Medical Education. 1976, 10, 193-197
A teaching methods course in Manchester for general practitioner teachers C . M . H A R R I S , B. E. L. LONG*
AND
P. S . B Y R N E t
Department of General Practice St Mary’s Hospital Medical School, London, *Department of General Practice, University of Manchester, and ?Department of General Practice, University of Manchester
therefore extends over 2 years and forty-eight sessions (120 hours). The format has been deterA teaching-methods course for general practitioner mined by the aims and methods of the organizers. teachers is described. It lasts for 20 days, split into The course involves members in a series of unfour 5-day residential sections held at intervals of 6 familiar situations selected for their educational months. The sections are respectively entitled potential; they then consider what has been learned person-to-person teaching, small group teaching, that may be relevant for their future teaching beteaching behaviour, and a micro-training laboratory. haviour. It therefore requires an atmosphere of some They recur in a cycle. intensity. In addition, members come from all parts The approach in each section is that of experiential of the U.K. and often from other countries; it must learning-necessarily, since an aim of the course is to therefore be residential. The variety of the situations enable the members to apply the same approach in and the need to reinforce learning dictate the length their own teaching. and the splitting of the content. The requirements of The methods of three of the sections are given in a course for local teachers may be regular one-session some detail. The person-to-person teaching section, meetings over a period of years; those of a course concerned mainly with the learning of counselling teaching educational theory or educational technoskills, is dealt with fully by Long et al. (1976), and is logy may be five to ten sessions concentrated into a here presented very briefly. comparatively brief period ; ours are necessarily The limited evaluation and assessment procedures, different. and their results, are offered together with certain The decision to use the method of ‘experientialgeneral conclusions. learning’ was dictated by the directors’ aims. Since we wished members to develop skills as ‘non-direcKey words: TEAcHING/*methods; GENERAL tive’ teachers, able to help their students or trainees learn from their own experiences, our methods had to PRACTICE/*edUC; *EDUCATION, MEDICAL, CONTINdemonstrate these skills, not just describe them. We UING ; CURRICULUM ; COUNSELLING/edUC; ROLE ; BEHAVIOUR ; PHYSICIAN-PATIENT RELATIONS ; ENGLAND could not logically advocate a method which we were not seen to practice. The medium was also the message. The term ‘non-directive’ is often misunderstood. Since 1971 the Department of General Practice in It does not mean that the teacher has no objectives or Manchester has offered a teaching methods course that he is not deeply involved in what happens. It which is divided into four sections. These sections are implies rather that he tries to help the learner draw each 5 day, twelve session, residential courses, and his own conclusions from his own experiences. Nonthey are held at intervals of 6 months. The full course directive teaching is based on the belief that people Correspondence: Professor P. S. Byrne, Department of will learn what they are ready and motivated to General Practice, Darbishire House, Upper Brook Street, Manchester M I 3 OFW. learn, not what they are told they should learn. The Summary
193
194
C. M . Harris,B. E. L. Long and P . S . Byrne
teacher may put course-members into situations potentially valuable to all of them, but he expects them to take only what they are individually ready to take. This may be different for each member. The four parts of the course share this non-directive approach; it seems to be unfamiliar to those who have received a traditional medical education. We hope that each member will find it so stimulating that he will wish to incorporate it into his own teaching; he will show he has done so by changes in his behaviour as the course goes on. The course also has objectives at a different level. Specific educational techniques are demonstrated, which members may learn, and which they may later apply in their own teaching. Thus we deal with the application to teaching of counselling, telling, roleplay, the case-study, games, micro-teaching, and the understanding and use of group-dynamics. We pay close attention to the concepts of ‘task’ and ‘process’: the ‘task’ is what a pair or group is trying to achieve and the ‘process’ is the way in which the people involved behave towards each other while doing so. We are concerned to show that the ‘process’ affects the achievement of the ‘task‘, often hindering it considerably. The teacher must therefore be able to understand this ‘process’ and be able to intervene in order to modify it. Each of the four component courses is limited to twenty-four members. After 3 years there are several doctors who have completed all four, and more than half the members of recent courses have already attended one or more. The four may be completed in any sequence, but we believe that there are advantages in starting with the iirst, since it displays the basic approach most clearly. The titles of the courses are : (1) Person-to-person teaching: counselling and telling; (2) Small group teaching; (3) Teaching behaviour ; (4) A micro-training laboratory. The content of the courses is outlined below, but it is a natural outcome of our approach that no two courses with the same programme will ever be similar. The two course directors were, respectively, a general practitioner with an interest in teachingmethods, and an educationist with an interest in general practice. On some occasions the courses required extra tutors: some of them were general practitioners, some psychologists, some educationists, and one a tutor in psychiatric social work. Their personal abilities were more important than their professional labels.
