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Teaching at Tufts: lessons from the School of Medicine
6 February 2012
Peter Delves, Professor of Immunology and Vice-Dean (Education) for the Faculty of Medical Sciences, shares observations gleaned during a recent trip to the School of Medicine at Boston’s Tufts University. Interview by Ele Cooper.
I have worked at UCL for over 30 years and I’m generally considered to be a ‘good teacher’, but while I was visiting Tufts University's School of Medicine I started to think about how you judge what a good teacher is. Generally speaking, we tend to go on student feedback, which is appropriate but just one indicator. We’re also part of a much larger machine: the most important thing in the Medical School is that you produce competent, skilled doctors, and that is somewhat harder to measure.
The most striking thing I noticed during my recent visit to Tufts was that of the 13 teachers I spent time with, all had a very good knowledge of the theory of teaching. By contrast, at UCL, a lot of our academic staff – including myself, I dread to say – have never had formal training in teaching.
But this is just one of many interesting things I observed while I was in Boston…
At Tufts, all students are expected to be involved in teaching, which is rather different from UCL where many students do teach in our Medical School but it’s certainly not an expectation that they would all do so.
The way Tufts do it is to get fourth-year students to teach problem-based learning sessions to first-years. The first-years are split into groups of around six and then asked to investigate various things about a case of, for example, rheumatoid arthritis.
However, the sessions are not really about learning the clinical material because they get that later in the course anyway; they’re about group interaction, how people come to decisions and work with each other. So while the fourth-year students will have had training in the relevant clinical area, they are also specifically trained in the process of facilitation, so they can look at group dynamics and give feedback on how well they are doing that.
There are at least two advantages to this system: one is that the fourth-year medical students get experience of teaching, but perhaps equally importantly they really get a feel for how much they’ve progressed during the four years, because quite often they underestimate how much they’ve learned.
Meet the patients
At Tufts, students see patients from very early on – in fact they meet patients or the parents of child patients on two separate occasions during the first three weeks of medical school, which is something that we don’t do to the same extent. I think that it is important that medical students don’t get disappointed by how few patients they actually see. We are addressing this in the Medical School and we have improved greatly over the last few years, but I think Tufts is doing even more.
One of their staff has also developed a scheme whereby staff film students interviewing patients, and then afterwards they are given feedback from the clinician and the patient (although sometimes the clinician edits the patient feedback if he feels that some of their comments are inappropriate or not relevant).
The students then watch the video and assess themselves: were they looking at their watch, were they tapping their pen on the table, or doing anything else that made the consultation less than optimal? The aim is to instil compassionate care in the students and it seems to be a very successful course; students felt they learnt a lot.
Developing clinical reasoning
One of Tufts’ teachers has developed an online programme in which students are taught to question the whole process of clinical reasoning: what are the thought processes that they go through when coming to a clinical decision? How do they consider the possible diagnoses? How do they ensure that they don’t jump to the obvious diagnosis when the patient might actually have something different?
They want their students to gain clinical reasoning skills because – and this was rather honest of them to say, but factually correct I am sure –once they go out onto the wards they will see examples of bad clinical reasoning, and they don’t want their students to be “contaminated” – that was the word they used – by poor practice on the wards, which does occasionally happen.
Tufts has been running an MD/MBA programme, which is a joint medical and business degree, for 11 years, with an intake of 10-15 students per year. The MBA component is in healthcare administration; it’s not about entrepreneurship, it’s related very closely to medicine.
It is highly successful despite being a very intensive programme – students have to do all of the work in the same number of years as those just taking the MD – and only two students have ever dropped out in the time the course has been running.
There has been some discussion here at UCL about doing something similar, but that is really at a very preliminary level indeed. I think it would certainly be worthwhile our considering a similar kind of programme, because the changes that are happening in the NHS now will mean that more and more medical students will need to have skills in financial management.
Bridging the gap between scientists and clinicians
Like us, Tufts has a modular programme, but unlike us, every module is jointly run by a scientist and a clinician. We always have a module leader and a deputy, but they might in the early years both be scientists and in the later years both be clinicians. At Tufts, students get both viewpoints, and I think that’s very interesting and maybe something that our Medical School would like to discuss.
Another thing, which I think would meet resistance from some of my colleagues here but nonetheless is potentially very important, is that the clinicians tell the scientists what the students need to know, because they feel that a lot of the science being taught actually isn’t necessary to produce a good doctor.
