A Personal Perspective on Philosophy of Teaching: The Clinical Learning Environment,Teaching Session and Assessment

Abstract

A clinical educator's job includes having a philosophy on teaching. This involves defining their roles, responsibilities and values within a teaching setting. By exploring the factors that contribute to a philosophy of teaching, teachers can build an approach that might best service the learners. I use my own experience and reflections as an example of how this works in practice. The utilisation of environment within the context of various teaching modalities becomes a key contributing factor in this. Unfortunately, specifically designed spaces are often in short supply. Environment means much more than just the physical space and also encompasses the psychological safety of the learner and how the educator can foster a culture to accommodate this. By gaining an understanding of the impact of space on the learner, changes can be made that better utilise space in education. I also explore other features of my philosophy including structuring sessions and utilisation of assessments. It is important to correctly utilise formative and summative assessments; acknowledging evidence of a recent shift towards greater use of formative assessments. Previous literature on constructive alignment of education, from grass-roots through on-the-ward teaching and up to modular learning objectives demonstrates the necessity for consideration of the bigger picture. A ‘bigger picture’ perspective allows oversight to ensure decision-making is aligned through all levels of the education structure. Through this evaluation of my experience, I hope to highlight the need for a teacher or teaching organisation to identify and define its teaching philosophy. As well as highlighting the need for this, my reflections should provide a few pillars upon which an individual philosophy of teaching can be built, and justify why they are crucial foundations through evaluation of relevant literature.

Introduction to a Personal Teaching Philosophy

Defining the clinical educator appears to be the key to defining an individuals’ philosophy of teaching. This includes establishing their roles and responsibilities. The themes that define my philosophy of teaching appear to be: the learning environment, the teaching session and its structure, and the attitude to assessment within the teaching environment.

By focussing on these three key pillars that define my philosophy of teaching, I hope to lay out my philosophy while exploring these topics and justifying the necessity for individuals and organisations to develop their own philosophy on teaching.

Examples and case studies have proven useful as a framework upon which to explore these aspects of my philosophy of teaching. Building upon these cases, I review the surrounding literature and discuss why they are relevant cornerstones to one's teaching philosophy and how they might shape this.

I hope to map out clearly my philosophy of teaching through reflection on my past experiences and how they have shaped why and how I teach. Alongside this, recognising my weaknesses as a teacher and where I hope to go with my progression as an educator.

Clinical Learning Environment

Introduction

A clinical learning environment has been defined before with some variation.^1,2 However, there appear to be common threads on the components of the learning environment. These include the physical and virtual space, the social and psychological context, and the organisational structure and culture.

This environment plays an important role in the experience and engagement of the learner. The days of predominantly lecture-based teaching programmes reflecting the didactic nature of teachers have long gone. The inability to engage and interact in this setting is just one of many hurdles formed by this approach. Importantly, the setting can and should be chosen in line with the objectives for the session; the skills gained in a simulation can greatly aid the understanding of how an acute exacerbation of asthma is managed in an acute setting but is unlikely to facilitate the learning of renal pathology. Both are examples of important areas to understand, however different learning environments and modalities would be optimal in each case.

It was important for me to understand my role in relation to the learning environment. This felt important as an educator so as to explore what was or was not within my control. I discuss predominantly the influence I can have on the space and context components of the environment. I have a larger influence over these, as someone delivering teaching directly to students. An understanding of the organisational structure, including the objectives across the module, year and course, allows me to deliver teaching that assists in meeting students expectations and targets. This is an important concept known as congruent alignment, discussed later on in the context of assessment.

In trying to define and discuss my clinical learning environment, I think it's important to answer a few questions over the next few pages. Firstly, and most simply, what does my clinical learning environment consist of and look like. Secondly, to understand my motivation and why that has led to the learning environment I favourably teach in; how do my other roles influence my teaching and visa versa. Finally, I want to know how I could improve any aspect of the clinical learning environment that I create and teach in.

Description

This first case example will explore the physical aspects of one of the learning environments I teach in. The doctors' office in the emergency department does not offer the most ideal setting for conducting teaching. It has four computers within 10 m squared of floor space and there are plenty of interruptions and distractions. Students often appear anxious, reporting they don’t want to get in people's way while they wait for learning opportunities. Optimising the space in an emergency department is difficult and opportunism is often the name of the game.

