Br.J. Anaesth. (1976), 48, 495
AN ANALYTICAL APPROACH TO POSTGRADUATE MEDICAL EDUCATION R. D. JACK AND C. E. ENGEL
1966; American Society of Internal Medicine, 1969, 1970), statistics concerning hospital discharge and length of stay in hospital (Commission on Professional and Hospital Activities, 1971; Korst, 1974) and observations of "critical incidents" (Miller, 1968) have also been used. The American Board of Pediatrics (Burg, 1975) gave a detailed analysis of clinical responsibilities in that specialty. However, none of these attempts seems entirely successful, partly because they have been applied without full regard to all the responsibilities of the profession. We have evolved an analysis in the hope that it should provide both for flexibility and the truly comprehensive education of anaesthetists. To do this we defined first what the senior member of the profession does that distinguishes him from the technician. The anaesthetist will: (a) recognize a situation that needs correction; (b) analyse that situation in terms of its constituent parts and their interplay; (c) plan its resolution; (d) effect the execution of the plan. If this definition is accepted, it follows that certain qualities should be fostered during the period of postgraduate education, for example observation, data analysis, evaluation of scientificreportsandleaderTHE ANALYSIS ship as well as collaboration with other members of a To ensure that both the content and the conduct of a team. Since such attributes are best learned through postgraduate course can adjust tp meet new conditions constant practice, our analysis has adopted an of professional practice, the analysis must be flexible. approach that encourages such practice throughout To achieve this flexibility, different methods of analy- the course. sis have been used by different authors. As our analysis is based upon the premise that the A theoretical task analysis for paediatric vocational responsibilities of the consultant imply dealing with training of general practitioners was proposed by problems, it ensures that postgraduate studies will Glaser (1973). Surveys of practising physicians continue to meet the needs of current practice. The (Bergman, Dassel and Wedgwood, 1966; Hodgkin, necessary flexibility is assured, since problems and their solution can be adjusted in response to changes R. D. JACK, M.D., CM., F.F.A.R.C.S., Department of Anaesthetics, Royal Postgraduate Medical School, London in both clinical responsibilities and scientific knowledge. W12 OHS. C. E. ENGEL, F.R.P.S., F.B.P.A., A.I.M.B.I., D.G.PH., Centre for Educational Development in Health Weproceeded from the general to the specific by first Care, British Medical Association and British Life defining the major areas in which decisions must be Assurance Trust for Health Education, B.M.A. House, made in the practice of anaesthetics. As the postTavistock Square, London WCllj 9JP. Correspondence to Dr R. D. Jack, Wexham Park graduate must receive education which encompasses the wider role of the medical specialist, the field of Hospital, Slough, Berks SL2 4HL. PURPOSE OF THE INVESTIGATION
41
Downloaded from http://bja.oxfordjournals.org/ at University of Toronto Library on July 15, 2015
Postgraduate students of medicine have little idea of what they need to learn and what skills they must acquire to be judged fully trained. The body of knowledge and skills required for independent practice should be denned to guide the postgraduate and help teachers design courses and examinations. Such guidance should emphasize education for senior members of the profession rather than technical training. To investigate the possibilities of producing a guide, we have selected as an example postgraduate training in anaesthetics; but we believe our approach can be applied to all specialties. Pur aim has been to analyse the specialty of anaesthetics so that "learning objectives", denned as a precise specification of what a student should be able to do, in order to demonstrate that .he has learned successfully (Engel, 1975), may be specified to illustrate the. nature and level of performance expected of the student. The analysis provides a logical basis for course and examination design, as the learning objectiyes may be used to determine priorities in learning^ a suitable order of learning tasks and their implementation, and how appropriate testing may be performed.
