Reform of the NHS has systematically eroded medical apprenticeship. The shift from time-served apprenticeship to time-measured training has left doctors in a contradictory positioning: they must adopt approaches to medical training antithetical to their own learning histories and the literature on learning. New forms of work activity, framed as 'faculty developmenf are emerging in response. The policy and practice literatures urge the new faculty development workforce to 'professionalise medical education', signalling a particular type of response, where certain teaching, learning and assessment practices are advocated and accreditation for educational roles is instigated. The medical profession is faced with a choice: to conform or transform? This study draws upon the theoretical tools of Cultural Historical Activity Theory (CHAT) to analyse the medical profession's response (Engestrom, 2001, 2004, 2008 and Daniels 2009). It is argued that responses will be shaped by the biographical, theoretical and conceptual resources faculty developers bring to bear on their activity: in particular the conceptions of learning they hold. Drawing upon and extending Sfard's original work (Sfard 1998), three metaphors for learning (learning-as-acquisition, learning-as-participation and learning-as-expansion) become powerful analytical tools, used as an adjunct to CHAT, in order to trace a range of positions towards the professionalisation of medical education. An analysis of emerging practices across one postgraduate deanery reveals more differentiated responses than those reported in the literatures. Ideal-typical features of the identified conforming, reforming and transforming responses are elaborated and illustrated. This study concludes by arguing that if faculty development is to move beyond 'teaching-the-teachers-toteach', the faculty development community needs to radically re-think its practices and expand the range of resources it draws upon in its work. This means valuing the rich cultural heritage of medical apprenticeship, problematising medical education reform and seeking to establish new ways of developing practice through practice, alongside their medical colleagues

This qualitative study investigates the subject of Clinical Communication and how it is taught, learned and practised in one London Medical School and Hospital. It is informed by theoretical perspectives from workplace learning and in particular the theoretical construct of Recontextualisation. Five clinical communication teachers and five fourth year medical students took part in a series of semi structured interviews and ward observations over a period of four months. Teachers were interviewed about their teaching practice, they were asked to observe students in the clinical workplace and finally were asked to reflect upon whether these observations had informed their teaching practice. Students were interviewed about how they had learned and subsequently practised clinical communication in the clinical workplace. In total fifteen interviews and nine ward observations were carried out and nine reflective accounts were collected. Data from the interviews and observations were analysed using Responsive Interviewing Analysis. Results suggest that teachers wished to develop a more authentic and integrated teaching practice focused on the clinical workplace and wanted to go beyond the traditional notion of clinical communication as 'skills' based only. Students seemed able to apply the clinical communication skills they had been previously taught to the clinical workplace, but the patient centred philosophy underpinning these was lost and was also not reflected in the clinical workplace culture. Conceptually, the research shifts focus to the clinical workplace as the legitimate location for teaching and learning clinical communication and proposes a new and expanded way of understanding learning in this context. Significant implications for discussion are raised about the theoretical stance taken by the clinical communication community of practice and the way in which it understands and articulates fundamental beliefs about clinical communication.

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This is a phenomenological study about problem-based learning (PBL) in medical education. Whilst there are strong arguments for PBL having a key presence in today's undergraduate medical curriculum, there is little empirical evidence to show whether or not students fully engage in the opportunities that advocates of PBL claim it offers. This study was approached from the viewpoint that it is important to establish the students’ interpretation and acceptance of PBL, as they are, in practice, the key protagonists. Eleven in-depth, one-to-one, semi structured interviews with medical students offered the main focus for exploring PBL as a phenomenon, but additional sources of evidence were included; observation of PBL sessions, photographs of student study areas, copies of student note taking, and data on a student's weekly study activity. The students' narratives from the interviews, and additional sources of data, enabled a detailed exploration of PBL. Further analysis of the data took place against the backdrop of literature on PBL. The data suggest that whilst students were identifying some of the opportunities that PBL affords, there were a number of constraints and conflicts which were affecting their learning and that, at times, this was leading to a sense of frustration. This study supported the view of PBL as a pragmatic solution for designers of undergraduate medical education because, within PBL's methodology, it promotes self-directed learning, which can be closely tailored to the programme objectives. However, if the adopted process of PBL leads to an emphasis on participation over that of construction of knowledge, medical students can be left feeling frustrated by PBLs seemingly inefficiency. The findings of this study suggest that PBL can address relevant learning objectives for preparing students to be doctors but its methodology is, at present, not successfully competing against the heavy presence of knowledge based assessments within a medical curriculum.