Therefore, I take students to an empty side room to avoid the distractions of working doctors. Students have reported gratitude towards on-the-job learning that is free from distraction. The reflections on perceiving learning in terms of Maslow's hierarchy of needs ³ have made me consider the need to put more effort into prioritising the physical environment. Maslow groups psychological safety factors as the second most important need, behind our basic physiological needs (food, water, sleep etc) in his hierarchy. Without a secure base within a clinical environment, and without some level of psychological security from chastisement of staff busily carrying out jobs, an otherwise excellent teaching environment is undermined. This subsequently compromises the learning opportunity.

The emergency department above is an excellent example of a learning environment that is often overlooked, yet has a high level of discrepancy in quality.^4,5 It is by its nature sporadic, unstructured and, due to the fast-paced nature of the patient flow, will sometimes yield minimal learning opportunities. However, it is real-life, practical and engaging. The role of setting a teaching plan and environment that identifies the needs of the student can therefore be missed. As a result of this, I have learned to establish two things with students: firstly, why I think the chosen topic of teaching is relevant and ask their opinion on its utility; secondly, what we can hope to cover in the session and what we won’t cover.

Aside from the physical aspects of a learning environment, fostering a culture of friendliness, inquisitiveness and support is not something I have found hard. Due to insecurities about my knowledge base, what is sometimes more challenging is admission of ignorance – to which I have now found the simplest solution is to co-enquire.

What prevents me from optimising the learning environment in this setting? We’ve discussed physical space, sometimes a lack of time. Where does this come from? Ultimately, the increased workload on doctors within the National Health Service (NHS) is increasing and this inevitably impacts on the quality and quantity of teaching that can be given to junior doctors, let alone medical students. Setting a precedent for low expectations going into further career training is likely to have the same poor outcomes on patient care, learning and burnout as demonstrated in studies on a poor clinical learning environment.^2,6

So how can these be overcome, or if not, best managed? Exploring an alternative approach in an alternative setting helps to explore this. In a more controlled environment on the ward, having a planned structure for delivering teaching in clinical settings is helpful. My first consideration is setting out to students what they could do to be involved, without detriment to patient care. This opportunity often gets missed on ward rounds, where medical students stand in the corner and observe instead of being observed. By establishing these opportunities with medical students, you start to fulfil the role of facilitator of learning.

The next step is to discuss what was done well and not so well and to discuss the clinical aspects of the case. However, as I often have to document at this point, I take the chance to direct the students towards learning resources to read around the subject area. This seems to be in keeping with encouraging autonomy of students to direct their own learning.

We can then discuss the practicalities of managing the condition diagnosed or the other differentials. This allows me to impart knowledge based off my experience that may be hard to gain from a book. This is hopefully relevant to the student as my reflection of working in paediatrics at a junior level may offer insight that wouldn’t otherwise be obtainable from studying alone.

This whole approach enables students to be able to have more autonomy in seeing patients by themselves where they can fulfil the whole role of a junior doctor with closer supervision.

Discussion

Both the ad-hoc teaching in the emergency department and the structured session on the ward are learning opportunities and they both have pros and cons; On one end of the balance is a controlled learning environment where the correct knowledge can be curated and transferred to precisely match the required objectives. However, this lacks the real-world application that can be found by the opposing experience. It appears the cost of one, is the other.

The last question is what can I do better to improve this: The first and most important, according to Maslow's hierarchy of needs, is ensuring that if substantial discussion for learning purpose is going to take place then to find an appropriate physical environment. Preferably one that will avoid distraction and noise and allow full concentration. Some of these revelations came about through reflecting on a teaching session delivered in this setting (Figure 1). Given there was no opportunity to plan this session as rigorously as a timetabled teaching session, reflecting was more important, as there was no structure or benchmark to meet. Reflecting allowed me simply to understand how the teaching I delivered could be improved.

Figure 1.

Reflections after spontaneous teaching session.

There are certainly more opportunities to give students the chance to lead clerking or ward rounds. When this isn’t suitable, I think it's important to explain to students why you want or need to do something yourself.

The next improvement is following this up. Ensuring that I’ve directed students towards written resources to further follow-up their knowledge is vital for ensuring consolidation of knowledge and my next step is to build up a bank of resources for students.

Conclusion

In summary, this discussion about the clinical learning environment has explored how different environments may have different benefits to learning. Alongside this, the approach required will therefore differ. An understanding of the limitations and potential benefits of each environment allows a structure to teaching that best harnesses that potential.

