training an auxiliary health worker, it is often suggested, allows for the listing of a set
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
216
I. G. Premadasa & Fikri M. Abu Zidan
of specific outcomes with relative ease. On the other hand, identifying appropriate role models of practising physicians, detecting the crucial elements of performance and the ease of writing objectives for trivial aims have been cited as major problems in using objectives in medical education (Simpson, 1980). While the utility or the feasibility of defining specific behavioural objectives for an entire course could be debated, it is generally felt that clarification of educational intentions is highly desirable. One may wonder whether graduate medical training programmes offer in fact a more appropriate level for defining clearer objectives than has been done hitherto: the in-depth study in a narrow field of content may by itself facilitate the delineation of expected outcomes. The Surgery Residency Training Programme in Kuwait, organized by the Faculty of Surgery, Kuwait Institute of Medical Specialization (KIMS), has been in existence since 1983. The programme aims to produce a surgeon who is able to assume responsibility for the assessment, management, critical decisions and accept responsibility for the outcome of the actions based on his clinical judgment. The trainees are “required to acquire (a) an understanding of basic sciences, (b) clinical application of these areas to surgery with emphasis on functional recovery and (c) appropriate basic technical skills”. Medical graduates of varying periods of post-qualification experience and serving under the Ministry of Public Health, State of Kuwait enrol in the programme. A total of 72 candidates entered the training programme, with 21 dropping out. Ten trainees have already completed the course. Instruction in the course is provided by consultant staff at the major hospitals and the academic staff of the Faculty of Medicine, Kuwait University. Additional instructional support is provided by KIMS in the form of seminars and conferences on special topics.
Aims of study The investigation reported here was conducted to ascertain (1) the extent of definition and use of learning objectives in the training programme, (2) the competencies acquired in relevant areas in surgery with the opportunities that were available, and (3) the effectiveness of the different learning opportunities in reaching the overall aims. It was hoped that the data collected would prove useful to the planners of the course in re-orienting the course so that appropriate emphasis could be given in selecting content and organising learning opportunities.
Method of investigation Data was collected using a questionnaire that was answered anonymously. The survey forms were handed over to all residents (39) who had completed the first year in the training programme, by a resident in training at present. A total of 26 questionnaires were received for analysis. The questionnaire consisted of six main sections. Except for the section on background data on the trainee, it had a series of Likert-type statements and room for open comments. The scale ranged from 1 (poor), through 2 (fair), 3 (good), and 4
General surgery training in Kuwait
217
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
(very good) to 5 (excellent). This approach to scaling to assess the views was used to minimize the possibility of a non-committal mid-position response and to allow for grouping of responses to quantify the worth of the programme to some extent. Though the different points in the response scale were identified with numerical figures, the values were treated only as nominal data. Therefore, the responses at any given point in the scale were only counted, with no attempt being made at summing or averaging. Thus, for a single respondent, counts of five points each would reflect excellence in all areas in a single section while five counts of one point indicated areas of concern. A similar approach of counting the corresponding values in the rating scale across respondents was used to get an assessment of the strengths and weaknesses of the overall programme.
Results Twenty six questionnaires were studied in the data analysis. Of these, three were from those who had already completed the training programme. The highest number of responses in a single year of training (12) was from the third year trainees.
Background of trainees Six residents were graduates of Kuwait University Medical School, while the rest had received their undergraduate training outside Kuwait. The year of graduation ranged from 1974 to 1985, with the average age at entry to the training programme being 28 years. Postgraduate qualifications obtained by the residents were the Primary FRCS and the Final FRCS Examinations. While 14 had passed the Primary FRCS before enrolling in the programme, two passed this examination during the training period. Twelve residents had obtained the Final FRCS qualification, while being in training. The residents had had an average of four years of postgraduate experience before joining the programme, while the specific experience in the field of surgery was 2 years.