Course 1. Person-to-person teaching: counselling and telling The greater part of this course is occupied by sessions devoted to learning counselling; these sessions are described by Long et al. (1976). in addition there are four wherein we look at the nature, implications and use of telling as a teaching method. Groups of six members are formed, and each group is given a different briefly-described situation which ends with the words ‘In 10 minutes, what would you tell him? After three sessions of groupwork the results are presented at a plenary session. The ensuing discussion brings out the strengths and weaknesses of telling as a teaching method. Sometimes we have videotaped the presentations, and played part of them back to reinforce learning. At one of the evening sessions we have a film. We have shown Carl Rogers counselling a client, and also used Twelve Angry Men, ajury-room drama, for an exercise in process-observation. The last day is for debriefing, trying to identify the practical uses of counselling and telling as teaching methods, and the effects of the week‘s work on the behaviour of members when they return to their patients, students, trainees and spouses.
Course 2. Small group teaching The techniques offered on this course are those of role-play, the case-study, role incident analysis, and the uses of interpreting group behaviour. On one occasion we planned the three sessions devoted to role-play in some detail. Members were divided into three equal groups, and one of the organizers led a discussion with each group in a different style. He then gave a lecture to each group, again in different styles. There was no explanation beforehand of what he was doing, but the very different effects of the styles he played spoke for themselves. The group involved in each activity was observed by the other two, and discussions involved all the members. Members were then asked to roleplay certain situations devised by the staff; and finally they had to devise their own situations and play them out. On another occasion a less structured approach was used. Initially some of the members played ‘doctor’ to a ‘patient’ simulated by one of the directors, but the rest of the time was filled by members’ own role-plays. Exactly the same points
A teaching methods course for GP teachers
emerged in the discussion after these two ways of dealing with role-play, and we are happy that either approach is viable. The case-study is allotted four or five sessions. The origin of the method in business management training is described, and the difference from the traditional medical teaching method of case-history analysis is pointed out. Three groups work through a classical Harvard Business School case-study, and then through a case-study with a medical background. Members are divided in their opinions about the relative values of the two for a medical audience, but most agree that there is little effective difference. In proposing solutions to the case-studies, members discover the intended educational objectives, which concern the effects of various behaviours, difficulties in communication, and dual loyalties; they extrapolate this learning to their own situation. Solutions are sometimes tested by spontaneous roleplays. Each group has to invent a case-study. This is taken by a member to another group, which works with it and is ‘taught’ from it by the visiting member. The case-study and the ‘teacher’s’ performance are criticized by the group. Role-incident analysis is not a technique likely to be used by many GP teachers, but we have included it experimentally. One of the directors plays all the characters involved in an industrial dispute, while half the members form a ‘tribunal’ whose job is to settle the dispute quickly. They interview whichever witnesses they wish to call, in an attempt to discover a solution to fit the very complex problem. They are not accustomed to dealing with people who often lie consciously and cleverly, nor to looking for cynical but practical solutions to a power-conflict ; they find the exercise very difficult. The rest of the members observe for half the time, and then change places with the first ‘tribunal’. The exercise is discussed in plenary session. It should be possible to devise a role-incident based on a family or group-practice situation that might be more useful, but we have not yet done so. The study of the behaviour of groups is dealt with in two ways. Every group activity which occurs on the course is observed by one of the two directors, and he draws the group’s attention to its behaviour when he considers it appropriate to do so. In practice, this means the occasions on which the group’s ‘process’ is getting in the way of its task performance. Secondly, certain tasks may be set whose purpose is solely to provide ‘process’ for analysis.