Teaching Session

Introduction

Closely linked to the setting, is the other teaching tools employed. Those that I have utilised have been based on my experience and what I understand to be effective teaching techniques. However, moving forward, I want to ensure that I understand the evidence base behind teaching techniques and methods. I hope this enables me to ensure I’m delivering effective teaching across the board, not just to those who learn in a similar way to me.

There are many aspects of what makes good teaching exactly that. Ultimately, teaching quality is linked to the intended outcome, to impart knowledge effectively. How this is achieved is dependent on the nature of the knowledge to be imparted, the resources available and the individuals involved. To explore this through a case study I have chosen to focus on a few areas.

Firstly, the structuring of a teaching session is very important for a number of reasons. It ensures that the crucial features of a teaching session aren’t missed. These include outlining learning objectives, learning activities and summarising the key learning points. I provide an example of how I planned my teaching session, in order to mitigate the risk of drifting away from intended learning outcomes in the session as well as sticking to a structure that ensured an appropriate time scale for delivering the teaching (Figure 2).

Figure 2.

Written lesson plan for paediatric history taking.

A well-planned structure ensures the attention of students is kept throughout. Studies have shown that the attention of students can rarely be maintained beyond thirty minutes.^7,8 I explore some of the ways this can be overcome later. This revelation has proven a vital driving force for the transition in attitudes towards teaching, reflected in the development of new classical learning theories chronologically arising throughout the late 20th century. ⁹ Behaviourism considered that the primary driver of learning was the response of the learner to an external stimulus, directed by internal or external motivation. Cognitivism then sought to understand learning through the evolving knowledge of the parts involved – sensation, short- and long-term memory, and executive processing. Evolution of both these theories, collectively known as objectivisim, lead to constructivism. Constructivism looked at internal experience of the learner as synonymous with building knowledge. With this framework, learning is intrinsically motivated, and the environment required is one that allows exploration and discovery of the learner autonomously.

Through this case study, I explore how my own teaching fits into the changes that we have observed in teaching practice over recent decades. I aim to consider how various teaching theories can be effective in different settings and with differing aims. An understanding of the classical teaching theories and how they developed helps to aid teaching by ensuring teachers reflect on their roles as a teacher and understand how best they can use those roles to best support student learning. ¹⁰

One factor that may affect the context of the teaching to be delivered would be students’ own expectations and previous experiences as well as their perception of teaching and the relevance of their “learning style.” I explore how I tackle this and my personal outlook on this.

Description

To give a clear description of what the teaching session consisted of seems vital before exploring my reflections and learnings from it. This includes description of the physical location, the content and nature of the learning delivered, alongside the teaching theories and techniques deployed therein.

The teaching session that I have chosen to use as my case study was the introductory classroom teaching session given to medical students on their first day of paediatric placement. The aim of the teaching session was to provide students with a basis in the theory behind taking a paediatric history and provide them with the information required to develop the skill.

Working our way through some of the logistics of the teaching session; We were in the playroom on the ward, comfortable and largely undisturbed. We also had a table and appropriate space to be able to interact. We were positioned in an appropriate way around a circular table to allow eye contact between all three of us which provided a seemingly flattened hierarchy. ¹¹

As per the guide by McKimm, ¹² I started by defining my learning objectives, outlining the overall aims for the teaching session. In my notes (Figure 2) I have failed to use clear verbs, however, I knew what my interpretation of these shorthand notes was and I realised that it was important to communicate this. The objectives were as [SMART] ¹² as they could be. They were specific, although not largely measurable. Objectives were definitely achievable and relevant; it could clearly be inferred that the timescale for achieving the objectives was either the end of the teaching session or the end of the placement.

Within the introduction, the importance of paediatric history taking was discussed. This was a two-way discussion, engaging students to consider why this skill was important. This is a process commonly known as scaffolding. ¹³ There was generally a good consensus on many points but I was able to add some statistics and evidence to support the process. In future this is something I will continue to prepare prior to sessions.

There is often a tendency to presume shared motivation within the healthcare profession. However, it is important to appreciate that with regard to specialty placement, pupils’ interests will dictate the usefulness of teaching to them based on their goals being orientated around competency to practice or to pass exams. Sobral ¹⁴ demonstrated that autonomous (intrinsic) motivation was more strongly correlated with academic success compared with controlled motivation. Herein lies the importance of establishing with a student, what their personal aims and motivations are. This will improve overall engagement in the sessions.

