340 Teaching postgraduate surgery
b) Gordon Audio-Visual Carrel, 28/30 Market Place, Oxford Circus, London WiN 3PH. Every new item needs space for its use and it will soon be necessary for centres to put aside a room for this work. It is suggested that these should be divided into listening booths for private study with adequate cupboard space to store the slides and tapes. Such a facility could become a subsection of the library under the care of the librarian. The following bodies supply audiovisual aid packs: i) Medical Recording Service Foundation,
Kitts Croft, Writtle, Chelmsford CMI 3EH, Essex. 2) BLAT Centre for Health and Medical Education, BMA House, Tavistock Square, London WCi 9JR. 3) Midlands Recording Centre (Mr F G Hollands FRCS), Royal Infirmary, Derby. Apart from these many regions have their own collection of films, videotapes, and slide-tapes. The fear that machinery will replace man in teaching is unfounded and there will always be a demand for the skilled teacher. We should, however, explore the possibilities where his skill can be used to the best advantage at a time when it is in short supply.
THE ART OF LECTURING Robert Ollerenshaw ERD TD DL FRCS Director, Department of Medical Illustration, University of Manchester.
The formal lecture preserves a very ancient tradition derived from the extreme scarcity and expense in earlier days of textbooks from which the student might teach himself. The form of lecturing, essentially didactic and designed (according to one well-known and rather unkind description) to transfer facts from the notes of the lecturer to the notebook of the student without going through the mind of either, has changed little over the years, although its popularity as a method of teaching is undoubtedly on the wane. The view that the lecture is outdated and unnecessary is not new; Samuel Johnson considered that 'lectures were once useful, but now, when all can read and books are numerous, lectures are unnecessary'. His view is not unsupported today. Without argument, the lecture is the most difficult educational tool; the really good lecturer is probably born, like a good artist in any art. I did not choose my title, 'The art of lecuring', but I would not quarrel with it. Personally, I do not like lecturing,, for I am not a 'natural'. Everyone in medicine can think of the naturals-Osler, Jefferson, Aird, their names come readily to mind, and the list does not necessarily correlate with that of the great medical writers. Reading is more leisurely and
the reader can pause when he wishes; at a lecture the listener is captive so that the onus of establishing contact is with the lecturer. Jeffermn may be remembered for two dicta on lecturing: 'Make it so simple the cat can understand it' and, even more to the point, 'Obscurity is not a sign of greatness'. But very few of us are naturals and many of us will be faced with the duty of lecturing with or without the modem armamentarium of socalled visual aids, which can only too often become visual booby-traps. The inexpert may improve his expertise by practice; this need not be live every time and the tape recorder is a valuable and very revealing critic. For the beginner there are methods of cheating. Bright is reputed to have carried notes for his parliamentary speeches in his top hat. Mark Twain wrote key letters on his fingernails but came to grief when he lost count of the ones he had licked off. The teleprompter, unless one is a trained newsreader, can be a highway to disaster. An American president once threw in a substantial aside in one of his TV interviews, only to come back to the teleprompter to find that it was several jumps ahead of him. He never did catch up and the event was a disaster. Completing the list of
Teaching postgraduate surgery 341 potential pitfalls, Clifford Hawkins of Birmingham, one of our outstandingly good lecturers, is convinced that all electrical devices are inventions of the Devil and in league against the teacher. Where does this leave the neophyte lecturer? In one word-preparation. Do not be manoeuvred into doing anything 'off the cuff'; nothing needs more preparation than an impromptu speech. Once the script or notes are complete, the slides in foolproof sequence, and the dry run over, get to the lecture theatre early. Smell the jumps: the projectionist, who may need briefing on such things as house lights; the microphone, which with luck will be attached to the lecturer, so that he does not have to remain glued to the lectern; the buttons on the lectern, so that a request for a slide change does not make the screen disappear. With a little luck the slide change will be self-operated, a great time-saver and an aid to an easy flow. But make sure that you know which key is forward and which reverse. A lecturer should try to speak from short notes or, if he be very experienced, no notes at all. If this is beyond you, do not be afraid to read, but continually lift your eyes and direct them to the audience. Polish comes with practice. Today, with so many teaching tools available, it is not easy to define the occasion for a lecture. Leaving out eponymous celebrations, the most likely reason is that you have something new, something to expound. The worst reason is the old-fashioned set-course lecture, repeated from year to year with dusty slides taken from obsolete textbooks. This should be as dead as the dodo, but regrettably is not. The greatest hazard of any lecture is dullness; avoid this by using an occasional lighter refference or quotation. Assemble good visual material, consulting your medical illustration department early enough to give them a chance to do you well; your subject may be difficult, but that is no reason why it should be dull. Remember, however, that too many rapidly changing visuals can themselves be soporific. Though pictures may be essential, they should never be used for their own sake, and some subjects may not need them at all. There is Ctill room for the chalkboard and duster, which have a welcome element of mobility even