195
A group may be asked to discuss a controversial topic while another group specifically observes and later comments on the ‘process’ which has taken place. There are also exercises where the organizer does not declare beforehand that the purpose is ‘process’ observation-such as a game whose solution is usually hindered both by intra-group and inter-group conflict. The final day is largely given to reviewing of what has been learned about the teaching methods and from the teaching methods used on the course, and considering ways in which members may wish to adapt them for their own use. Course 3. Teaching behaviour
The ambiguity of this title is usually queried at the very beginning by the members; it is intentional. The course begins with an exercise called ‘The contract’. Members form very small groups in which they try to define their expectations of the course. One representative from each group then presents them to the staff in plenary session, and by a counselling process the staff attempt to make them more precise. After plenary discussion it is understood that the aims of the members have been at least tentatively declared, and that it is the responsibility of the staff to help in their achievement. The main work of the course consists of playing games and then discussing how members behaved. We use variations on standard management training material : ‘Setting objectives’, ‘Achievement’, ‘Negotiating behaviour’, ‘Interacting systems’, ‘Supervisory behaviour’, and ‘Motivation’, and a version of the well-known ‘Maudsley Hospital game’. Each game is followed by a ‘debriefing-session’ about what has been learned. Members are then asked to invent a game whose purpose is to influence. favourably the behaviour of trainees who resist adapting to general practice. In addition there are two sessions devoted to nonverbal communication. Three groups each hold a discussion on a controversial topic for about 15 minutes. These discussions are video-taped and played back without sound, stopping the tape as cues appear. We also have an American film on nonverbal communication which presents both soundless pictures and picture-less sound of clinical interviews, finally combining the two. On the last day, the original small groups who worked on the ‘Contract’ re-form to consider how
196
C. M . Harris, B. E. L. Long and P. S. Byrne
far their objectives have been achieved. The value of games as a teaching method for trainees is debated in plenary session, as are ways of teaching about nonverbal communication. Course 4. A micro-training laboratory One of the directors is conducting research into the verbal behaviour of general practitioners during their consultations. He has constructed a list of about forty defined behaviours-the following are a few examples : ‘asks direct question’, ‘offers reassurance’, ‘uses silence’, ‘reflects question’. This list is used to analyse the consultations of course members, since it is reasonable to assume that a doctor’s consulting style will resemble his teaching style. Before the course, members send a cassetterecording of 1-2 hours of their normal consultations to the directors, and these are analysed sentence by sentence in terms of the list of behaviours. Thus a profile of each member is constructed, and is given to him. He then decides for himself if there is a specific behaviour which he wishes to learn or unlearn. The directors explain the method of analysis in detail, and members divide into groups of three to practise analysing each others’ tapes. This enables them to analyse their trainees’ tapes at a future date. Within the trios, members construct situations to help each other learn the specific behaviours they have chosen for themselves, and the directors assist them to do so. This work, and the discussion which arises from it, comfortably fill the twelve sessions. On one course we brought in real trainees, one to each trio, bearing cassettes of some of their consultations. Each trio then analysed their trainee’s recording and tried to help him develop a behaviour he selected for himself. The list of behaviours is not yet in its final state, and indeed has been modified after each course on which it has been used. Despite its acknowledged imperfections, it has proved a useful tool, and has been regarded as helpful by course-members. This completes the description of the four component courses. The unfamiliarity of the methods prompts many questions, of which the most important probably are those about evaluation. We have been more concerned with assessing the learning of the skills and behaviours we offer than in evaluating the use of non-directive teaching, since we regard it as self-evident that there will be teaching situations where a non-directive approach is required.
