MED-NET Conference 1997. Rotterdam, the Netherlands.
Proceedings 4.3.

Professionalisation of teachers: An example from the Portuguese situation

M.Patrício (Lisbon, Portugal)

Introduction

The increased need for rationalisation and improved efficiency of medical education means that teaching has to meet higher quality criteria. This includes the need for teachers' professionalisation in addition to their medical, clinical and scientific qualifications.

Professionalisation is generally viewed as a process whereby an occupation increasingly meets the criteria attributed to a profession (1). Two major components must be considered: a descriptive one (which assumes that professions have some particular characteristics that distinguish them from other occupations) and a prescriptive one (meaning what should desirably be  achieved). The concept of teacher professionalisation still seems to need some clarification due to a certain degree of ambiguity. In fact in the past (late 18th and 19th century), professionalisation and occupation had the same meaning. This created a false dichotomy that has lasted to our days, making it necessary to define the characteristics of a true profession. A large sociological debate was then initiated trying to list the common features that differentiate occupation from profession.

Hoyle (1) defines professionalisation in terms of teachers' commitment to the improvement of both status and practice. In this context, professionalisation implies accepting, for example, the existence of criteria for good teaching, accreditation of teachers and the idea of accountability.

Accountability has become a major topic on the educational agenda in the last few years. Teachers "should take the challenge of making themselves accountable and this might be done in part to the development of a professional code of conduct of practice". (2)

The World Summit on Medical Education suggested there is a lack of accountability, and stressed that "many medical schools have no mission statement ....Conceivably, the absence of a mission statement and the presence of nationally mandated curricula create passive institutions which in turn creates passive graduates". (3)

Underlying this debate is the issue of teacher autonomy, a question of being responsible in the sense that teachers are, in fact, the principal agents of teaching (not acting for others), pursuing appropriate goals to achieve a common ideal.

If in a broad sense professionalisation is related to accountability, it would be useful to have a more precise understanding of its translation into practice. In fact many aspects may be considered when speaking about teacher professionalisation.

Some were selected at the "Medische hulpbron Conference" as topics for discussion:

• Education qualification
• Education skills training
• Career development
• Specialisation/differentiation
• Education management
• Educational process evaluation

An enormous variability regarding the degree of achievement of each of these aspects can easily be observed all over the world. In fact each country, or even each institution, lives in a particular situation with specific demands concerning the above-mentioned aspects.

At the first "Medische hulpbron Conference" a debate on Professionalisation was initiated. Focusing the topic of "Education skills training" three case histories - from the United Kingdom, Portugal and the Netherlands - were presented as a starting point to promote a useful discussion that will desirably be continued later on through the "Medische hulpbron Home Page", thus facilitating an open and broad exchange of experiences.

The Portuguese situation: a case history
A global view of the Portuguese situation regarding the aspects referred above, is presented in table 1.

Table 1: Professionalisation of Teachers: the Portuguese Situation

It is important to stress that these selected aspects are not the only ones implicated, and should not be considered independent from each other. Obviously, there are internal connections between them and the only objective of the global picture here presented is to make it easier to understand the Portuguese Situation.

Education qualification:
In Portugal as in many other countries the selection of teachers for medical schools is mainly based on scientific competency (scientific and/or clinical domain) and not on pedagogical competence. One assumes that higher scientific competence means higher qualifications for teaching, which is not always true.

In Portugal, entry into the academic career occurs by invitation, transference or appointment. In fact, candidates may be selected through personal invitation and this possibility could explain the fact that in Portugal, under some circumstances, a Professor is called Invited Professor.  The following quotation, from the Portuguese by-laws on Professorship, confirms that pedagogical competency is still not a requirement: ".....Invited Professors are recruited by invitation amongst national and foreign personalities whose prestige in the area concerned is proved by validated scientific work, or by a scientific CV, as well as by the acknowledgement of the competence of their professional performance" (4).

Education skills training:
Although the literature strongly emphasises that teachers should be prepared for their pedagogical task, in Portugal there is no formal demand for education skills training.

Career development:
Although, as previously mentioned, there are no pedagogical demands for entry into the academic career and skills training, in what regards academic progression the situation is completely different.