Definition of objectives The questionnaire included five statements which dealt with the delineation and utilization of learning objectives in the training programme. Opinions on the extent to which general objectives of the programme had been clearly laid down were divided almost equally between the good or very good and the fair or poor categories. The two areas viz. the trainee’s knowledge of what was expected of him during each year of training and the feasibility of achieving the objectives within the available time too, received similar assessments with equal numbers of trainees responding in the two groups. The evaluation of the achievement of objectives at appropriate times was rated as fair or poor by nearly two thirds of the trainees while a third indicated that this aspect of the programme was good. The degree to which evaluation was related to achievement of objectives was assessed as fair or poor and good or very good by equal numbers, with five subjects not responding to this statement (Fig. 1). Additional observations that had been made by the trainees emphasized the need for defining the general objectives of the programme more clearly. Approximately a third
218
I. G. Premadasa &’ Fikri M . Abu Zidan
Aspects of objectives
Clearly specified
Expectations known
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Feasible to achieve
Matching evaluation
Evaluation timely
t
0
I
I
I
I
I
I
2
4
6
8
10
12
I 14
I
I
16
18
Number responding
FIG. 1. Objectives-definition and use (W good/very good;
poodfair).
of the respondents indicated their concern about the inadequacy of discussion of the objectives of the programme with the learners and the lack of awareness of tutors of the overall expectations. The latter factor was suggested as having led to some degree of disorganization of the activities.
Competencies acquired Learning factual knowledge (concepts and theories) in the field of surgery and developing clarity and precision in oral communication, such as presenting a surgical problem, received very high ratings (Fig. 2). The opportunities for acquiring skills in selecting special investigations for data collection and developing patient management plans were rated positively by most of the trainees. Developing desirable attitudes and values of a surgeon, learning to interpret the results of special investigations, acquiring skills in performing diagnostic and therapeutic procedures and developing abilities in written communication (e.g. writing surgical reports) were also assessed favourably as regards the opportunities that were available for their acquisition. The learning experiences for improving interpersonal relations with patient and family, though receiving a lower total, were still categorized as favourable by the majority. Learning relevant factual knowledge in basic sciences was rated the lowest with only ten responses in the good or very good categories. Sixteen trainees, in fact had indicated this aspect as either poor or fair.
General surgery training in Kuwait
-
219
Competencies ossessed os very good/gwd
Leorning focts
Orol cornmunicotion
Selecting tests
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Potient monogernent plons
Interpreting tests Doing procedures I nterpersonol ski1 Is
Basic sciences
I
0
I
I
1
1
I
5
10
15
20
25
I 30
Number responding
FIG.2. Acquiring surgical skills.
Eflectiveness of learning opportunities A variety of learning opportunities were made available to the trainees. While some of these sessions were conducted by the members of the faculty and visiting lecturers, the others were of the format of self-directed learning where the trainees took the overall responsibility for planning and implementing. The survey analysed the trainees’ views on the contribution of the different types of learning opportunities to achieving the overall aims of the programme. Nearly all the respondents rated the symposia arranged by special organizations such as the Kuwait Institute of Medical Specialization inviting external lecturers as good, very good or excellent (Fig. 3). Literature review sessions conducted by the residents and discussions of special topics were two other areas which received very high ratings. Other activities which were assessed very positively as regards their contribution to the overall aims of the programme were morbidity/mortality discussions and symposia and case discussions presented by the fifth year residents. Bedside teaching and learning surgical skills in the theatre received a relatively poor assessment. While the former area was rated as poor or fair by fifteen trainees, the latter was categorized in this fashion by half the respondents. Discussion
While it was not possible to draw definite conclusions from some of the early studies of the effects of learning objectives on achievement, the usefulness of employing clearly defined objectives in instruction was evident in the later studies (Duchastel & Merrill, 1973; Day, 1972; Engel, 1980; Varagunam, 1971). The need to employ
220
I. G. Premadasa & Fikri M. Abu Zidan
Learning opportunities assessed as very gaad/good
Symposia-KIMS
3
Literature review
Discussion of special topics
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Morbidity/mortality conference
Symposia by 5 t h yrs
Theatre sessions
Bedside teaching
I
0
I
I
I
I
I
5
10
15
20
25
I 30
Number responding
FIG.3. Learning opportunities.