The courses are so constructed that a fair measure of feedback is available immediately, for members are observed practising the skills they are learning. The debriefing sessions give us some idea of the extent to which our approach is accepted and our techniques deemed practical. We are in a position to assess subjectively the changes we see in doctors who attend more than one of the courses. There is an obvious method of assessing the effect of Course 4: members can be asked to send us tapes of consultations at various times after the 5 days are over. We have tried to do this, but the number of doctors who have provided us with such tapes is small, and it is not possible yet to say more than that some appear to have incorporated the changes they set out to learn into their behaviour several months later, others show less change, and a few seem not to have changed at all. Four weeks after the end of our first Course 1 we sent out a questionnaire as agreed with members in the final session. It asked for self-reported changes in counselling and telling behaviours in both clinical and educational contexts. The biggest changes noted were in the ability to listen to patients, ways of asking questions, the range of data elicited during history taking, and the ability to remain silent. Over half the members were making some regular use of counselling techniques with patients, and over half deliberately refrained from offering advice that they would previously have given. Only half of the members had taught during the month, and they reported parallel changes. Refinement of this questionnaire would be possible, though it probably could not be given more than once to the same doctor, because progressive minor changes would be too difficult for him to detect in himself. An important question is raised by the group paranoia which these intense residential courses can engender. The directors are sometimes credited with superhuman powers, which provoke mixed emotions. An extreme example was reported to us on the fourth day of a teaching behaviour course. Members had apparently decided the previous night to refuse to play our games, which they felt made them look silly. In the end they decided against rebellion, on the grounds that we would certainly react by teaching from rebellion-behaviour, and hence there was no escape. This was reported with great good humour, and very little aggression, suggesting that on this occasion the tensions had been resolved. The incident enforces the point that non-directive
A teaching methods course for GP teachers techniques may be experienced as highly manipulative and that great care must be taken to see that learners are coping with the emotional trauma that such methods can produce. On the course our programme and the residential setting allow the directors to be fairly close to what is happening, and under most circumstances they can be well enough informed to be able to react to any crisis which may occur. Members learn this lesson as one to remember when they teach. It needs to be stressed that a course such as this does produce problems. We suspect that all courses produce problems, and believe that our methods permit difficulties to emerge more quickly than is
197
possible where teaching is given priority over learning. A great deal of work remains to be done on the design of teaching methods courses, on assessing what is learned, and on following up the effects of this learning upon members’ teaching. Much effort is being made here and in other centres to improve our knowledge in these areas, but it must be accepted that medical teaching-methods courses are still in their infancy. Reference LONG,B.E.L., HARRIS, C.M. & BYRNE, P.S. (1976) A method of teaching counselling. Medical Education, 10, 198.
A teaching methods course in Manchester for general practitioner teachers C . M . H A R R I S , B. E. L. LONG*
AND
P. S . B Y R N E t
Department of General Practice St Mary’s Hospital Medical School, London, *Department of General Practice, University of Manchester, and ?Department of General Practice, University of Manchester
therefore extends over 2 years and forty-eight sessions (120 hours). The format has been deterA teaching-methods course for general practitioner mined by the aims and methods of the organizers. teachers is described. It lasts for 20 days, split into The course involves members in a series of unfour 5-day residential sections held at intervals of 6 familiar situations selected for their educational months. The sections are respectively entitled potential; they then consider what has been learned person-to-person teaching, small group teaching, that may be relevant for their future teaching beteaching behaviour, and a micro-training laboratory. haviour. It therefore requires an atmosphere of some They recur in a cycle. intensity. In addition, members come from all parts The approach in each section is that of experiential of the U.K. and often from other countries; it must learning-necessarily, since an aim of the course is to therefore be residential. The variety of the situations enable the members to apply the same approach in and the need to reinforce learning dictate the length their own teaching. and the splitting of the content. The requirements of The methods of three of the sections are given in a course for local teachers may be regular one-session some detail. The person-to-person teaching section, meetings over a period of years; those of a course concerned mainly with