496
BRITISH JOURNAL OF ANAESTHESIA
sibility does not end automatically. First he must recognize whether there is a need for further care. If he decides there is no such need, it is sufficient that he remain in contact with the patient, directly or indirectly, and that he supply his colleagues, the patient and the patient's family with any relevant information. If the postgraduate decides that further care is necessary he must return again to the Chnical Decision Areas (table II). These questions may lead to answers which provide a progression of decision and actions which portray the responsibilities of the practising specialist. Thus a theoretical analysis emerges that reflects the TABLE I. Major decision areas attributes desirable in a professional. This analysis (A) Patient: patient-related clinical problems can be used to decide what knowledge, skills and (B) Management: non-clinical problems attitudes are necessary for independent practice. It will (C) Teaching also reveal the relationship with other specialties, and (D) Research (E) Social responsibilities with the basic sciences. While it will underline the educational requirements it can also be used to ensure that realistic limits are set for the appropriate studies TABLE II. Clinical decision areas and subsequent examinations. (A) Patient: patient-related clinical problems An examination of the "Regulation of Conscious(1) Regulation of consciousness ness" (table IV) illustrates our approach. To answer (2) Regulation of sensation (3) Regulation of muscle tone the question "Why regulate ?" the postgraduate must (4) Regulation of the circulation be able to recognize the need to control patient (5) Control of ventilation awareness, or to control perception of sensation, and (6) Regulation of body water and constituents he must determine the desired state to be attained. (7) Regulation of temperature He must then estimate the patient's existing state of awareness or perception of pain (analyse the situation). TABLE III. Questions asked of each clinical area Only then can he plan and manage the resolution. (table II) Each of these steps correlates with our definition of an anaesthetist. (1) Why regulate? (2) What is to be regulated ? To answer the question "What is to be regulated ?", (3) How is regulation to be effected ? the postgraduate must first recognize the need to (4) How are continuing responsibilities met ? control various factors such as patient alertness, patient memory or the sensory input to the patient. The answers to the question "Why regulate?" Then he must be able to analyse the situation in order (table III) indicate that the handling of problems to decide which he will regulate and in what manner. His decision on how to regulate best (table IV, generally involves one or more of three processes: (1) anticipation of abnormality, followed by pro- third column) will depend on considerations which phylaxis ; (2) recognition of abnormality, followed by will influence, first, his choice of method and techtherapy; (3) deliberate production of abnormality, nique and, later, whether he continues or modifies followed by temporary intervention. his treatment. Representative examples of these conWhen the postgraduate has decided why he wants siderations are referred to at the top of the third to provide regulation he must decide "What is to be column and are listed in table V. In addition, the regulated?" The answer will define the factors he postgraduate must assess continually whether regucan control. The next logical question, "How is lation has been achieved or whether further regulation regulation to be effected ?" will call for the definition is required. The assessment may cause him to change of the methods and techniques from which he can his treatment (third column, table IV), to reassess his analysis (second column), or even to consider select. Once the postgraduate has restored the patient to whether there are aspects which he has failed to the normal state, he must be aware that his respon- recognize (first column).
responsibilities was enlarged well beyond the chnical boundaries (table I). Each major area was further divided. For example, the area of Patient Care was broken down (table II). Teachers who disagreed with this breakdown of chnical practice would, of course, be free to add further responsibilities at the same level of generality without detracting from the usefulness of this analysis. In order to explore each of these clinical areas (table II) we posed questions which correspond to our concept of a consultant (table III).
Downloaded from http://bja.oxfordjournals.org/ at University of Toronto Library on July 15, 2015
Why regulate ?
What is to be regulated ? 1. Patient alertness
I. To control patient awareness: recognize the need to control patient awareness: in order to ensure control of patient awareness: estimate patient's state of awareness determine desired state of awareness decide upon and implement any treatment to produce change assure return to normal state
2. Patient memory
3. Sensory input to patient 4. Control sensitivity of sensory nerve endings II. To control perception of sensation: recognize the need to control perception of sensation; in order to ensure control of pain perception: estimate patient's perception of pain determine desired state of perception of pain decide upon and implement any treatment to produce change assure return to normal state III. To control muscle tone: recognize the need to control muscle tone; in order to ensure control of muscle tone: estimate patient's muscle tone determine desired amount of muscle tone decide upon and implement any treatment to produce change assure return to normal state.
