Koens et al.s’ model

Koens et al. (2005) developed a model for considering the role of context within medical education. They suggest that there are three dimensions to context: physical, semantic and commitment. Each of these dimensions spans a continuum from very reduced to enriched contexts (Table 9). I will explain this model by first providing illustrations for learning medicine. Then I develop this by drawing on examples about developing as a doctor teacher.

Table 9 Dimensions of context (Koens et al., 2005)

Reduced context →→→→→→→→→→→→→→→→→→→→→→→→ Enhanced context Physical dimension Learning in the

library Learning in a skills laboratory Learning in the OR Semantic/cognitive dimension Learning facts unrelated to clinical practice Reading and understanding a basic science text Constructing a physiological explanation of a clinical case Commitment dimension Listening to medical news on the radio Reading a text to report to peers Learning with

responsibility for patient care

The physical dimension relates to the physical surroundings of the learner. For example, reading about the anatomy of the knee joint, alone in the library, will be at the reduced end. In contrast, learning within the OR as a surgeon operates on a knee, when the learner can see the anatomy, will be at the enhanced end. The semantic or cognitive dimension relates to the connection between the learner’s knowledge and the learning task. For example, a simple task of learning facts, such as three causes of a low blood pressure, will be at the reduced end. In contrast, constructing a physiological explanation of why a real patient, in hospital, has a low blood pressure will be at the enhanced end. The commitment dimension relates those aspects of learning that determine the learner’s motivation. For example, listening to medical news on the radio, such as the problems of miscarriages, will be at the reduced end. In contrast, the experience of the learner, who has to deal directly with a couple struggling with multiple miscarriages, will provide a commitment to learn at the enhanced end.

This model also relates to doctors learning to be teachers. In the physical dimension, reading in the library about how to teach in the clinical arena, will be at the reduced end. In contrast, a skilled teacher showing and guiding the learner to teach effectively at the bedside will have an enhanced context. In the cognitive dimension, the learner who learns a list of the key points

about how adults learn would be at the reduced end. In contrast, the context is enhanced for the learner who delivers bedside teaching for a group of medical students based on the principles of adult education. Within the commitment dimension, reading about the

importance of assessing trainees may have reduced contextual importance. However, when the learner has to assess others, whose careers may depend on their decisions, it is at the enhanced end.

In addition to these dimensions, I believe that there is something special about how the teaching affects the care of the patient. This relates to the potential danger posed to the patients when trainees are learning or being taught on real patients in the clinical setting. The lowest risk is at the level of an elective attendance at a clinic appointment or GP surgery. I say this because this is a situation that can be controlled by the teacher. The teacher can be present or absent. The trainee can take their time and the teacher has the opportunity to check what has happened and if necessary make adjustments. This is true for both the patient’s medical care and the learning of the trainee. The time available is determined by the teacher rather than by the urgency of the delivery of patient care.

At the bedside, in hospital, for elective or non-urgent cases, the same criteria apply. The teacher can devise teaching ward rounds. Here the teacher can pre-select and gain consent of the patients for teaching. However if a patient requires urgent or emergency treatment then there may not be time for the teacher to pre-select patients, which may remove the safety net of the actions of the trainee being correctable. The risk to the patient becomes more acute once the learners start to perform procedures on the patients. In this instance, the procedure may be relatively safe, for example taking blood. On the other hand, it might be potentially life threatening, for the patient, for example administering a general anaesthetic.

I suggest this model would benefit from an expansion of the physical dimension to include the location of the teaching. The enhanced end of each dimension could include a gradation into where the teaching interaction takes place such as; classroom, clinic, bedside or OR. Much of the literature, as reviewed above, has related TTT to classroom teaching. This can translate into circumstances where there is a degree of teacher control over the physical environment and the sequence of events. Perhaps this lack of control, by the teacher, explains the

reluctance for some doctors to relinquish the safety of the classroom to teach at the bedside (Ramani et al., 2003).

In addition, I suggest there should be a fourth dimension to take account of the urgency of the patient’s care in the form of diagnosis or treatment. At the reduced context, there would be no urgency, as in the elective attendance at an outpatient clinic. In contrast, an example of the enhanced context would be the management of a patient with an acute and life threatening haemorrhage. I would suggest that learning and teaching in the workplace has to include this element of urgency or time.

The inclusion of the context of the workplace and patient safety require that the quality of the teaching be of a high standard. Otherwise, patients are at risk. One approach might be to consider ‘teaching in the workplace’ as a series of competencies in a similar manner to the competencies associated with giving an anaesthetic. I address this concept in the next section.