the learning of counselling teaching educational theory or educational technoskills, is dealt with fully by Long et al. (1976), and is logy may be five to ten sessions concentrated into a here presented very briefly. comparatively brief period ; ours are necessarily The limited evaluation and assessment procedures, different. and their results, are offered together with certain The decision to use the method of ‘experientialgeneral conclusions. learning’ was dictated by the directors’ aims. Since we wished members to develop skills as ‘non-direcKey words: TEAcHING/*methods; GENERAL tive’ teachers, able to help their students or trainees learn from their own experiences, our methods had to PRACTICE/*edUC; *EDUCATION, MEDICAL, CONTINdemonstrate these skills, not just describe them. We UING ; CURRICULUM ; COUNSELLING/edUC; ROLE ; BEHAVIOUR ; PHYSICIAN-PATIENT RELATIONS ; ENGLAND could not logically advocate a method which we were not seen to practice. The medium was also the message. The term ‘non-directive’ is often misunderstood. Since 1971 the Department of General Practice in It does not mean that the teacher has no objectives or Manchester has offered a teaching methods course that he is not deeply involved in what happens. It which is divided into four sections. These sections are implies rather that he tries to help the learner draw each 5 day, twelve session, residential courses, and his own conclusions from his own experiences. Nonthey are held at intervals of 6 months. The full course directive teaching is based on the belief that people Correspondence: Professor P. S. Byrne, Department of will learn what they are ready and motivated to General Practice, Darbishire House, Upper Brook Street, Manchester M I 3 OFW. learn, not what they are told they should learn. The Summary
193
194
C. M . Harris,B. E. L. Long and P . S . Byrne
teacher may put course-members into situations potentially valuable to all of them, but he expects them to take only what they are individually ready to take. This may be different for each member. The four parts of the course share this non-directive approach; it seems to be unfamiliar to those who have received a traditional medical education. We hope that each member will find it so stimulating that he will wish to incorporate it into his own teaching; he will show he has done so by changes in his behaviour as the course goes on. The course also has objectives at a different level. Specific educational techniques are demonstrated, which members may learn, and which they may later apply in their own teaching. Thus we deal with the application to teaching of counselling, telling, roleplay, the case-study, games, micro-teaching, and the understanding and use of group-dynamics. We pay close attention to the concepts of ‘task’ and ‘process’: the ‘task’ is what a pair or group is trying to achieve and the ‘process’ is the way in which the people involved behave towards each other while doing so. We are concerned to show that the ‘process’ affects the achievement of the ‘task‘, often hindering it considerably. The teacher must therefore be able to understand this ‘process’ and be able to intervene in order to modify it. Each of the four component courses is limited to twenty-four members. After 3 years there are several doctors who have completed all four, and more than half the members of recent courses have already attended one or more. The four may be completed in any sequence, but we believe that there are advantages in starting with the iirst, since it displays the basic approach most clearly. The titles of the courses are : (1) Person-to-person teaching: counselling and telling; (2) Small group teaching; (3) Teaching behaviour ; (4) A micro-training laboratory. The content of the courses is outlined below, but it is a natural outcome of our approach that no two courses with the same programme will ever be similar. The two course directors were, respectively, a general practitioner with an interest in teachingmethods, and an educationist with an interest in general practice. On some occasions the courses required extra tutors: some of them were general practitioners, some psychologists, some educationists, and one a tutor in psychiatric social work. Their personal abilities were more important than their professional labels.
Course 1. Person-to-person teaching: counselling and telling The greater part of this course is occupied by sessions devoted to learning counselling; these sessions are described by Long et al. (1976). in addition there are four wherein we look at the nature, implications and use of telling as a teaching method. Groups of six members are formed, and each group is given a different briefly-described situation which ends with the words ‘In 10 minutes, what would you tell him? After three sessions of groupwork the results are presented at a plenary session. The ensuing discussion brings out the strengths and weaknesses of telling as a teaching method. Sometimes we have videotaped the presentations, and played part of them back to reinforce learning. At one of the evening sessions we have a film. We have shown Carl Rogers counselling a client, and also used Twelve Angry Men, ajury-room drama, for an exercise in process-observation. The last day is for debriefing, trying to identify the practical uses of counselling and telling as teaching methods, and the effects of the week‘s work on the behaviour of members when they return to their patients, students, trainees and spouses.