In fact for a teacher to be promoted some pedagogical skills are compulsory to approach the different academic career levels as is shown in Fig.1

Figure 1: Pedagogical demands on career progression

From Fig. 1 one understands that some pedagogical demands are needed for academic promotion. Although, as it was shown, the philosophy of some pedagogical demands is underlying the academic career progression, the criteria for assessment are somehow ambiguous for the different steps the candidate must accomplish. Candidates have to make improvements on their own, there being no precise criteria to define the quality to be achieved. In the absence of more specific criteria candidates tend to adapt their performance to the perception they have about the institutional feeling.  They then tend to replicate the perceived institutional model and innovations are deeply pondered by the candidate, who is always very cautious when proposing any  kind of pedagogical change. In fact, candidates seem to feel uncomfortable to propose innovation, since they are always  afraid of the evaluators' perceptions. Candidates believe that the evaluator teachers may consider their innovative pedagogical proposals as a criticism to their own, more traditional, way of teaching.

In this context, in the present time, we may admit that the pedagogical demands of the academic career are not always a tool for progress in   Education.

Specialisation/Differentiation:
No policy exists regarding the pedagogical domain but specialisation/differentiation is compulsory for certain scientific areas, mainly for Clinical Teaching.

In what concerns pedagogical specialisation/differentiation, once again this is up to the candidate, and as it so happens it finishes by being institutionally recognised without being previously established.

Education management:
As for other issues, education management is not the object of a detailed policy at a national level and each university decides on its own rules.

Educational process evaluation:
Two levels can be considered under this topic: individual and institutional. Considering the individual level, as previously stated, staff appraisal underlies the philosophy of the academic career progression but, although there are data available, no precise criteria are defined for evaluation.

As for the institutional level, in 1988, the law on the autonomy of the universities (5) established a system for the evaluation of higher education

In spite of this statute, only now are we really turning to a new stage concerning quality evaluation in Education including concepts adopted from other disciplinary fields like audit, quality control, internal and external evaluation, management etc. Nowadays, a new educational philosophy implies that objectives should be clearly defined and that mechanisms should be introduced for evaluating the institutions' pedagogical quality.

The state of the art in 1997: new trends

In Portugal, as all over the world, there is now a growing awareness that teaching needs to be conceived as a professional activity.

Several reports at an international (3,6-7) and national level (8) recommend important steps to be achieved in order to implement the specialisation of medical teachers. Some quotations from these reports point to the actual trends on Medical Education:

"... the need for teachers trained as educators "(3)
"... to establish a system to evaluate the quality of teaching of all medical faculties"(6)
"... medical schools should institute programs to enhance the teaching expertise of their staff". (7)
"... justifiable concern that the poor learning habits of medical students are frequently associated with the lack of educational expertise in their teachers..(7)
"... to establish in each Faculty a Department of Medical Education as an institutional board for the co-ordination and evaluation of programmes and assessment methods. This Department should also promote the Education and Evaluation of the teaching staff. (8)

Each institution is, therefore, more or less compromised with this obvious demand. Autonomy and freedom in programming the improvement of the quality of education allows the different Faculties to establish their own priorities.

Recent developments at the Lisbon Faculty of Medicine of Lisbon (FML) - one of the five medical schools in Portugal - have led to the creation of the Department of Medical Education in 1993, which endeavours to develop the expertise of health professionals and particularly the faculty involved in education. With this aim several actions have been undertaken in order to improve teaching quality.

A pedagogical experience in education skills training - the "Master's Course in Medical Education" - which is probably the paradigm of the educational activity of this Department - is described in this paper.

"Master's Course in Medical Education" - an example on "Education Skills Training" at the FML.

Pursuing the recommendations of the World Federation of Medical Education, in order to ascribe responsibility to Medical Schools for the improvement of the educational knowledge of their teaching staff, the Department of Medical Education (FML), organised the "1st Master's Course in Medical Education" in collaboration with the University of Wales, College of Medicine.

The course lasts for four semesters (October 95 - October 97) with a curricular part - taught course - (first two semesters) - and the elaboration/presentation of a Master Dissertation (two last semesters). The taught component of the Master's Course is based on the Diploma in Medical Education run in Cardiff since 1988. Some modifications have been introduced to meet the Portuguese needs.

Course Outline:
Aim
To improve health professionals' skills and knowledge.