For the remainder of the teaching session, I laid out the structure and the content of each subheading within that structure. Throughout this I provided points of reflection and tips that I had gained from my experience, demonstrating the importance of the role as a “more knowledgeable other.” ¹⁵

The next step was to allow the students to engage in practising this skill. They trialled a scenario that was straightforward. We established that the aim of this was to familiarise students with the structure of the history and the new components.

Before concluding I spoke to the students about how best to use their time on placement and where their learning opportunities for history taking and examination would be. This is a recently developed and hugely important aspect of my teaching, signposting students and empowering them to take control of their own learning.

We took a moment's break at this point before moving on to examination teaching. This gave the students a chance to refresh their attention and consolidate what they had learnt before moving on to a new topic.

Reflections and feedback

I discussed the teaching session with an observer who had several key points I’m going to discuss as well as many other points of improvement (Figure 3).

Figure 3.

Personal reflections and written feedback based on discussion with an observer.

We discussed the use of questions in teaching. The advice I received was that I used questions effectively when introducing a question. This both maintains interaction and interest as well as establishes prior knowledge. However, where I could develop this would be to use questions to re-cap and therefore solidify knowledge. The other suggestion was made to encourage students to write in a way that encourages sharing and discussion such as using post-it notes to write opinions or list knowledge of a topic which can then be added to or discussed.

We also discussed the use of feedback as a teaching tool. It was suggested to me that phrasing feedback as a question increases a student's self-efficacy and insight into their knowledge and skills. This also provides an opportunity for students to explain why they did something or thought something and therefore any underlying misconceptions can be discussed or challenged if necessary.

Discussion

I have begun to consider how my approach to teaching can be related to the classical learning theories. This has highlighted to me that the way we teach rarely fits within the parameters of a single theory or approach. Pat Guild discusses that “no teaching theory is a panacea” ¹⁶ and on reflection I have come to realise we constantly flow between them, adapting pedagogical approach depending on the circumstance and the student; teaching ability and style develop with insight into when to utilise different teaching styles and approaches.

Linking teaching theories to instructional theory demonstrated a slight delay with the introduction of elaboration theory and linking theory. ¹⁷ Both are forms of instructional theory; elaboration theory being based on instructing people to teach and not just to learn. Linking theory connects the learning theory to the educational goals. These collectively began to help us to understand how the theories being developed can best be utilised to help provide teaching.

Robert Gagne described his framework for instructional design in his 1985 book conditions of learning, ¹⁸ discussing the crucial stages of delivering instruction. These steps can be summarised as the process of establishing prior knowledge, engaging the learner in content that builds thereon in the appropriate manner, and providing feedback to aid that process.

I’ve begun to consider this a bridging between cognitivism and constructivism theories. The pivotal point becomes the autonomy of the student to direct their learning. I believe that gauging the self-awareness and autonomy of the learner becomes one of the most crucial factors in determining the teaching style utilised.

Tennyson and Rasch ¹⁹ provide a parallel framework exploring specifics of the intended learning outcomes and the “cognitive subsystem”. This is divided into declarative knowledge, procedural knowledge, contextual knowledge, differentiation/integration and construction. This was a new way for me to consider approaching how I teach with specific considerations on how best to teach for the desired purpose.

To evaluate this in the context of my case study, one of the objectives was “To know the relevant titles in the structure of a paediatric clerking”. This can be considered declarative knowledge, the didactic approach taken was appropriate and the subsequent time efficiency allowed more time for later activities. However, linking to prior knowledge is more characteristic of the utilisation of constructivism. This highlights yet again the spectrum from behaviourism through cognitivism to constructivism. In the above example, an overlap occurred. The feeding of information with the intention of students being able to employ that when taking a history was very much in keeping with a behaviourist framework. However linking to prior knowledge and building upon that is an example of constructivist theory being deployed.

To improve in my utilisation of this, I could have used questions at the end of each topic covered. This engages students and utilises “rehearsal” in repetition of recently processed information in short-term memory. This elaborate rehearsal contributes to transferring the information to long-term memory. ²⁰ My use of questions to establish prior knowledge and engage students has already been verified in settings such as online lectures. ²¹

The taking of history itself can be considered a skill. As such I think it is important to consider the skill from two aspects, both as procedural knowledge and as contextual knowledge. The use of the appropriate generic questions under each heading, asked in a sensitive and appropriate manner is procedural. There is little variation in the requirement of these questions, and therefore the aim of the role-play scenario was in establishing procedural skill by utilising deliberate practice. By simplifying the scenario, students were able to minimise attention applied to the clinical situation and assign more attention to working through the headings of a paediatric history. The aim of this was to familiarise the headings and structure of a paediatric history.