though their use does need practice. The overhead projector is a more difficult version of the blackboard and requires even more practice; if simple projection without the facility to add by hand is required it is kinder to the audience to use slides. Where projected material is used try to arrange it in compact 'chunks' and avoid constant changes in the room lighting. Plain grey slides are valuable for covering short gaps when you are not quite ready for the next illustration, and they are easier on the eyes of the audience than putting up the main lighting. There are many more practical points on the use of visual material, and your illustration department should always be asked for advice. The actual construction of a lecture or lecture demonstration should follow a fairly well-defined pattern. We can do much worse than act on the advice of the old wartime Methods of Instruction manual, which laid down some extremely simple but not always obvious criteria. A lecture must have a beginning, a middle, and an end. Write down the first and the last, a discipline that will concentrate the mind like the knowledge that you are to be hanged tomorrow! Define your target: what are you trying to teach? to whom? how much do they know already? Decide on the amount you can cover in the given time: what must they know? what should they know? what could they know if there were only time to tell themn? Avoid massive tables of data; the right place for these is in print, where time is not a factor. Ask the help of the illustrators in putting over essential information visually. Never make your audience plough their way through a page of figures resembling the railway timetable. Make sure your graphs and diagrams are honest; if a scale does not start from zero, say so. Today it is rare, yet not unknown, for a speaker to put most of his discourse on the screen and then proceed to read it to the audience in words that are almost the same. This is quite maddening and assumes that the audience is illiterate, rather like the football results on television, where a disembodied voice reads a rolling title to the proles. In my department we recommend putting only headlines on the screen and telling the full story in
342 Teaching postgraduate surgery
words. Printed or duplicated handouts may save much time, and if paper space is generous the audience can add their own notes. But if they are to do this they must have some ambient light in the room, which if the architect knew his job will provide enough for writing and reading without spilling too much light on the screen. A secondary advantage of this is that the lecturer can see if his audience is still awake! Full blackout is really needed only
for motion pictures. I have said that I dislike lectures and I have warned against the over-lavish use of audiovisual aids. It perhaps looks as if I am preaching against my own job. This is not true: Confucius may have said that one picture is worth a thousand words, but I would suggest that this is true only if the thousand words have previously been employed in thought by the teacher and the illustrator.
CLINICAL TEACHING P G Bevan chM FRCS Chairman, Board of Surgical Training, Royal College of Surgeons
In the past hospitals were classified into two groups-teaching and non-teaching. However, today this distinction has gone. During the past io years, particularly as a result of the training programmes that have been encouraged and fostered by the Royal Colleges, all hospitals have become teaching hospitals. This is, after all, a reflection of what should happen in a leared profession. Wherever surgery is practised it must be taught and learnt. Down the ages famous surgeons have become famous because of their teaching and because they influenced the minds of those who worked with them and those who followed. This goes right back to Hippocrates and is included in his Oath, which we adopt as our creed. 'I swear . . . to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to pupils who have taken the physicians' oath.'
Today I am sure that we all believe that teaching is part of the clinical duty of the surgeon whatever hospital, whatever unit, whatever field he is working in. The important corollary is that time must be allowed for it. If the workload is so heavy that teaching is excluded, then the standard of that work will suffer and the service to the patient will deteriorate. We must remind not only ourselves but also the public, our patients, of this fact. The technique of clinical teaching can be summarized under four headings-personal
teaching, small group teaching, fonnal activities, and courses. Personal teaching Traditionally surgeons have learnt their craft by apprenticeship, with the apprentice learning from his master. In modern times the concept of the apprentice has been at a discount because in the past it has gained a connotation of slavery and servitude. Indeed, we have only just left the era in Britain of the surgical trainee working for one consultant for many years, slowly losing enthusiasm and interest, entirely dependent upon his senior for promotion, and eventtually gaining clinical independence late in life. This system still operates in some countries abroad. The basis of surgical teaching today is the personal relationship between the consultant and his registrar. This means reviving and redefining for our time the idea of apprenticeship, but without patronage. There must be a free spirit of give and take on the part of both. One other ingredient is needed as a dynamic for training by apprenticeship; it should be set against a background of rotational training, so that the registrar can learn from a number of chiefs and select their best ideas to assemble his own technique. The rotational programmes that we have developed during the past decade both at pre-Fellowship level and for higher surgical training form a unique British contribution to
b) Gordon Audio-Visual Carrel, 28/30 Market Place, Oxford Circus, London WiN 3PH. Every new item needs space for its use and it will soon be necessary for centres to put aside a room for this work. It is suggested that these should be divided into listening booths for private study with adequate cupboard space to store the slides and tapes. Such a facility could become a subsection of the library under the care of the librarian. The following bodies supply audiovisual aid packs: i) Medical Recording Service Foundation,
Kitts Croft, Writtle, Chelmsford CMI 3EH, Essex. 2) BLAT Centre for Health and Medical Education, BMA House, Tavistock Square, London WCi 9JR. 3) Midlands Recording Centre (Mr F G Hollands FRCS), Royal Infirmary, Derby. Apart from these many regions have their own collection of films, videotapes, and slide-tapes. The fear that machinery will replace man in teaching is unfounded and there will always be a demand for the skilled teacher. We should, however, explore the possibilities where his skill can be used to the best advantage at a time when it is in short supply.