5. Control conduction of action potentials in afferent nerve fibres 6. Control perception of sensory input 7. Control reaction to sensory input 8. Control voluntary muscle tone
9. Control reflex muscle tone 10. Control background muscle tone
Downloaded from http://bja.oxfordjournals.org/ at University of Toronto Library on July 15, 2015
TABLE IV. Regulation of consciousness
How is regulation achieved ?*
. decrease: inhalation hypnotic agents parenteral hypnotic agents . restore: spontaneous recovery narcotic reversal agents , decrease: inhalation hypnotic agents parenteral hypnotic agents restore: spontaneous recovery narcotic reversal agents i. control noise in patient area ii. control lighting in patient area iii. control surgical manipulation of patient iv. control passive movement of patient
How are continuing responsibilities met ? If further care is not necessary: remain in direct/ indirect contact with the patient inform colleagues inform patient's family If further care is necessary: reconsider Clinical Decision Areas
S
3 n r1 % o n H O
i. decrease: infiltration with local anaesthetic agents administration of analgesics i. decrease: inhalation hypnotic agents parenteral hypnotic agents local anaesthetic nerve block i. decrease: inhalation hypnotic agents parenteral hypnotic agents flooded sensory input suggestion ii. restore: spontaneous recovery narcotic reversal agents i. decrease: produce mild euphoria suggestion
H O
i. decrease: inhalation hypnotic agents parenteral hypnotic agents ii. restore: spontaneous recovery i. decrease: inhalation hypnotic agents parenteral hypnotic agents infiltration with local anaesthetic agents ii. restore: spontaneous recovery i. decrease: inhalation hypnotic agents parenteral hypnotic agents ii. restore: spontaneous recovery
6
d
§
* The selection of method(s) and technique(s) for implementation are based on the factors indicated in table V. During implementation consideration must ^ be given to the effects upon and the effects resulting from the factors indicated in table V. *•*
BRITISH JOURNAL OF ANAESTHESIA
498
TABLE V. Examples of considerations influencing decisions on "How is regulation achieved?" (table IV) During implementation, consideration must be given to the effects upon, and the effects resulting from: other effects of drugs used to alter consciousness effectiveness of other techniques of analgesia being used effectiveness of other techniques of muscle relaxation being used changes in noise or lighting in patient area changes in extent of surgical manipulation or of passive movement of patient change in patient's desire or need for alteration of consciousness change in staff's desire for alteration of patient's consciousness
It is important to emphasize that, in a normal clinical situation, the student would be required to deal with several Clinical Decision Areas (table II) simultaneously.
the practicability of this analytical approach to course design and examination can be assessed fully.
REFERENCES
APPLICATION
Studies based on this task analysis will make the postgraduate alert to developments which call for action, recognize and analyse each as it appears and plan and manage a successful resolution. As new situations emerge they may force him to look again at decisions he has made. Thus education based on this analysis will provide the constant practice that is required for the acquisition of the essential skills. Preliminary experience indicates that postgraduates respond favourably to clinically based studies. Topics were selected from the analysis and learning objectives were defined in terms of clinical situations. Discussion explored matters requiring decisions so that the postgraduates were encouraged to emulate the consultant's approach to problems. The use of this analysis has shown that it reveals interrelationships between topics, and the logical progression from one topic to another, and that it can assist in the establishment of priorities for learning. While it may aid the teacher in the planning of a course of study, postgraduates have found that it provides a greater sense of order and relevance for their learning. Although this guide has already proved its worth in helping postgraduates towards independent study, more detailed work remains to be undertaken before
American Society of Internal Medicine (1969, 1970). Profile of an internist. Internist (October, November, December 1969, June 1970). Bergman, A. B., Dassel, S. W., and Wedgwood, R. J. (1966). Time-motion study of practising pediatricians. Pediatrics, 38, 254. Burg, F. D. (ed.) (1975). Foundations for Evaluating the Competency of Pediatricians. Chicago: American Board of Pediatrics. Commission on Professional and Hospital Activities (1971). Length of Stay in PAS Hospitals, United States. Ann Arbor, Michigan: Ann Arbor. Engel, C. E. (1975). Learning objectives in medical education; in The Objectives of Undergraduate Medical Education. Report of a Workshop held by the Association for Medical Education in Europe, 1974. Dundee: A.M.E.E. Glaser, D. (1973). Case Study in Educational Technology. I: An Application of the Systems Approach to Postgraduate Medical Education. London: National Council for Educational Technology and Department of Audio Visual Communication, British Medical Association and British Life Assurance Trust for Health Education. Distributed by Councils and Education Press, London. Hodgkin, K. (1966). Toward Earlier Diagnosis. Edinburgh and London: E. & S. Livingstone. Korst, D. R. (1974). Objectives in Internal Medicine for Medical Students—A Guide to the Clinical Clerkship. Madison, Wisconsin: University of Wisconsin Medical School. Miller, G. E. (1968). The Orthopedic Training Study. J.A.M.A., 206, 601.
