The teaching of health personnel has become more complex than it used to be, especially if it is accepted that the teacher should consider the benefit of the learner and not only his own satisfaction. More than a dozen of the teacher's functions are described below. A teacher should feel satisfied if he fulfils only a few of them, because the present educational environment does not greatly help him along this road. Nevertheless, he will do well to improve his performance by training as an educator.
It is sometimes thought that a teacher's activities are so intricately related to the local culture in which he functions that the description of his tasks should differ if he teaches in Antwerp, Dar-es-Salaam or Moscow. However, there is no support for this concept in reality. Data concerning teachers' behaviour during teacher training workshops organized by the World Health Organization over the last 10 years with participants from a great variety of geographical or sociopolitical backgrounds clearly indicate that teachers are more like each other than they are like the people of the community to which they belong. The worldwide academic community seems to be one cohesive entity modelled on nineteenth century western European concepts of academic freedom, exclusiveness and detachment.
Most teachers in schools for health personnel conduct scientific research, write reports and articles, plan and supervise laboratory or clinical units and, finally, teach, in that order of priority. To teach means, in most instances, to prepare and deliver lectures, to supervise students during laboratory and clinical work, to decide which questions should be asked at examinations, and to score papers and oral examinations. Added to all this is attendance at numerous scientific or administrative meetings.
Instructional duties are sometimes called “teaching load”, an expression which clearly conveys the attitude to that function. Teaching staff are jokingly depicted as secretly believing that academic life would be much easier if there were no students. As in all jokes, there is much truth in this.
Some teachers are seldom seen by students while others spend many pleasant hours in stimulating discussion with their students.
Rather than pursue this description, in which no teacher would ever want to recognize himself, let us consider what are the teacher's functions in the light of present-day educational concepts.
1. To be available
The teacher should be available to give students constructive criticism of their working objectives and methods. The key-word here is “available”. It constrasts sharply with the habit of the traditional academician who proclaims “I am always happy to meet students ... my door is always open”, but who, in fact, is so rarely in his office that only very stubborn and highly motivated students manage to catch him once he has left the lecture hall. Really available is the professor who has a notice on his office door saying “I am at the disposal of students in this office every Tuesday and Friday from 10 a.m. to 12 a.m.”, and who is actually there at those times.
2. To provide constructive criticism of the student's learning objectives and working methods
It is of the utmost importance that the student's working objectives and methods should be exposed to constructive criticism as, after training, health personnel should be able to relate their own professional goals to the organized system of health care, and to develop their own tactics for achieving those goals.
It is also important to develop the student's desire to seek criticism, supervision and advice from teachers and fellow-students.
3. To analyse and evaluate health problems
Generally speaking, clinical teachers are able to guide students in solving patients' particular problems, but students should also collect and use relevant information for the solution of community health problems. It is less certain that all teachers have enough understanding of epidemiology and of health manpower planning principles and methods to assist students in that respect. This is especially true of teachers of the so-called basic science subjects.
It would be an advantage if all teachers had sufficient competence to ensure that whatever they teach is relevant to the community. The teacher should be able to analyse and evaluate health problems raised by students, as well as proposed solutions.
4. To define learning objectives
The teacher should be able to define the abilities that students need to acquire in order to solve a given health problem. For example, a teacher should be able to define explicit and relevant learning objectives so as to help students to understand a problem. Moreover, when programmes are being constructed, it is preferable to indicate clearly the standard of performance to be acquired by students than to state only the amount of time to be spent teaching the subject. It is well known that the time needed to master a subject varies from student to student depending on ability, motivation and drive, and on the availability of teachers and educational facilities. What is important for the average person is not the length of time during which teachers teach or students learn, but the ability of the person providing health care to perform a given task. If my son needs a hernia operation, I do not wish to be told that the surgeon has graduated from a six-year course in an institution in the World Directory of Medical Schools. What I want to know is whether he is competent to perform that operation in the best and safest way. As for the nurse who will comfort him in this strange and frightening hospital world, I do not care whether she has had 72 hours in a psychology course as long as she is able to give him the reassurance he may need.