THE ART OF LECTURING Robert Ollerenshaw ERD TD DL FRCS Director, Department of Medical Illustration, University of Manchester.
The formal lecture preserves a very ancient tradition derived from the extreme scarcity and expense in earlier days of textbooks from which the student might teach himself. The form of lecturing, essentially didactic and designed (according to one well-known and rather unkind description) to transfer facts from the notes of the lecturer to the notebook of the student without going through the mind of either, has changed little over the years, although its popularity as a method of teaching is undoubtedly on the wane. The view that the lecture is outdated and unnecessary is not new; Samuel Johnson considered that 'lectures were once useful, but now, when all can read and books are numerous, lectures are unnecessary'. His view is not unsupported today. Without argument, the lecture is the most difficult educational tool; the really good lecturer is probably born, like a good artist in any art. I did not choose my title, 'The art of lecuring', but I would not quarrel with it. Personally, I do not like lecturing,, for I am not a 'natural'. Everyone in medicine can think of the naturals-Osler, Jefferson, Aird, their names come readily to mind, and the list does not necessarily correlate with that of the great medical writers. Reading is more leisurely and
the reader can pause when he wishes; at a lecture the listener is captive so that the onus of establishing contact is with the lecturer. Jeffermn may be remembered for two dicta on lecturing: 'Make it so simple the cat can understand it' and, even more to the point, 'Obscurity is not a sign of greatness'. But very few of us are naturals and many of us will be faced with the duty of lecturing with or without the modem armamentarium of socalled visual aids, which can only too often become visual booby-traps. The inexpert may improve his expertise by practice; this need not be live every time and the tape recorder is a valuable and very revealing critic. For the beginner there are methods of cheating. Bright is reputed to have carried notes for his parliamentary speeches in his top hat. Mark Twain wrote key letters on his fingernails but came to grief when he lost count of the ones he had licked off. The teleprompter, unless one is a trained newsreader, can be a highway to disaster. An American president once threw in a substantial aside in one of his TV interviews, only to come back to the teleprompter to find that it was several jumps ahead of him. He never did catch up and the event was a disaster. Completing the list of
Teaching postgraduate surgery 341 potential pitfalls, Clifford Hawkins of Birmingham, one of our outstandingly good lecturers, is convinced that all electrical devices are inventions of the Devil and in league against the teacher. Where does this leave the neophyte lecturer? In one word-preparation. Do not be manoeuvred into doing anything 'off the cuff'; nothing needs more preparation than an impromptu speech. Once the script or notes are complete, the slides in foolproof sequence, and the dry run over, get to the lecture theatre early. Smell the jumps: the projectionist, who may need briefing on such things as house lights; the microphone, which with luck will be attached to the lecturer, so that he does not have to remain glued to the lectern; the buttons on the lectern, so that a request for a slide change does not make the screen disappear. With a little luck the slide change will be self-operated, a great time-saver and an aid to an easy flow. But make sure that you know which key is forward and which reverse. A lecturer should try to speak from short notes or, if he be very experienced, no notes at all. If this is beyond you, do not be afraid to read, but continually lift your eyes and direct them to the audience. Polish comes with practice. Today, with so many teaching tools available, it is not easy to define the occasion for a lecture. Leaving out eponymous celebrations, the most likely reason is that you have something new, something to expound. The worst reason is the old-fashioned set-course lecture, repeated from year to year with dusty slides taken from obsolete textbooks. This should be as dead as the dodo, but regrettably is not. The greatest hazard of any lecture is dullness; avoid this by using an occasional lighter refference or quotation. Assemble good visual material, consulting your medical illustration department early enough to give them a chance to do you well; your subject may be difficult, but that is no reason why it should be dull. Remember, however, that too many rapidly changing visuals can themselves be soporific. Though pictures may be essential, they should never be used for their own sake, and some subjects may not need them at all. There is Ctill room for the chalkboard and duster, which have a welcome element of mobility even
