Bringing the classroom and the clinical together


Nursing theorist, author, and legend Prof Patricia Benner opened today’s plenary, clearly announcing what she was set out to do, “It is very tempting to believe that knowing about is better than knowing how. I’m here to convince you otherwise.”


Prof Benner, Professor Emerita at the University of California’s School of Nursing, continued, “Education is a place for practice and not just a place to stamp theories on to students. Don’t only show them the map – bring them through the journey.” 

In a real clinical situation, those involved need to be able to recognise a rapidly changing situation, and quickly identify the priorities in an unstructured scenario.


This is where critical thinking comes in – where the healthcare professional can stand outside the situation and look at it objectively, deconstructing the problem into its elements.


That is in an ideal world, or maybe a simulated medical scenario. Prof Benner said, “Critical thinking is necessary but not sufficient. We can't be always standing outside like an observer because in reality we are engaged in the clinical situation.”


“However,” she continued, “Such critical thinking is needed in system redesign. It’s needed to find answers for a novel problem or a recurring one with no good answer.”


It is clear that educators need to bring as much real experience for the trainees.


Hence the need to integrate classroom learning with the clinical. Prof Benner concluded, “This is essential for deeper learning that your students will forever be grateful to you for.”

Trainees as teachers – why?


What we usually think about teaching is that the person with much more experience and practice hours is the better teacher: the senior professional who has been in the hospital for years is the best one. But anyone can be a teacher, including those still in training.

At the Conference, Dr Cristelle Chow, Associate Consultant at KK Women’s and Children’s Hospital, introduced the concept of near-peer teaching.


This is where a trainee who is slightly more knowledgeable teaches his peer who will be going through the same assessment he has just gone through – a first year resident teaching a soon-to-graduate medical student, a second year resident teaching a first year resident.


Dr Chow explained the benefits, “Studies find that compared to traditional teaching by the professor, trainee teachers gives a better learning experience and the students they teach gain more similar levels of knowledge.


“They can empathise better with their peer and puts lower pressure, anticipate learning needs better based on their recent experience, and also provides inspiration and confidence to succeed – providing a role model.


Dr Chow added, “Any health professional in this room can attest that the way our role models behave influences our career choices and behavior later on.


Information provider, facilitator, role model. These are the roles that near-peer teachers can fulfill in bridging the gap between the professor and the student, complimenting the roles of the faculty in assessment, planning, and resource development.


Managing stress in simulation training 


The use of simulation in medical education is essential in teaching clinical skills and assessing how individuals and teams perform in a clinical scenario. However, simulation-based education (SBE) can be stressful for the learners.


Existing theory holds that stress helps improve performance to a degree. Dr Bong Choon Loi, Senior Consultant, KK Women's and Children's Hospital, set out to prove if this is true in clinical settings and if it is, how much stress is needed for optimal performance. 


She and her team measured physiological stress responses (heart rate, salivary cortisol level) of participants of a medical simulation.


Not surprisingly, individuals in the simulation group had increased stress responses, although interestingly the tutorial based had a decrease.


Even with repeated scenarios, the physiological responses remain the same, showing no blunting of the effects of stress on repeat performances. 


However, after repeated scenarios, the self-reported stress level decreased.


Studies have also found that a moderate degree of stress can improve memory retention and help learners engage better. 


Even with the benefits, simulation produces a degree of overshoot compared to a real clinical event. A study noticed three times the cortisol level in a simulation versus a real situation. Another showed that non-technical performance is not necessarily improved by repeated simulation exercises.


Dr Bong reflected, "Some degree of stress is beneficial. But we may be making simulation based education more stressful than it needs to be."


Collaborative practice in healthcare


Professor Susan Baptiste has seen inter professional practice evolve. As an experienced occupational therapist, her work has brought her within close collaborative circles of healthcare professionals with the aim of providing best care for her patients.


“I loved the sense of pride of belonging to something that made a difference. But on the other hand I also had colleagues who were just being told what to do, even if they knew they were right.” The Professor at the School of Rehabilitative Science at McMaster University recalls.


Thankfully, those times have changed. Our healthcare system has matured into one that values collaborative practice and its impact on patience care.


Gone are the times when the entire team looks to the advice of one expert to make decisions.


“No one profession can address the complex needs of our clients. It’s very important that we learn about each other, and know what we all do,” she said.


“We’ve grown our professions for a reason. We now need to spend time to be versed in what our colleagues do and to value their contributions.”


To that end, Prof Baptiste believes that the provision of care has evolved from being patient-centered to being client-centered. The core difference is in the way healthcare professionals treat the patient.


In client-centered service, the professionals and patient have honest and open communications in an environment that realises the importance in openness of care. Care given should be integrated with the patient’s own needs, their purpose in life and what it important for them to be involved in their care.


 Backing her up is research pointing to the positive impact on patients who receive client-centered service. They are more receptive to treatment and more compliant to care.


Despite sounding like healthcare professionals having to lose their medical authority over their patients, Prof Baptiste thinks this is the way forward, “We’re in a wonderful place. I look at occupational therapists and physiotherapists and physicians now – able to sit down and discuss complex situations.”


“What we have to do to take the next step is to make it live and breathe instead of having them remain as words on a presentation.”


The role of education research in patient care


“There is absolutely no literature on this,” began Associate Professor Vicki Drury, Academic Advisor with the SingHealth Duke-NUS Ophthalmology and Visual Sciences Academic Clinical Programme (ACP).


While most of the research on education talks about its impact on learners or the organization, its relation to patient care remains unexplored. That, to Prof Drury, is a fantastic opportunity for clinicians in our Academic Medical Centre (AMC) to see how they can continually generate new evidence into the provision of care.


It provokes us to take something we believe is done in the correct way and question its origin and reason. How did we arrive at that conviction? How do we know it’s the right thing to do?


“Sacred cows,” she said. The room laughed, almost uncomfortably. She probed deeper, “traditions are often based on the idolised past, having nothing to do with reality and are not based on evidence.”


To move beyond this, Prof Drury advocates education research. It’s not restricted to just students, she said. In healthcare, it includes any activity related to the provision of care.


“There is scope for all of you as clinicians to be involved.”