One can obviously discuss ad infinitum what ‘a good doctor’ is, but it’s really the concept of the science that needs to be taught rather than some of the more molecular details. One of the people I spoke to who, like me, is an immunologist, said that over the last few years he has been decreasing the level of detail he gives in certain areas. I’ve been doing the same, because I felt that the level of detail I was giving was actually way beyond what a medical student really needs to know.
Tufts’ Medical School has a curriculum committee – as do we – but in ours we’ll discuss changes to the curriculum, we’ll consult with people and then we’ll come to a consensus. At Tufts they actually vote: there are eight student votes, 32 faculty votes by teaching staff, and one vote from the dean, and they go with whatever the majority decides, which is incredibly democratic!
Librarians and libraries
The majority of the library staff at Tufts are very actively involved in teaching, particularly teaching skills related to databases and so forth, and work in these areas is assessed and marked by the library staff.
Also, they have just opened a brand-new continuous learning space, with computers, books on shelves, a canteen, sofas, desks, lots of different areas for small group work and so on. I was slightly horrified at first: it looked extremely nice but there were people eating pasta whilst working at a computer, and that would be a complete no-no at UCL!
However, the librarians said they really didn’t think it was a problem at all – the worst that could happen was that they’d have to replace a keyboard or a couple of floor tiles. So that was interesting in that it really allowed students to study whenever they want, however they want.
I originally applied for the funding to visit Tufts because I wanted to learn about TUSK, the Tufts University Science Knowledgebase. It does much more than Moodle currently can. The key difference is that it offers searchability, which Moodle currently does not: if students want to find out about coronary heart disease or some sort of aspect of immunology or neuroscience, they can’t search for it in Moodle, they just have to trawl through, which makes it a very inefficient process.
TUSK has inbuilt software that allows a continuous scanning of the content. Once the content is uploaded onto the VLE [virtual learning environment] it is automatically scanned for a very large number of keywords and then tagged automatically with those keywords, so it’s quite sophisticated.
However, speaking with Steve Rowett from LTSS just before I went, they are now beginning to develop ways of tagging content in Moodle, so we may be able to search to some extent in Moodle 2.
Outcomes of the trip
On an individual level the trip has made me think about the amount of detail that I put into my individual lectures and how that relates to clinical medicine, but it has also made me think, why am I teaching? What is the aim of my teaching in relation to medical education?
On a broader level, I have already submitted a report to the Vice-Provost (Education), but I am also on various management groups within the Medical School so I will be discussing my findings with them.
Obviously you want to walk before you run but I think that, given the fact that the people at Tufts feel the changes they’ve made to their curriculum have been successful, the trip will have a genuine impact on the way we take the curriculum forward here too.
The MBBS has just undergone a curriculum review, with the new programme starting in September 2012, so we’re unlikely to make any radical changes in the next two or three years. However, teaching is an intuitive process and we can all change various aspects of how we teach to some extent.
As far as the theory of education goes, it seems to me that certain things can be very much in vogue for five or six years and then go out of fashion, and one doesn’t want to make major decisions based upon something that’s just a passing fad. However, there are things that are very solidly established through proper research: for example, there’s now firm evidence that active learning is much better than passive learning.
Certainly some understanding of the theory behind teaching is useful, and one needs to be aware of the developments that are going on in education all the time, both technological and theoretical. Students are now using mobile media and education needs to be a continuum of what they’re doing in their daily lives. But younger teachers will be given training in this from day one, unlike us dinosaurs!
Although the MD course (the American equivalent of our MBBS) at Tufts lasts four years because their students start as postgrads aged 22 or 23 while at UCL it’s six years because the MBBS is the first degree most of our students take, there are many things that Tufts are doing that seem to be going in parallel with us.
For example, in the past, the first two years of their programme were primarily science-based, then students focused on clinical material in the final two years. At UCL, the first three years are primarily science and the last three years are primarily clinical. Tufts are increasing the amount of clinical material in the first couple of years, and also increasing the amount of science in the last two years. We’re doing exactly the same here at UCL.
They also have specific diseases that they focus on throughout the four years. We’re developing what we’re calling ‘patient pathways’, which is a very similar idea, where much of the material we teach is set within the context of six medical conditions. It’s reassuring to know that we’re broadly moving in the same direction as another world-renowned medical school.
Professor Delves was eligible for the funding that enabled him to go to Boston because he is a Provost's Teaching Award winner.
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