Downloaded from http://bja.oxfordjournals.org/ at University of Toronto Library on July 15, 2015
To regulate consciousness the selection of method(s) to be used and the techniques for implementation are based on: patient's existing level of consciousness patient's desire or need for alteration of consciousness staff's desire for alteration of patient's consciousness other techniques of analgesia to be used other techniques of muscle relaxation to be used safety to patient of drugs used to alter consciousness control of noise and lighting in patient area extent of passive movement of patient nature of surgical manipulation of patient
AN ANALYTICAL APPROACH TO POSTGRADUATE MEDICAL EDUCATION R. D. JACK AND C. E. ENGEL
1966; American Society of Internal Medicine, 1969, 1970), statistics concerning hospital discharge and length of stay in hospital (Commission on Professional and Hospital Activities, 1971; Korst, 1974) and observations of "critical incidents" (Miller, 1968) have also been used. The American Board of Pediatrics (Burg, 1975) gave a detailed analysis of clinical responsibilities in that specialty. However, none of these attempts seems entirely successful, partly because they have been applied without full regard to all the responsibilities of the profession. We have evolved an analysis in the hope that it should provide both for flexibility and the truly comprehensive education of anaesthetists. To do this we defined first what the senior member of the profession does that distinguishes him from the technician. The anaesthetist will: (a) recognize a situation that needs correction; (b) analyse that situation in terms of its constituent parts and their interplay; (c) plan its resolution; (d) effect the execution of the plan. If this definition is accepted, it follows that certain qualities should be fostered during the period of postgraduate education, for example observation, data analysis, evaluation of scientificreportsandleaderTHE ANALYSIS ship as well as collaboration with other members of a To ensure that both the content and the conduct of a team. Since such attributes are best learned through postgraduate course can adjust tp meet new conditions constant practice, our analysis has adopted an of professional practice, the analysis must be flexible. approach that encourages such practice throughout To achieve this flexibility, different methods of analy- the course. sis have been used by different authors. As our analysis is based upon the premise that the A theoretical task analysis for paediatric vocational responsibilities of the consultant imply dealing with training of general practitioners was proposed by problems, it ensures that postgraduate studies will Glaser (1973). Surveys of practising physicians continue to meet the needs of current practice. The (Bergman, Dassel and Wedgwood, 1966; Hodgkin, necessary flexibility is assured, since problems and their solution can be adjusted in response to changes R. D. JACK, M.D., CM., F.F.A.R.C.S., Department of Anaesthetics, Royal Postgraduate Medical School, London in both clinical responsibilities and scientific knowledge. W12 OHS. C. E. ENGEL, F.R.P.S., F.B.P.A., A.I.M.B.I., D.G.PH., Centre for Educational Development in Health Weproceeded from the general to the specific by first Care, British Medical Association and British Life defining the major areas in which decisions must be Assurance Trust for Health Education, B.M.A. House, made in the practice of anaesthetics. As the postTavistock Square, London WCllj 9JP. Correspondence to Dr R. D. Jack, Wexham Park graduate must receive education which encompasses the wider role of the medical specialist, the field of Hospital, Slough, Berks SL2 4HL. PURPOSE OF THE INVESTIGATION
41
Downloaded from http://bja.oxfordjournals.org/ at University of Toronto Library on July 15, 2015
Postgraduate students of medicine have little idea of what they need to learn and what skills they must acquire to be judged fully trained. The body of knowledge and skills required for independent practice should be denned to guide the postgraduate and help teachers design courses and examinations. Such guidance should emphasize education for senior members of the profession rather than technical training. To investigate the possibilities of producing a guide, we have selected as an example postgraduate training in anaesthetics; but we believe our approach can be applied to all specialties. Pur aim has been to analyse the specialty of anaesthetics so that "learning objectives", denned as a precise specification of what a student should be able to do, in order to demonstrate that .he has learned successfully (Engel, 1975), may be specified to illustrate the. nature and level of performance expected of the student. The analysis provides a logical basis for course and examination design, as the learning objectiyes may be used to determine priorities in learning^ a suitable order of learning tasks and their implementation, and how appropriate testing may be performed.