Objectives
At the end of the course participants should be able to:
- demonstrate an understanding of educational theories, methods and practices
- acquire the skills required to design, lead, manage and evaluate courses and curricula
- choose and evaluate methods of student assessment
- demonstrate an improvement in their real practical teaching skills
- appreciate and evaluate innovations in medical education
- assess the educational needs of students, courses and institutions

Structure
The taught course has been organised into 9 modules including a taught component, an independent study component and a synthesis component. (Fig.2)

Figure 2: modular structure M1 = 1st module; M2 = 2nd module; M3 = 3rd module

The students attend at the beginning of each module a concentrated 1-3 day period of taught course, followed by approximately 2 months of independent study and completed by a synthesis session, which is already part of the following module. Thus the period between modules will allow time for:

• reflection on the most recent module
• completion of the set assignment
• work on "course journal"

Content of the modules
The following themes are sequentially approached in the nine modules:

• Introduction and overview
• Teaching and learning
• Teaching techniques
• Educational media
• Research skills
• Curriculum design and development
• Assessing students
• Evaluating courses
• Educational change

Teaching Methods
Instructional methods will include group discussions, tutorials, instructor centred presentations and individual study. The period of independent study allows time for reading and project work.

A significant part of the course outline is drawn on the valuable resource of experience of each participant. Each module defines goals and sets aims. In addition, students are encouraged to set their own aims for the module and focus their independent study around them. The modules have been specifically designed to allow each participant the flexibility to meet his/her individual needs.

Assessment
Students are continuously assessed based on the taught block and the independent study. Assignments, Practical Teaching Assessment and the Course Journal are components for the students' assessment.

• Assignments: Students are asked to make 6 written assignments related to the content of the different modules (some modules are grouped for a common assignment). Only 5 will count towards the Diploma: the first one, undertaken as part of the first module, aims to provide students with an opportunity to experience the type of work needed for the course.
• Practical Teaching Assignment: Students are required to work in small groups (5 persons) to plan and deliver a one day course on Medical Education to other medical professionals (actively involved in teaching).
  Participants of this courses on Medical Education (maximum 20 per course) attend the course not knowing that the performance of the teachers (students of the Master's Course) is being assessed.

The students have:

• to choose an educational subject for the course
• to prepare a written justification for the course design and teaching methods used based on practical constraints and educational theory
• to deliver the course (every student has to take a fair share of the teaching)
• to submit a written evaluation for the course

Master students' performances are observed by Portuguese and British examiners.

• Course Journal: Students are expected to maintain a record of their observations, reflections and practical applications of the taught course. The journal offers an opportunity to share their learning reflections with the local course tutor on an individual level.

Course Evaluation
Each module is subjected to a written evaluation as well as an oral reflection on the teaching/learning process. Apart from this modular evaluation, three semi-structured interviews are set along the period of the taught course to give students the opportunity to better express their feelings: a 1st interview - before the beginning of the course; a 2nd interview - after the first 5 modules (at half-time of the taught course), and 3rd interview - after the Practical Teaching Assignment, at the end of the taught course.

Audience
A maximum of 20 participants, medical graduated and currently involved in teaching as a professional activity.

Course Language
With two exceptions - the Course Journal and the Practical Teaching Assignment, all the course is run in English and this explains that fluency in English is one of the criteria for admission

Fees
Each participant has to pay an amount of £2,000. A grant of £500 is attributed by the Department of Medical Education to the participants from the FML.

Venue
The course takes place at the FML.

Master's Course on Medical Education: first year of experience

After this brief presentation of the design of the Master Course, we will describe how the course has been experienced during its first year.

Twenty students have been selected from the teaching staff of the five Portuguese medical schools. A great majority (17) were enrolled from the FML as one of the criteria was to give priority for those from our own university to improve our teaching. From the remaining, 2 came from another University of Lisbon and 1 came from Oporto.

Surprisingly, 14 were senior teachers (13 Professors and 1 Full Professor). In fact, when planning the course, we did not expect that such a long effort (two years of hard work) and such an expensive course (£2,000) could appeal to people placed at the top of our Faculty's hierarchy.

Several disciplines were represented: Paediatrics (4), Surgery (2), Public Health (2), Internal Medicine (2), Anaesthesiology (1), Psychiatry (1), Microbiology (2), Rehabilitation Medicine (1), General Practice (1), Anatomy (1) Obstetrics and Gynaecology (1), Health management (1), Biochemistry (1).

As the background of the course was based on individual experience as well as on the definition of personal goals, it is easy to imagine how important the contribution of those experienced senior teachers coming from such different fields has been for the liveliness and dynamics of the course. Those teachers were indeed acknowledging that they have a long way to go as far as Education skills are concerned.