This in turn allows contextual skill to be applied. The mastery of clinical history taking comes with this skill set. As laid out by Tennyson and Rasch, ¹⁹ this requires problem-oriented strategies that deploy a wide range of knowledge in a wide range of situations. This was not within the scope of this teaching session. However, in my role as a provider of resources, ²² I discussed with students where the opportunities to develop this skill lay in their placement.

The adoption of a wider range of learning techniques was a huge feedback point from the teaching. I had outlined a scenario that introduces learning through a different sensory learning style. The concept of “a learning style” dates as far back to Aristotle in 334 BC. ²³ This has conceived the belief that every individual learns best within one of these styles. ²⁴ Research since has disputed this ²⁵ and shown that, in fact, the effectiveness of a learning style is determined by how appropriate it is with regards to the nature of what is being learnt and not to the individual receiving the teaching. ²⁶

Given that history is a spoken and listening process, it follows that the teaching style that would be most effective in teaching it would be auditory. Use of visual techniques is often primarily helpful. ²⁶ Therefore, moving forward I will adopt the use of post-it notes to get students to write notes with specific tasks assigned. Although this seems like a strategy not best applied to adult learners, direction with a specific aim during a focussed teaching session to assist engagement does not seem detrimental.

Discussions around the difference in approach to adult learners have long stood as topic of debate. Although theories by Knowles ²⁷ and Cooper ²⁸ have suggested that adults rely on different roles of their teacher, a lot of the teaching provided to medical students is of new material. Therefore a focus on how best to communicate and facilitate learning appears more significant than modifying other strategies due to the age of the students. These medical students will also vary in age and level of independence.

Conclusion

In conclusion, the greatest takeaways from analysing this case study have been to utilise a structure in designing a lesson plan. This should focus on the anticipated previous knowledge, the nature of the learning objectives and the setting of the teaching. This should dictate the learning styles and instructional design of activities and teaching.

The second point of development was use of activities, designed with the nature of the knowledge acquisition required. These should be spaced out appropriately to tie in with both the material covered at that point and also to engage the students and prevent loss of attention after 25‒30 min.

Assessment

Introduction

The final pillar of my philosophy of teaching to discuss is assessments. Assessments are a key learning tool when used correctly. However, for a prolonged period of my journey in education as a learner, I perceived tests only as competition – with myself or others. I can’t think of many times when educators attempted to challenge or offer an alternative perspective. It took the significant failure of my fourth-year practical exam for me to understand the significance of this. A crushing moment at the time, it flipped a switch; preceding this any test was measured by the mark and its relative position to the line representing an arbitrary pass mark or grade boundary. But now, the feedback and opportunity to learn are the overwhelming focus of my attention when the combined marksheet and feedback are handed over.

Assessments can be considered a vital part of the teaching process. The role of the assessment can often be considered either as a formative or summative assessment. The formative assessment is one that is used to guide the learner, through reflection and feedback, to highlight the areas that they need to improve and to provide learning directly. By contrast, summative assessments are used to evaluate students’ learning, often utilised at the end of a learning block.

In either formative or summative assessment, it is important to ensure that the goals of the assessment match up with the learning objectives and the teaching material covered. ²⁹ This is in the interest of fairness in the case of summative assessments. In the case a formative assessment, it is a matter of maximising learning opportunity as it can be considered to be a part of the learning material. Although there is good evidence for the effectiveness of formative assessment, there are concerns expressed by some over the broad definition used, which makes study and understanding of the topic more challenging. ³⁰ This may explain the observations by Siobhan Leahy and Dylan Wiliam ³¹ that, as well as teacher habit proving a limit to expanded use of formative assessment, there is no clear strategy for expansion of formative assessment to a national scale.