5. To assess students' work
The teacher should be able to define criteria for assessing students' work and measuring their abilities. Such criteria need to be carefully drawn up, and teachers should share the task of preparing them with their students. The sad state of most examination systems in faculties and schools is largely the result of the absence of such criteria, which could serve not only for certification purposes but also in guiding the students' learning, a point that is certainly no less important. Everybody in the health professions should cultivate this ability to define criteria, as it is essential that they should be able to audit their own performance and that of their colleagues.
6. To prepare learning aids
The teacher should prepare learning aids and materials, provide information that will facilitate students' independent work, and evaluate the usefulness of such materials. Most of what is usually transmitted by traditional lecture courses could be better acquired by students working independently and studying books, scientific journals and duplicated texts in self-learning format, with or without audiovisual aids. In such cases, students should be aware of related learning objectives, and feedback evaluation exercises, based on those objectives, should be available.
The preparation of such materials may well be a joint effort among colleagues from several faculties. It calls for a lot of work, but may be considered as an investment that will pay off during several years through setting up banks. It should help to eliminate passive learning which is often all that is required of students. The assessment of the usefulness of such materials, which requires a level of educational competence some teachers do not yet have, may call for the collaboration of specialists in education.
7. To select professional activities for students
The teacher should select professional activities of graded difficulty appropriate to the student's level of progress during the whole of his learning curriculum. There is agreement among professional educators that students should acquire professional competence through the practice of real (or, if that is not possible, simulated) professional activities. Even students fresh from secondary school are perfectly capable of drawing valuable lessons from the study of real cases.
8. To confront students with new problems
The teacher should confront students with a diversity of new problems in order to help them define the terms of the problems and find solutions to them. If it is true that the estimated half-life of medical knowledge is about five years, and it is slowly but constantly shrinking, it is essential that today's graduates, among whom are tomorrow's leaders of health services, should be able to solve the new problems that arise in new situations. It is here that the basic sciences have an important role to play as they can help the student to acquire a scientific method of inquiry. Such an approach is essential to keep knowledge and skills up to date. The fact that the graduate will have to replace much of what he knows is the least part of the problem; the main difficulty is that we, the teachers, do not know which half.
9. To develop problem-solving skills
The teacher should facilitate students' learning by asking questions requiring problem-solving skills rather than simple recall of facts. Even the most traditional teacher will agree that students must acquire basic skills, either manual (e.g. inserting an intravenous drip) or intellectual (e.g. taking a history), should behave in an appropriate manner with the patient and his family, and should not merely possess theoretical knowledge.
In spite of this, whenever the final examinations used in faculties and schools are analysed, it is found that a majority of the questions test only simple recall and not the intellectual skill of interpreting data and solving problems. No attempt is made to measure practical skills and attitudes. The fact that most examinations require students to recall facts without recourse to books is highly significant. Of course, health personnel must possess a large amount of knowledge that they can call upon without reference to books, otherwise their usefulness in an emergency situation would be seriously impaired.
Teachers should therefore test students on their ability to recall those facts that will be needed immediately in emergencies and have been clearly specified as such from the start. Apart from this, examinations should confront students with typical individual or community health problems and allow them access to books, in accordance with the sound practice adopted in everyday professional life.
10. To aid the understanding of basic scientific principles
The teacher should endeavour to ensure that students understand the basic principles underlying the activities and tasks they are learning to master. Factual details can be readily added to an understanding of basic principles and concepts, but such principles are not easily derived from a mass of facts. Students usually learn the so-called basic sciences early in the curriculum before they have met the real-life problems which require an understanding of those subjects. They are thus poorly motivated and soon forget what they have learned. It has repeatedly been found that students tested 18 to 24 months after having followed a basic sciences course answered at random, just as if they had never studied the subject.