After 12 months, an evaluation on the perceived impact of the course was undertaken based on three components:
a) initial expectations (stated before beginning the course)
b) written module evaluation (after each module)
c) interim interviews (after the first 12 months)

a) Initial expectations
From the first semi-structure interview (before the course started) the following themes were identified through content analysis: (Fig.3)
Figure 3: Master course in medical education: students' initial expectations

"... Improve teaching" (18) - mentioned they wanted to access/improve and reflect on their own teaching practice
"... Increase knowledge" (6) - desired to have a better understanding of updated educational knowledge in order to establish a theoretical basis
"... Little training" (6) - felt they had little or no education for teaching
"... Preparation for structural reforms" (5) - hoping the course could contribute to an improved response to the current demands placed by the teaching reformation at the FML
"... Influencing departmental changes" (4) - hoping to influence others in their Department
"... Course content" (1) and " Course style" (2) motivated by the process of the course
"... Reflection with colleagues" (2) - viewed the opportunity to share their experience with colleagues as one of the most important factors

b) Module evaluation
For the written module evaluation the participants were asked to give their opinion about the module's strengths and weaknesses. They expressed as positive aspects the collaboration between the two institutions (Welsh and Portuguese Faculties), the course's atmosphere, the cohesion of participants, the methodology, the theory-practice link and the support materials. As weak areas they referred time constraints, theory/practice balance, language issues, logistics constraints and venue limitations for the Cardiff team.

c) Interim Interview
All participants were interviewed in order to obtain information about fulfilment of initial expectations and impact on practice.

1. fulfilment of initial expectations
   Students referred that most of their initial expectations have been met, namely, the desire to improve teaching and increase knowledge as well as their motivation to better respond to the Faculty's structural reforms. They also mentioned the unexpected importance of the cohesion created within the group of students and the high level of pressure they were submitted to (time & hard work).
2. perceived impact on practice
   Students referred to improvement on different areas: preparation of teaching activities, use of media, variability of techniques used, practical teaching, relationship with students, preparation for change and overview of change.

To better document the students' perceptions some quotations are presented:
"... deliberate major changes have occurred"
"... so far the course has provided many solutions"
"... not a day goes by without myself applying or reflecting on the Masters' "
"... it was spectacular the way it opens new perspectives"
"... it was a real standstill to recycle and to improve my approach to teaching"
"... the great difference is in the way we approach teaching"

For a final balance of this first year, and from this evaluation, it appears that students' expectations have been met, there was a real impact on practice as medical educators and there is a strong motivation to change. For the future, considering the possible impact of the Master's Course on Faculty teaching, one must admit that the force for changing is probably the most important factor to be stressed. More than increasing knowledge or improving practical skills, the experience of the Master's Course throughout these two years has put together a critical mass of senior medical teachers who are motivated for change, prepared for change and taking change upon themselves.   

Final Comments

It is important that Education training skills, as well as the other dimensions of the teaching profession, could be fully explored at a time when the future of the professionalisation of teaching is necessarily being discussed.

We hope that the Portuguese case history together with the other two (from the United Kingdom and the Netherlands) presented at the MED-NET Conference could be a helpful contribution towards initiating a debate on professionalisation.

In fact, MED-NET Networks, aiming to be a forum for discussion and a source for information on Medical Education in Europe, appears to create a relatively low-cost and unique opportunity for exchanging ideas and experiences, that will hopefully bring more quality to Medical Education.

References

1. Hoyle E. "The professionalization of teachers: a paradox". in Gordon P. Is teaching a profession? Institute of Education, University of London. 2nd edition .Great Britain 1995.
2. Sochett H. "Towards a professional code in teaching". in Gordon P. "Is teaching a profession?" Institute of Education, University of London. 2nd edition .Great Britain 1995.
3. World Summit on Medical Education: the changing medical profession. Edinburgh 1993
4. Anteprojecto de Articulado do Estatuto da Carreira Docente Universitária. Versão preliminar. (28./10) Lisboa, Portugal. 1996
5. Lei da Autonomia das Universidades. (Lei 108/88 - 24/09). Diário da Republica, Portugal, 1988
6. Edinburgh Declaration. World Conference WFME, Edinburgh, 1988.
7. Consultive Committee for Medical Education: Report and recommendations for Higher Teaching on Medicine. European Commission, Brussels, 1992.
8. Working Group for the Revision of the Medical Teaching. CIREM Interministerial Commission, Lisbon, 1989

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