schemes of instruction and assessment based on clearly defined objectives at graduate level of medical education as well has been pointed out (Iseri, Mulbert & Ansell, 1977; Kravath, 1977; Love & Stone, 1978). Writing learning objectives consisting of performance standards and conditions as was advocated widely in the 1960s (Mager, 1962) though, appears to have lost its appeal (Williams & Osborne, 1982; Popham, 1988). A point that the instructor needs to emphasize in using learning objectives is that they state the minimum competencies that all learners are expected to achieve. This implies that the capable student is in no way barred from going beyond the target level of achievement and the instructor is not compelled to operate within a straitjacket. The investigation reported here indicates that the learners felt that there was a need for the learning objectives of the programme to be defined more clearly than in the past. It is important that the expectations of the programme planners are communicated with the residents and the instructors, so that suitable learning situations could be organized. Approximately two thirds of the residents who answered the questionnaire pointed out the need for improving the evaluation system so that learner achievement would be assessed at appropriate times. As is bound to happen in most training programmes, the cognitive aspects of learning appear to have received considerable emphasis in the surgery residency programme. This is evident from the observations of almost all the respondents. A point of much value to the course planners is the useful role of sessions that contributed to the improvement of oral communication skills. Acquiring the skills of presenting surgical problems has been rated as one of the strengths of the programme by almost all trainees who responded. A matter of concern is the relatively poor assessment of bedside teaching and learning surgical skills in the operating theatre. Though it is commendable that the
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
General surgery training in Kuwait
221
programme has promoted, to a very high extent, the learning of concepts and theories relevant in surgical practice, the greater emphasis needs to be on content areas that can be mastered only during clinician-patient encounters. It is therefore important to identify the competencies for which bedside teaching and similar encounters with the patient can be best used, so that optimum use is made of the resources invested. The majority of the respondents felt that the sessions organized by the residents themselves were of considerable value. Similar opinions had been expressed on the utility of programmes arranged by specialized bodies such as KIMS. Though it may not have been obvious initially, this result need not be something unexpected. The average age of the resident at entry to the programme was 28 years, with a 4-year postgraduate experience in the practice of medicine. Being adult learners, the residents were therefore well equipped to take over the responsibility for their own learning and to get considerable benefit from non-formal learning activities. The programme planners could provide appropriate guidance to the resident by indicating the direction in which to proceed and the goals to be reached.
Conclusion This investigation on the role of learning objectives in the residency training programme showed that delineation and utilization of objectives needed to be given greater emphasis. Though it did not assess the competencies of the trainees, but only obtained their perceptions, the findings, however, suggest that providing clearly defined learning objectives in advance to the learners and the instructors is likely to be useful. An important benefit of such a step is that the relative importance of different content areas, as perceived by the planners, could be maintained during the implementation of the training programme. If learning objectives are to be of use to the learners, they need to be meaningful and relevant, clear to all concerned groups and achievable within the available resources. An additional aspect of the use of objectives is that they should be shared with the learners at an early stage in the programme. It was also seen that learning concepts and theories related to surgical topics was a major strength of the programme, while the area of acquiring practical skills needed to be augmented.
Correspondence:I. G . Premadasa, Centre for Medical Education, Faculty of Medicine, Kuwait University, PO Box 24923, Safat 13110, Kuwait. REFERENCES ABRAHAMSON, S. (1978) Diseases of the curriculum, Journal of Medical Education, 53, pp. 951-957. &SOCIATION OF &ERICAN ~’~EDICAL COLLEGES (1977) Preliminary Report of the faculty development survey, (Washington DC), pp. 112-119. Corn, C.R. & GALE,J.G. (1985) Curriculum evalution in medical and health care education, Medical Education, 19, pp. 403-422. DAY,J. (1972) Definition of objectives for teaching clinical medicine, Medical Teacher, December 1972, pp. 5-9. DUCHASTFJLL, P.C. & MERRILL,P.F. (1973) The effects of behavioural objectives on learning, Review of Educational Research, 43, pp. 53-69. ENGEL,C.E. (1980) For the use of objectives, Medical Teacher, 2, pp. 232-237. IRBY, D. & RAKBTRAW, P. (1981) Evaluating clinical teaching in medicine, Journal of Medical Education, 55, pp. 181-186.
222
I. G.Premadasa & Fikri M. Abu Zidan
Med Teach Downloaded from informahealthcare.com by Queen's University on 12/28/14 For personal use only.
Ismu, M., MULBERT,L. & ANSELL,T. (1977) Educational objectives for residency tr-g Urology,I X , pp. 478-483.
in urology,
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