though their use does need practice. The overhead projector is a more difficult version of the blackboard and requires even more practice; if simple projection without the facility to add by hand is required it is kinder to the audience to use slides. Where projected material is used try to arrange it in compact 'chunks' and avoid constant changes in the room lighting. Plain grey slides are valuable for covering short gaps when you are not quite ready for the next illustration, and they are easier on the eyes of the audience than putting up the main lighting. There are many more practical points on the use of visual material, and your illustration department should always be asked for advice. The actual construction of a lecture or lecture demonstration should follow a fairly well-defined pattern. We can do much worse than act on the advice of the old wartime Methods of Instruction manual, which laid down some extremely simple but not always obvious criteria. A lecture must have a beginning, a middle, and an end. Write down the first and the last, a discipline that will concentrate the mind like the knowledge that you are to be hanged tomorrow! Define your target: what are you trying to teach? to whom? how much do they know already? Decide on the amount you can cover in the given time: what must they know? what should they know? what could they know if there were only time to tell themn? Avoid massive tables of data; the right place for these is in print, where time is not a factor. Ask the help of the illustrators in putting over essential information visually. Never make your audience plough their way through a page of figures resembling the railway timetable. Make sure your graphs and diagrams are honest; if a scale does not start from zero, say so. Today it is rare, yet not unknown, for a speaker to put most of his discourse on the screen and then proceed to read it to the audience in words that are almost the same. This is quite maddening and assumes that the audience is illiterate, rather like the football results on television, where a disembodied voice reads a rolling title to the proles. In my department we recommend putting only headlines on the screen and telling the full story in
342 Teaching postgraduate surgery
words. Printed or duplicated handouts may save much time, and if paper space is generous the audience can add their own notes. But if they are to do this they must have some ambient light in the room, which if the architect knew his job will provide enough for writing and reading without spilling too much light on the screen. A secondary advantage of this is that the lecturer can see if his audience is still awake! Full blackout is really needed only
for motion pictures. I have said that I dislike lectures and I have warned against the over-lavish use of audiovisual aids. It perhaps looks as if I am preaching against my own job. This is not true: Confucius may have said that one picture is worth a thousand words, but I would suggest that this is true only if the thousand words have previously been employed in thought by the teacher and the illustrator.
CLINICAL TEACHING P G Bevan chM FRCS Chairman, Board of Surgical Training, Royal College of Surgeons
In the past hospitals were classified into two groups-teaching and non-teaching. However, today this distinction has gone. During the past io years, particularly as a result of the training programmes that have been encouraged and fostered by the Royal Colleges, all hospitals have become teaching hospitals. This is, after all, a reflection of what should happen in a leared profession. Wherever surgery is practised it must be taught and learnt. Down the ages famous surgeons have become famous because of their teaching and because they influenced the minds of those who worked with them and those who followed. This goes right back to Hippocrates and is included in his Oath, which we adopt as our creed. 'I swear . . . to teach them this art, if they want to learn it, without fee or indenture; to impart precept, oral instruction, and all other instruction to my own sons, the sons of my teacher, and to pupils who have taken the physicians' oath.'
Today I am sure that we all believe that teaching is part of the clinical duty of the surgeon whatever hospital, whatever unit, whatever field he is working in. The important corollary is that time must be allowed for it. If the workload is so heavy that teaching is excluded, then the standard of that work will suffer and the service to the patient will deteriorate. We must remind not only ourselves but also the public, our patients, of this fact. The technique of clinical teaching can be summarized under four headings-personal
teaching, small group teaching, fonnal activities, and courses. Personal teaching Traditionally surgeons have learnt their craft by apprenticeship, with the apprentice learning from his master. In modern times the concept of the apprentice has been at a discount because in the past it has gained a connotation of slavery and servitude. Indeed, we have only just left the era in Britain of the surgical trainee working for one consultant for many years, slowly losing enthusiasm and interest, entirely dependent upon his senior for promotion, and eventtually gaining clinical independence late in life. This system still operates in some countries abroad. The basis of surgical teaching today is the personal relationship between the consultant and his registrar. This means reviving and redefining for our time the idea of apprenticeship, but without patronage. There must be a free spirit of give and take on the part of both. One other ingredient is needed as a dynamic for training by apprenticeship; it should be set against a background of rotational training, so that the registrar can learn from a number of chiefs and select their best ideas to assemble his own technique. The rotational programmes that we have developed during the past decade both at pre-Fellowship level and for higher surgical training form a unique British contribution to