Summative assessments, although not largely the topic of this case study, are also extremely important in their role of quality assurance. ³² Summative assessments play an important role in learning, although arguably more indirectly; through their role in providing extrinsic motivation, summative assessments cause learners to modify their learning aims and behaviours – as demonstrated in studies such as Newble and Jaeger's. ³³ By considering desired learning outcomes, we can design summative assessments to align what the learner does and what the teacher does. With the added considerations of designing learning outcomes and learning environments, this became the premise of Biggs’ theory on constructive alignment. ²⁹ As Biggs explains, constructive alignment is the concept that all aspects and levels of an educational structure are pulling in the same direction, such that learning objectives of a module align with the requirements of the course and any assessment seek to test those learning objectives. Not forgetting that any teaching sessions within that module is aimed to impart knowledge matched to those learning objectives, and the techniques utilised to do so are appropriate and effective at achieving that. Hopefully, you can see how this chain links across multiple levels of the educational structure.

The shift in recent years towards formative assessments has occurred for a number of reasons. Firstly high-stakes summative assessments have been shown to lead to unwarranted anxiety and stress around the assessment process. ³⁴ As discussed above, formative assessments can provide huge learning opportunities provided the learner is open to the feedback provided. ³⁵

Tied inherently to this is the emotional aspect of teaching and the teacher-learner relationship. Schools across the country are filled with students anxiety-ridden due to the thought of learning and testing. Conversations reveal that medical students perceive teachers who ask them questions as “grilling them” and they feel uncomfortable as a result. This provides an insight into the perception of assessment, even in its most informal shape. There must therefore be great benefit in fostering an understanding of the educational benefits of assessments in all forms.

This highlights my final point, understanding the emotional drivers and the objectives of your learners. Understanding that some learners are there primarily to succeed in exams and some to prepare themselves as doctors, with a majority somewhere in between. This means not judging or influencing either, but establishing what the objectives of a teaching session or programme are.

Description

The question starts with a clinical vignette, outlining the role that the student is expected to take on, the setting and the initial details of the case. Most importantly, details of sex, age and presenting complaint are named first, followed by a few salient details and observations.

This was aimed to represent real-life situations where you may have limited information regarding the patient before you see them, but can still start considering your preparation to see them and what differentials you will want to consider.

It is at this point that I have framed a few multiple-choice questions. These test declarative knowledge and can help a student establish if they have a good grasp of the epidemiology, causes, aetiology and management of common conditions. These replicate common exam questions of summative assessments. These questions did not necessarily require all the information provided in order to answer them but the vignette lays the context-rich background for the question and allows students to demonstrate further knowledge in the following questions.

The next questions, as outlined, are more relevant to the scenario and explore the student's ability to think laterally and consider how they might apply knowledge contextually. I explore this in a little more detail lower down.

I have covered common topics in the cases discussed and they have been selected in the interest primarily of helping medical students prepare themselves for life as a junior doctor. While they are expected to demonstrate declarative knowledge, a bulk of marks are aimed at being able to apply to a clinical situation and consider both acute and long-term treatment and investigations for the cases described.

I designed these exam questions and their flow on Microsoft Word (Figure 4). This allowed me to add information throughout, as the learner student manoeuvres through the questions, in much the same way as doctors will receive information and investigation results in a staggered manner. This allows students to begin dealing with psychological phenomenon such as confirmation bias.

Figure 4.

Example of entire question as planned on Microsoft word. Red demarks the correct answer.

I then applied this to a free online test generator (Figures 5 and 6) to present to students who could access this virtually and in a more user-friendly manner.

Figure 5.

Example of assessment multiple choice question.

Figure 6.

Screenshot of assessment written questions.

The final “question” of the assessment simply asks students to list the key learning points from the assessment. This reinforces to students the significance of the assessment as a tool for learning as well as helping to establish autonomy within their learning.

Evaluation

In a study by Duffield and Spencer, ³⁶ half of medical students felt that assessments shouldn’t be used to predict performance as a doctor. We could extrapolate from this that assessments often don’t reflect real life. There is some evidence that medical school exams correlate poorly with professional exam ³⁷ despite the two tests’ independent validity. In this study from the USA, correlation coefficients were used to assess the relationship between scores in a medical school Objective Structured Clinical Examination (OSCE) and a following professional clinical exam. It is hard to understand why this might be, and further research may help to understand the role of confounders, the time lag in this study or remediation. It would, however, be important to establish the effectiveness of summative assessment, in order that change could be affected, or that confidence in the necessity of testing prevailed.

The validity of both summative and formative assessments is important for differing reasons. In summative assessments, validity is important in establishing fairness and assessment of competence for quality assurance purposes. In formative assessments, validity is important to maximise educational impact. As discussed previously, this returns the focus to constructive alignment.