New medical educators (NMEs) receive less attention in research about transition compared to medical students and junior doctors. While medical students and junior doctors are assumed to be lacking in experience and more prone to making mistakes during transition, NMEs are assumed to be competent doctors because they have accumulated several years of clinical practice experience. The transition of NMEs from clinical practice into a formal teaching role, however, is not straightforward. The aim of this study was to explore doctors’ perceptions of how they negotiated their experience of learning in their transition to the role of medical educator and to study the implications of transitional learning processes for the management of NMEs’ teaching and learning needs, including what factors influenced their learning processes. In this comparative longitudinal qualitative research conducted in Malaysia and the United Kingdom, NMEs were interviewed three times over one year about how they learn how to teach, what they learned during the transition phase and what factors affected their learning processes. The NMEs were found to be developing competencies in three domains; teaching, clinical practice and research. NMEs were teaching medical students without knowing the best way to carry out their teaching roles and responsibilities, and were mostly relying on past experience of learning in medical schools. Factors which supported or hindered the learning processes of the NMEs have been identified and it was found that some of these factors were localised to each country’s context. Interestingly, the same factors could be experienced as either supportive or a hindrance to the learning of NMEs in different contexts. In explaining the learning processes of the NMEs in the workplace, it was found that the theory of Transformative Learning was more useful than the theory of a Community of Practice. The findings from this study have several implications for medical education systems in both countries. It is important that medical education providers acknowledge how NMEs navigate their transition into academia and identify what factors supported their learning, as easing the transition of NMEs into academia had the potential of developing them into excellent medical educators.

Problem-based learning (PBL) has been used extensively in medical education but its educational potential may not be fully realised due to several factors, including the variable interaction between students and tutors. Qassim Medical School (QMS) in Saudi Arabia implemented PBL 10 years ago. Three previous studies evaluating the Qassim curriculum have been published, which together with this researcher’s experience as a student at the same school, identified some difficulties and challenges with the collaborative learning aspect of PBL. A previous pilot study was conducted at QMS in 2010 exploring the integration of facilitated inter-sessional online discussion forums with PBL. The evaluation showed that students and tutors liked the integrated forums, and that the forums helped students to achieve the learning objectives effectively, enhanced collaboration, and increased use of learning resources. Students wanted the forums to be implemented in the other courses. Understanding the challenges and difficulties existing at QMS, the findings of the pilot study of integrated online discussions, and the lack of literature on the integration of the two teaching and learning methodologies have led to the development of the research question: ‘Does use of an inter-sessional facilitated online discussion forum between PBL sessions improve student learning?’ To address the research question, a conceptual model was developed, a training program was conducted, and a mixed-methods approach was applied. Analysis of the posts showed that knowledge construction occurs when discussion fora (DFs) are integrated between PBL sessions; student perception reported in this study validated the pilot study’s findings. This study gives insight for QMS and similar institutions that integration of facilitated DF can enhance students’ knowledge construction, overcome current issues with PBL, and improve student skills such as English writing.

Introduction: E-learning is a familiar feature of health worker education in developed countries and there is interest in its use in developing regions, including sub-Saharan Africa, to overcome health workers’ lack of access to information, learning and professional development opportunities. However, there is limited evidence to guide such developments. The issues are complex, more so due to the size and diversity of sub-Saharan Africa and its health workforce, and rapid technological progress. Objectives: - Understand issues affecting the development and implementation of e-learning for health workers in sub-Saharan Africa. - Develop and pilot an e-learning resource in eye health. - Evaluate its impact on clinical skills. Methods: Qualitative and quantitative methods were used to explore issues including infrastructure, skills, health systems, learners’ needs and preferences related to e-learning design, development and implementation. This was integrated with evidence from a study of patients’ journeys of care to develop a novel e-learning resource in eye health using a quality improvement approach. After piloting, the impact on medical students’ clinical skills was assessed using a ‘low stakes’ Objective Structured Clinical Examination in a randomised trial. Results: A holistic view of the current situation related to e-learning in sub-Saharan Africa was achieved. Piloting of the resource confirmed its broad acceptability and gave recommendations for final refinements and implementation. In the trial setting, students exposed to the resource demonstrated better clinical skills (mean scores: 71.6% and 68.4%, (p=0.048)); pass rate 90.0% vs 64.5% (p = 0.032) with significant improvements for ‘differential diagnosis’ and ‘making a management plan’. Conclusions: E-learning can be successfully applied in sub-Saharan Africa and a quality improvement approach integrating research with resource development is proposed. From this experience, an algorithm for e-learning development is presented.