496
BRITISH JOURNAL OF ANAESTHESIA
sibility does not end automatically. First he must recognize whether there is a need for further care. If he decides there is no such need, it is sufficient that he remain in contact with the patient, directly or indirectly, and that he supply his colleagues, the patient and the patient's family with any relevant information. If the postgraduate decides that further care is necessary he must return again to the Chnical Decision Areas (table II). These questions may lead to answers which provide a progression of decision and actions which portray the responsibilities of the practising specialist. Thus a theoretical analysis emerges that reflects the TABLE I. Major decision areas attributes desirable in a professional. This analysis (A) Patient: patient-related clinical problems can be used to decide what knowledge, skills and (B) Management: non-clinical problems attitudes are necessary for independent practice. It will (C) Teaching also reveal the relationship with other specialties, and (D) Research (E) Social responsibilities with the basic sciences. While it will underline the educational requirements it can also be used to ensure that realistic limits are set for the appropriate studies TABLE II. Clinical decision areas and subsequent examinations. (A) Patient: patient-related clinical problems An examination of the "Regulation of Conscious(1) Regulation of consciousness ness" (table IV) illustrates our approach. To answer (2) Regulation of sensation (3) Regulation of muscle tone the question "Why regulate ?" the postgraduate must (4) Regulation of the circulation be able to recognize the need to control patient (5) Control of ventilation awareness, or to control perception of sensation, and (6) Regulation of body water and constituents he must determine the desired state to be attained. (7) Regulation of temperature He must then estimate the patient's existing state of awareness or perception of pain (analyse the situation). TABLE III. Questions asked of each clinical area Only then can he plan and manage the resolution. (table II) Each of these steps correlates with our definition of an anaesthetist. (1) Why regulate? (2) What is to be regulated ? To answer the question "What is to be regulated ?", (3) How is regulation to be effected ? the postgraduate must first recognize the need to (4) How are continuing responsibilities met ? control various factors such as patient alertness, patient memory or the sensory input to the patient. The answers to the question "Why regulate?" Then he must be able to analyse the situation in order (table III) indicate that the handling of problems to decide which he will regulate and in what manner. His decision on how to regulate best (table IV, generally involves one or more of three processes: (1) anticipation of abnormality, followed by pro- third column) will depend on considerations which phylaxis ; (2) recognition of abnormality, followed by will influence, first, his choice of method and techtherapy; (3) deliberate production of abnormality, nique and, later, whether he continues or modifies followed by temporary intervention. his treatment. Representative examples of these conWhen the postgraduate has decided why he wants siderations are referred to at the top of the third to provide regulation he must decide "What is to be column and are listed in table V. In addition, the regulated?" The answer will define the factors he postgraduate must assess continually whether regucan control. The next logical question, "How is lation has been achieved or whether further regulation regulation to be effected ?" will call for the definition is required. The assessment may cause him to change of the methods and techniques from which he can his treatment (third column, table IV), to reassess his analysis (second column), or even to consider select. Once the postgraduate has restored the patient to whether there are aspects which he has failed to the normal state, he must be aware that his respon- recognize (first column).
responsibilities was enlarged well beyond the chnical boundaries (table I). Each major area was further divided. For example, the area of Patient Care was broken down (table II). Teachers who disagreed with this breakdown of chnical practice would, of course, be free to add further responsibilities at the same level of generality without detracting from the usefulness of this analysis. In order to explore each of these clinical areas (table II) we posed questions which correspond to our concept of a consultant (table III).
Downloaded from http://bja.oxfordjournals.org/ at University of Toronto Library on July 15, 2015
Why regulate ?
What is to be regulated ? 1. Patient alertness
I. To control patient awareness: recognize the need to control patient awareness: in order to ensure control of patient awareness: estimate patient's state of awareness determine desired state of awareness decide upon and implement any treatment to produce change assure return to normal state
2. Patient memory
3. Sensory input to patient 4. Control sensitivity of sensory nerve endings II. To control perception of sensation: recognize the need to control perception of sensation; in order to ensure control of pain perception: estimate patient's perception of pain determine desired state of perception of pain decide upon and implement any treatment to produce change assure return to normal state III. To control muscle tone: recognize the need to control muscle tone; in order to ensure control of muscle tone: estimate patient's muscle tone determine desired amount of muscle tone decide upon and implement any treatment to produce change assure return to normal state.