In the case of my assessment, I ensured alignment with the university objectives as well as common presentations to assist preparation for postgraduate work. I did not attempt to weight marks based on learning objectives. Questions were weighted based on the approximate frequency of the presentations in clinical practice. Weighting was considered less important given that the focus is on providing learning opportunity rather than quantifying ability in a fair manner.

One of the limitations of the assessment lies in the fact that I didn’t have control over their university-sanctioned learning objectives or all of their learning material and opportunities given to them. Therefore, although I attempted to align this assessment with the learning needs and opportunities of the students, the decisions about summative assessments and therefore the influence on students learning behaviour were beyond on my control.

Given my intended objective of preparing students for clinical practice, I made it a priority to place questions, even simple MCQs, within the context of a clinical situation in order to encourage critical thinking and provide real-life context.

As discussed by Macleod and Golby ³⁸ learning can lie in the range of situated and overt practice. Situated practice is the learning of a topic buried in social context while the more abstract learning of material, is described as overt practice. Both of these have a place in teaching and together contribute to the transformed practice – the student's ability to transfer knowledge across contextual domains.

I have discussed previously the differing priorities of medical students on clinical placements. Passing exams and preparing for life as a junior doctor are never perfectly congruent and therefore a student chooses where to invest time. My assessment aimed to deliver real-life situations in line with common exam and real-life situations in response to this.

Another consideration of this assessment was what I was attempting to assess. A framework for this is Miller's Pyramid of Competence. ³⁹ Miller describes four areas of competence in terms of their escalating ability to demonstrate expertise in a field.

My assessment focuses on the two steps that look at cognition (cf performance). The first of these areas, referred to by Miller as “Knows,” assesses knowledge and recall of facts through the MCQs at the start of clinical vignettes. The text box questions assessed the next step up in Miller's pyramid, the “Knows how,” looking at how students can interpret knowledge and begin to apply it. Pairing these forms of assessment together was intentionally designed upon consideration of Miller's pyramid. The escalating nature of the pyramid also influenced the structure of the questioning with the text box questions following the MCQs.

The other two areas of Miller's pyramid were not within the scope of this assessment and, particularly the “Does” step, are better assessed with practical assessments. Although the demonstration of knowledge of a skill ('Shows How”) can be assessed through theoretical assessments, it is better assessed in a practical assessment and it makes logical sense to pair this with assessment of the skill being practically applied.

Conclusion

In using the example of my formative assessment of medical students I have explored a number of concepts that are key to the assessment. In doing so I have conclusions to draw from my reflections and also have questions to pose which might provide areas of future research or discussion.

The role of formative and summative assessments are discussed at length and specifically the role of formative assessment in influencing learning. This explains the alternative name for formative assessment as “assessment for learning”, originating from Paul Black and Dylan Wiliam. ⁴⁰ I highlighted that there is a lack of clear definition and this has led to varying associations with learning outcomes. This has helped me identify that a further focus of research on the aspects of formative assessments that are most strongly associated with desired learning outcomes would benefit the ability to design assessments.

I discussed the intended outcomes of my assessment, in its role as a formative assessment. This included clearly defining what I wanted to assess in relation to Miller's pyramid of competence. This provided an opportunity to reflect on the benefit of establishing this before commencing the design of an assessment. An elaboration of this could be to consider how this assessment could expand into assessing other steps of the pyramid or how, when designing a curriculum, one can consider aligning all assessments in a teaching programme to cover all steps of Miller's pyramid.

I discussed the significance and relevance with regard to my assessment and its intended objective. There is an extensive opportunity to further explore this, as a topic in its own right. This case report on my assessment has established that there is a wealth of evidence on the topic that is explored in pre-existing literature. The importance of evidence-based validation of assessment tools is increasingly being recognised.

Final Conclusion and Take Home Messages

A personal philosophy of teaching could take many forms, however mine balances between three key pillars. I hope I have laid out the significance of the learning environment and why consideration should always be given to it. This is not only to ensure a “good” environment but also one that is specific to the needs of the learning.

Similarly with assessment, the unmet potential is huge. Reasons explored among this are the learners’ perception of assessment and the lack of alignment with other objectives.

Most significantly, I hope I have demonstrated through my own example, that the consideration of a personal or organisational teaching philosophy is important. It directs the teacher to consider what is important to them and their teaching and how they might improve. It is essential for improvement within learning.