Course 2. Small group teaching The techniques offered on this course are those of role-play, the case-study, role incident analysis, and the uses of interpreting group behaviour. On one occasion we planned the three sessions devoted to role-play in some detail. Members were divided into three equal groups, and one of the organizers led a discussion with each group in a different style. He then gave a lecture to each group, again in different styles. There was no explanation beforehand of what he was doing, but the very different effects of the styles he played spoke for themselves. The group involved in each activity was observed by the other two, and discussions involved all the members. Members were then asked to roleplay certain situations devised by the staff; and finally they had to devise their own situations and play them out. On another occasion a less structured approach was used. Initially some of the members played ‘doctor’ to a ‘patient’ simulated by one of the directors, but the rest of the time was filled by members’ own role-plays. Exactly the same points
A teaching methods course for GP teachers
emerged in the discussion after these two ways of dealing with role-play, and we are happy that either approach is viable. The case-study is allotted four or five sessions. The origin of the method in business management training is described, and the difference from the traditional medical teaching method of case-history analysis is pointed out. Three groups work through a classical Harvard Business School case-study, and then through a case-study with a medical background. Members are divided in their opinions about the relative values of the two for a medical audience, but most agree that there is little effective difference. In proposing solutions to the case-studies, members discover the intended educational objectives, which concern the effects of various behaviours, difficulties in communication, and dual loyalties; they extrapolate this learning to their own situation. Solutions are sometimes tested by spontaneous roleplays. Each group has to invent a case-study. This is taken by a member to another group, which works with it and is ‘taught’ from it by the visiting member. The case-study and the ‘teacher’s’ performance are criticized by the group. Role-incident analysis is not a technique likely to be used by many GP teachers, but we have included it experimentally. One of the directors plays all the characters involved in an industrial dispute, while half the members form a ‘tribunal’ whose job is to settle the dispute quickly. They interview whichever witnesses they wish to call, in an attempt to discover a solution to fit the very complex problem. They are not accustomed to dealing with people who often lie consciously and cleverly, nor to looking for cynical but practical solutions to a power-conflict ; they find the exercise very difficult. The rest of the members observe for half the time, and then change places with the first ‘tribunal’. The exercise is discussed in plenary session. It should be possible to devise a role-incident based on a family or group-practice situation that might be more useful, but we have not yet done so. The study of the behaviour of groups is dealt with in two ways. Every group activity which occurs on the course is observed by one of the two directors, and he draws the group’s attention to its behaviour when he considers it appropriate to do so. In practice, this means the occasions on which the group’s ‘process’ is getting in the way of its task performance. Secondly, certain tasks may be set whose purpose is solely to provide ‘process’ for analysis.
195
A group may be asked to discuss a controversial topic while another group specifically observes and later comments on the ‘process’ which has taken place. There are also exercises where the organizer does not declare beforehand that the purpose is ‘process’ observation-such as a game whose solution is usually hindered both by intra-group and inter-group conflict. The final day is largely given to reviewing of what has been learned about the teaching methods and from the teaching methods used on the course, and considering ways in which members may wish to adapt them for their own use. Course 3. Teaching behaviour
The ambiguity of this title is usually queried at the very beginning by the members; it is intentional. The course begins with an exercise called ‘The contract’. Members form very small groups in which they try to define their expectations of the course. One representative from each group then presents them to the staff in plenary session, and by a counselling process the staff attempt to make them more precise. After plenary discussion it is understood that the aims of the members have been at least tentatively declared, and that it is the responsibility of the staff to help in their achievement. The main work of the course consists of playing games and then discussing how members behaved. We use variations on standard management training material : ‘Setting objectives’, ‘Achievement’, ‘Negotiating behaviour’, ‘Interacting systems’, ‘Supervisory behaviour’, and ‘Motivation’, and a version of the well-known ‘Maudsley Hospital game’. Each game is followed by a ‘debriefing-session’ about what has been learned. Members are then asked to invent a game whose purpose is to influence. favourably the behaviour of trainees who resist adapting to general practice. In addition there are two sessions devoted to nonverbal communication. Three groups each hold a discussion on a controversial topic for about 15 minutes. These discussions are video-taped and played back without sound, stopping the tape as cues appear. We also have an American film on nonverbal communication which presents both soundless pictures and picture-less sound of clinical interviews, finally combining the two. On the last day, the original small groups who worked on the ‘Contract’ re-form to consider how
196
C. M . Harris, B. E. L. Long and P. S. Byrne