An educational design research approach (EDR) was adopted to understand what type of feedback is most effective to enhance medical trainees’ diagnostic decision making (DDM) in authentic clinical settings and how this understanding can be used to improve the feedback provided by clinical educators. Research was conducted within the three phases of EDR: 1) preliminary, 2) developmental and 3) assessment. Findings from the preliminary research phase indicated that more structured and specific feedback which focused on self-regulated learning (SRL) and contextual factors would be advantageous for medical trainees. A conceptual model of feedback that incorporated these findings was developed to inform a Personalised Model of Feedback (PFM) intervention in the development phase. Despite a positive response to the PFM intervention, recruitment was poor which highlighted barriers to involving clinical educators in research and training. Six clinical educators used the PFM intervention to provide feedback to their medical trainees after DDM in the authentic clinical setting. Using a mixed methods approach, the assessment phase evaluated participants’ perceptions of the PFM intervention. Participants found the PFM intervention useful, usable and effective for providing feedback on DDM. After participation more feedback was provided on SRL, confidence and the influence of contextual factors on DDM. Clinical educators and medical trainees also had an increased awareness of the influence of contextual factors on DDM. Medical trainees viewed SRL focused feedback as effective and useful for improving DDM and used more SRL skills on hypothetical reasoning cases. This research has added to current research on the use of SRL to provide feedback. It is the first research to specifically address how feedback after DDM can be better provided to medical trainees and shows that the PFM feedback can be given as an add on to feedback usually provided. Further research is necessary to modify the conceptual model and the PFM intervention to improve its ease of use in the authentic clinical setting, its receptivity by clinical educators and to determine whether it leads to an improvement in medical trainees’ DDM.

This study makes an original contribution to the evidence base for service user involvement in the teaching of interpersonal skills. The study is a synthesis of three different types of research activity. Firstly a systematic review which reviews the evidence base for service user involvement in interpersonal skills teaching. This review used inclusion criteria that restricted its scope to research that included elements that used outcomes, either qualitative or quantitative related to mental health service users involvement in teaching interpersonal skills. Four quantitative and eight qualitative studies met the criteria for inclusion. All the quantitative studies were methodologically weak. Qualitative studies lacked clear statements of qualitative methods used. Overall the studies reviewed provided some evidence of the efficacy of service user involvement. Qualitative findings included some negative effects of involvement. The second research approach used was reliability and validity testing of the Observed Assessment of Interpersonal Skills Scale (OAISS) using Factor Analysis and Cronbach’s Alpha. The OAISS is an observational instrument intended to measure an observer’s impression of another’s interpersonal skills during simulated interviews. Two factors were retained that accounted for 34% of the variance within the scale. Internal consistency of the scale was good. Two factors were interpreted to produce subscales called feedback and collaborative reflection and listening. The final study used mixed methods including a quasi-experiment and interview based qualitative data gathering. The quasi-experimental part of the study examined the effects on the student nurses (n = 75) interpersonal skills of a teaching intervention run by mental health service users. The experiment used a pre-test post-test design with a teaching as normal control group compared with the service user-teaching group. No significant difference was found between the two groups on measures of interpersonal skills. Qualitative results indicated that students had been affected by the service user teaching. Evidence was found of changes in empathic responses, attitudes and deep reflection on practice. Some polarization of views was also found particularly regarding the shocking nature of some of the personal accounts used in service user teaching and student concerns related to the representativeness of service users involved in teaching.

In 2004 unexplained pedagogical barriers were limiting Learning Object (LO) development. Few reference points existed preventing the formation of specific pedagogical questions as to the nature of these barriers - hence this PhD's rationale. This thesis 'uncovers' the most effective pedagogical and evaluation/assessment* approaches for LO design in Medical Education, and the underlying principles within these approaches - i.e. what is effective, and why. To determine why certain approaches are effective observation/interview/usability studies were performed using grounded theory to generate hypotheses (1A Participants n=57). To verify 1A findings, this process was replicated using different sites/samples in Phase 2(Eastern/Midlands, n=72). To determine what was most effective, systematic reviews using a purpose-built design were undertaken with additional questions on pedagogy and evaluation/assessment• components (1B Studies n=222). Approaches identified as 'effective' according to statistics, SCIE and my own rigor scoring systems were tested blind in two locations (Eastern/Midlands) with different samples under a null hypothesis (i.e. 'Each approach will score no differently to any other', Phase 2 participants n=72). This was further developed by replicating this process via mobile delivery. Section 1A generated over a hundred hypotheses. In Section 1B, two existing approaches scored consistently high. Phase 2 produced the same hypotheses/approaches when submitted to the blinded observation/interview/usability process thus tight theme linkage resulted in rigorous theory and empirical data. The two top-performing 1B approaches scored high resulting in the possible existence of generic principles. When replicating 1A, 1B and Phase 2 for mobile delivery, the existence of generic principles was verified and a possible model for practice formed. In summary, this thesis underlines the importance of learner input and how learners' perceptions form an essential part of the LO learning process. It discovers original generic principles for both desktop and mobile formats, highlights how branch and loop learning systems are necessary for learner customisation, and provides new knowledge verifying Wiley's molecular LO analogy. *In this thesis many types of evaluation approaches are tested. These are called 'evaluation approaches' by the authors that created them. However, in some disciplines the term 'evaluation' is viewed as being interchangeable with the term 'assessment'. For this reason explanatory footnotes will be given throughout where necessary.