5. Control conduction of action potentials in afferent nerve fibres 6. Control perception of sensory input 7. Control reaction to sensory input 8. Control voluntary muscle tone
9. Control reflex muscle tone 10. Control background muscle tone
Downloaded from http://bja.oxfordjournals.org/ at University of Toronto Library on July 15, 2015
TABLE IV. Regulation of consciousness
How is regulation achieved ?*
. decrease: inhalation hypnotic agents parenteral hypnotic agents . restore: spontaneous recovery narcotic reversal agents , decrease: inhalation hypnotic agents parenteral hypnotic agents restore: spontaneous recovery narcotic reversal agents i. control noise in patient area ii. control lighting in patient area iii. control surgical manipulation of patient iv. control passive movement of patient
How are continuing responsibilities met ? If further care is not necessary: remain in direct/ indirect contact with the patient inform colleagues inform patient's family If further care is necessary: reconsider Clinical Decision Areas
S
3 n r1 % o n H O
i. decrease: infiltration with local anaesthetic agents administration of analgesics i. decrease: inhalation hypnotic agents parenteral hypnotic agents local anaesthetic nerve block i. decrease: inhalation hypnotic agents parenteral hypnotic agents flooded sensory input suggestion ii. restore: spontaneous recovery narcotic reversal agents i. decrease: produce mild euphoria suggestion
H O
i. decrease: inhalation hypnotic agents parenteral hypnotic agents ii. restore: spontaneous recovery i. decrease: inhalation hypnotic agents parenteral hypnotic agents infiltration with local anaesthetic agents ii. restore: spontaneous recovery i. decrease: inhalation hypnotic agents parenteral hypnotic agents ii. restore: spontaneous recovery
6
d
§
* The selection of method(s) and technique(s) for implementation are based on the factors indicated in table V. During implementation consideration must ^ be given to the effects upon and the effects resulting from the factors indicated in table V. *•*
BRITISH JOURNAL OF ANAESTHESIA
498
TABLE V. Examples of considerations influencing decisions on "How is regulation achieved?" (table IV) During implementation, consideration must be given to the effects upon, and the effects resulting from: other effects of drugs used to alter consciousness effectiveness of other techniques of analgesia being used effectiveness of other techniques of muscle relaxation being used changes in noise or lighting in patient area changes in extent of surgical manipulation or of passive movement of patient change in patient's desire or need for alteration of consciousness change in staff's desire for alteration of patient's consciousness
It is important to emphasize that, in a normal clinical situation, the student would be required to deal with several Clinical Decision Areas (table II) simultaneously.
the practicability of this analytical approach to course design and examination can be assessed fully.
REFERENCES
APPLICATION
Studies based on this task analysis will make the postgraduate alert to developments which call for action, recognize and analyse each as it appears and plan and manage a successful resolution. As new situations emerge they may force him to look again at decisions he has made. Thus education based on this analysis will provide the constant practice that is required for the acquisition of the essential skills. Preliminary experience indicates that postgraduates respond favourably to clinically based studies. Topics were selected from the analysis and learning objectives were defined in terms of clinical situations. Discussion explored matters requiring decisions so that the postgraduates were encouraged to emulate the consultant's approach to problems. The use of this analysis has shown that it reveals interrelationships between topics, and the logical progression from one topic to another, and that it can assist in the establishment of priorities for learning. While it may aid the teacher in the planning of a course of study, postgraduates have found that it provides a greater sense of order and relevance for their learning. Although this guide has already proved its worth in helping postgraduates towards independent study, more detailed work remains to be undertaken before
American Society of Internal Medicine (1969, 1970). Profile of an internist. Internist (October, November, December 1969, June 1970). Bergman, A. B., Dassel, S. W., and Wedgwood, R. J. (1966). Time-motion study of practising pediatricians. Pediatrics, 38, 254. Burg, F. D. (ed.) (1975). Foundations for Evaluating the Competency of Pediatricians. Chicago: American Board of Pediatrics. Commission on Professional and Hospital Activities (1971). Length of Stay in PAS Hospitals, United States. Ann Arbor, Michigan: Ann Arbor. Engel, C. E. (1975). Learning objectives in medical education; in The Objectives of Undergraduate Medical Education. Report of a Workshop held by the Association for Medical Education in Europe, 1974. Dundee: A.M.E.E. Glaser, D. (1973). Case Study in Educational Technology. I: An Application of the Systems Approach to Postgraduate Medical Education. London: National Council for Educational Technology and Department of Audio Visual Communication, British Medical Association and British Life Assurance Trust for Health Education. Distributed by Councils and Education Press, London. Hodgkin, K. (1966). Toward Earlier Diagnosis. Edinburgh and London: E. & S. Livingstone. Korst, D. R. (1974). Objectives in Internal Medicine for Medical Students—A Guide to the Clinical Clerkship. Madison, Wisconsin: University of Wisconsin Medical School. Miller, G. E. (1968). The Orthopedic Training Study. J.A.M.A., 206, 601.
Downloaded from http://bja.oxfordjournals.org/ at University of Toronto Library on July 15, 2015
To regulate consciousness the selection of method(s) to be used and the techniques for implementation are based on: patient's existing level of consciousness patient's desire or need for alteration of consciousness staff's desire for alteration of patient's consciousness other techniques of analgesia to be used other techniques of muscle relaxation to be used safety to patient of drugs used to alter consciousness control of noise and lighting in patient area extent of passive movement of patient nature of surgical manipulation of patient