11. To supervise the student's progress
The teacher should check each step the student takes in solving health problems in order to discover the areas where he fails to take account of the relevant basic scientific principles. This role follows naturally from the previous one. As mentioned above, in the traditional curriculum, students are taught basic sciences in the first two or three years. Ideally, a student should be helped to reach an acceptable solution to problems through his understanding of the principles of the basic sciences and by adopting a scientific approach. One of the persons best qualified to judge whether the student is thinking in a scientific manner is the basic sciences teacher. In the training of a nurse or of a general practitioner, for example, the role of the basic sciences teacher is not to instruct in a given subject but to ensure that the nurse and the physician are capable of applying basic scientific principles in their daily work.
A physiologist could spend two hours a week in a ward or an outpatient clinic with his students, going through the medical records of current patients to check whether basic principles had been adhered to, and draw the students' attention to unsatisfactory examples. Such an association between basic sciences and clinical activities would be of greater value than the present so-called integrated forms of teaching in which teams or panels of teachers endeavour to teach in a coordinated manner.
12. To identify the factors underlying health problems
The teacher should make sure that the student identifies and takes account of the psychological, cultural and socioeconomic factors underlying the health problems with which he deals.
In practice, there is no natural frontier between the physical sciences and the humanities, nor between sciences and art in the broadest sense of the words. Giving courses in the humanities and the behavioural sciences does not automatically ensure that future health workers will be able to relate their daily activity to the culture to which they belong. They are more likely to do so if they are required in practice to define the patient's social and psychological problems in relation to his health problems, and to seek solutions, with the help of suitable specialists.
13. To encourage intellectual discipline
The teacher should encourage intellectual discipline by observing students' work and evaluating their activities in relation to defined standards of quality of care.
Both teachers and students pass much time, more or less usefully, in large lecture halls. A better distribution and use of teachers' time, and the practice of peer-teaching to enliven the course, could improve both the quantity and the quality of the instruction given and allow for more individualized supervision.
The quality and satisfactory performance of learning should be the only yardstick or criterion used by the teacher, to the exclusion of the time constant (“the duration of the curriculum is six academic years”). What should vary is the number of different types of task that any given kind of health professional can perform. Every member of the health team, and the physician most of all, is a potent therapeutic agent but a poorly tested one. The least toxic medication listed in The International Pharmacopoeia has undergone more thorough double-blind testing than any health professional anywhere, at any time. Cigarettes are sold with a printed health warning. Does not the university have a social duty to protect all citizens from the potential danger that physicians and the other members of the health team may represent?
14. To set an example
Finally, the teacher should serve as a model of professional conscientiousness, reliability, analytical sense and efficiency. We have all met such people in the course of our studies. We have also met the other kind. We tried to imitate the former and sometimes despised the latter. In connection with students' values and personality, the following quotation from the American Association of Medical Colleges Longitudinal Study, reported by E.B. Hutchins (1964), should be remembered. Describing the effects on students of their years of study, Hutchins says “... the interest in understanding how others feel about problems or the need to place one's self in another's shoes ... has, on the average, decreased”. To a potential patient, this statement is very disturbing. If it reflects a widespread reality, the cause could lie in the example that has been set.
Nostalgic remarks are often heard about the good old days before professional educators had begun to invade the educational black box. One could then lecture and enjoy the feeling of satisfaction any good teacher has the right to expect. Nowadays, teaching is somewhat more complex, especially if the idea is accepted that it should be for the benefit of the learner and not only for the satisfaction of the teacher. Some teachers have already undertaken some of the functions described in this paper. They may feel satisfied even if they fulfil only a few, as the present educational environment is of no great help to their efforts in that direction. The conclusion must be that, despite all that has been achieved in the field of teacher training, much still remains to be done. Some have more gift for teaching than others, but all have the possibility of improving their performance by training as educators, even though such courses are still too seldom sought after and too seldom available.
How many teachers are really prepared to have students reach conclusions different from their own, giving first consideration to the logic of reasoning rather than the ability to arrive at a predetermined solution?
The student body represents the largest untapped educational resource in most schools.
G.E. Miller (1977)
Read, or reread, carefully the description of the teacher's function (pp. 3.31-3.35) and circle the numbers of those that you believe yourself able to perform in your present situation taking into account the university regulations and any other local constraints. For each function, describe the precise activities that you personally will be able to start or continue during the 12 months to come.
Description of precise activities for each function