far their objectives have been achieved. The value of games as a teaching method for trainees is debated in plenary session, as are ways of teaching about nonverbal communication. Course 4. A micro-training laboratory One of the directors is conducting research into the verbal behaviour of general practitioners during their consultations. He has constructed a list of about forty defined behaviours-the following are a few examples : ‘asks direct question’, ‘offers reassurance’, ‘uses silence’, ‘reflects question’. This list is used to analyse the consultations of course members, since it is reasonable to assume that a doctor’s consulting style will resemble his teaching style. Before the course, members send a cassetterecording of 1-2 hours of their normal consultations to the directors, and these are analysed sentence by sentence in terms of the list of behaviours. Thus a profile of each member is constructed, and is given to him. He then decides for himself if there is a specific behaviour which he wishes to learn or unlearn. The directors explain the method of analysis in detail, and members divide into groups of three to practise analysing each others’ tapes. This enables them to analyse their trainees’ tapes at a future date. Within the trios, members construct situations to help each other learn the specific behaviours they have chosen for themselves, and the directors assist them to do so. This work, and the discussion which arises from it, comfortably fill the twelve sessions. On one course we brought in real trainees, one to each trio, bearing cassettes of some of their consultations. Each trio then analysed their trainee’s recording and tried to help him develop a behaviour he selected for himself. The list of behaviours is not yet in its final state, and indeed has been modified after each course on which it has been used. Despite its acknowledged imperfections, it has proved a useful tool, and has been regarded as helpful by course-members. This completes the description of the four component courses. The unfamiliarity of the methods prompts many questions, of which the most important probably are those about evaluation. We have been more concerned with assessing the learning of the skills and behaviours we offer than in evaluating the use of non-directive teaching, since we regard it as self-evident that there will be teaching situations where a non-directive approach is required.
The courses are so constructed that a fair measure of feedback is available immediately, for members are observed practising the skills they are learning. The debriefing sessions give us some idea of the extent to which our approach is accepted and our techniques deemed practical. We are in a position to assess subjectively the changes we see in doctors who attend more than one of the courses. There is an obvious method of assessing the effect of Course 4: members can be asked to send us tapes of consultations at various times after the 5 days are over. We have tried to do this, but the number of doctors who have provided us with such tapes is small, and it is not possible yet to say more than that some appear to have incorporated the changes they set out to learn into their behaviour several months later, others show less change, and a few seem not to have changed at all. Four weeks after the end of our first Course 1 we sent out a questionnaire as agreed with members in the final session. It asked for self-reported changes in counselling and telling behaviours in both clinical and educational contexts. The biggest changes noted were in the ability to listen to patients, ways of asking questions, the range of data elicited during history taking, and the ability to remain silent. Over half the members were making some regular use of counselling techniques with patients, and over half deliberately refrained from offering advice that they would previously have given. Only half of the members had taught during the month, and they reported parallel changes. Refinement of this questionnaire would be possible, though it probably could not be given more than once to the same doctor, because progressive minor changes would be too difficult for him to detect in himself. An important question is raised by the group paranoia which these intense residential courses can engender. The directors are sometimes credited with superhuman powers, which provoke mixed emotions. An extreme example was reported to us on the fourth day of a teaching behaviour course. Members had apparently decided the previous night to refuse to play our games, which they felt made them look silly. In the end they decided against rebellion, on the grounds that we would certainly react by teaching from rebellion-behaviour, and hence there was no escape. This was reported with great good humour, and very little aggression, suggesting that on this occasion the tensions had been resolved. The incident enforces the point that non-directive
A teaching methods course for GP teachers techniques may be experienced as highly manipulative and that great care must be taken to see that learners are coping with the emotional trauma that such methods can produce. On the course our programme and the residential setting allow the directors to be fairly close to what is happening, and under most circumstances they can be well enough informed to be able to react to any crisis which may occur. Members learn this lesson as one to remember when they teach. It needs to be stressed that a course such as this does produce problems. We suspect that all courses produce problems, and believe that our methods permit difficulties to emerge more quickly than is
197
possible where teaching is given priority over learning. A great deal of work remains to be done on the design of teaching methods courses, on assessing what is learned, and on following up the effects of this learning upon members’ teaching. Much effort is being made here and in other centres to improve our knowledge in these areas, but it must be accepted that medical teaching-methods courses are still in their infancy. Reference LONG,B.E.L., HARRIS, C.M. & BYRNE, P.S. (1976) A method of teaching counselling. Medical Education, 10, 198.
