State of the art on professionalisation of teachers at European Medical Faculties

Professionalisation of Medical Teachers

Madelena Folque Patricio

• Introduction
• Methods
• Results
• Discussion
• Conclusion
• Bibliography

1. Introduction

During the first MED-NET conference held in Rotterdam in 1997 the issue of professionalization of teachers in Medical schools was discussed by the reference group on "teachers professionalization". The task of this group was to characterise the professionalization of medical teachers in European countries.

Teachers play a crucial role in the quality of medical education. Their educational professionalism as well as the way they are perceived by others (as competent teachers and not only as competent doctors) are two main features, to be considered influential in the quality of medical education.

In recent years, many studies have been stressing the importance of teachers professionalization towards improvement of medical education. Teachers professionalization can be looked at from to different dimensions: 1) the practice of Education itself (selection/qualification criteria, training/development, teachers tasks, teaching evaluation, etc.) 2) the professional situation (structure to support Medical Education, teaching incentives/awards, policy to promote excellence in teaching, promotions based on teaching, etc.).

In order to understand the process of professionalization in European medical schools, the reference group tried to characterise medical schools, their teachers, and their level of professionalization throughout a survey conducted in 1997/8.

This survey aimed to tackle the following questions:

• how professionalizations process develops within the schools;
• how professionalizations process is conceived within the institution;
• what kind of barriers are perceived against professionalization.

2. Methods

A questionnaire was sent to all European medical schools, members of Medische hulpbron (175 schools). The reference group, with experts consultation, developed a questionnaire with the following structure:

Part I - Questions concerning the respondent

• Institution, city, country;
• Professional/academic post of the person who filled the questionnaire;

Part II - Questions concerning the characterisation of the faculty/medical school

• Number of students and teachers, teachers tasks and educational activities;
• Type of curriculum;

Pat III - Questions concerning professionalizations process

• Medical schools professionalization regarding educational practice
• Medical schools professionalization regarding professional situation
• Perception of the professionalization process within the school;
• Perception of the existent barriers against professionalization.
• Development of the professionalizations process

Thirty two Medical Schools respond initially to the questionnaire. A reminder was not sent to the "non-respondents" but they were informed about the ongoing inventory trough "Medische hulpbron newsletter", "Medische hulpbron annual conference" and "Medische hulpbron home page". Although the conference and the home-page did not lead to additional answers, 13 responses were received after the newsletter.

Data analysis indicated that responses received initially were not significantly different in any item of the questionnaire, from those received later. The sample is, therefore, constituted by the 45 schools who answer the questionnaire (25,7% of total).

In this context we are in the presence of a non random sample a convenience sample - where statistical inference is not allowed. However, as a pilot study, and in order to obtain tendencies to be confirmed in a future questionnaire we decided to compare the observed with the calculated frequencies resulting from variables crossing (contingency tables).

Results are presented according to the questionnaire structure.

3. Results

3.1 Characterisation of institutions and respondents

Institutions: city and country

The responses originated in 44 medical schools issued of 16 European countries (Table 1) and from the University of Beer Sheva in Israel (Israel was considered in this survey as a member of the European Health Region).

Table 1 - European Medical Schools who responded to the questionnaire *

(*n= 44)

Respondents academic post

The questionnaire was completed by administrative staff (Dean, Rector, Director, Administrative co-ordinators, etc.) in 44,4% of the medical schools or by someone in charge of an educational post (Professors, Educational co-ordinators, Educational project co-ordinators, Trainer, Staff, etc.) in 53,3 % (one school gave no answer to that question 2,2%). Detailed data are presented in Table 2.

Table 2 Function of Medical schools respondents *

(*n= 44)

We admit the possibility of an influence from the respondents function on the answers, i.e., we admit that respondents whose function was education-related might have a different perception, mainly, in what concerns the perception of the professionalization process and the barriers against professionalization.

This possible influence was checked but no significant associations were found with the post and other items of the questionnaire. This is an important finding to be considered when planning a future questionnaire regarding the reliabilitys issues.

3.2 Characterisation of medical school

Number of students

As shown in Table 3 the majority of the schools have more than one thousand students. A very high percentage of schools declare to have between 200 and 500 students entering on the first year of their pre-graduate course. From these results we can assume that our sample is mainly constituted schools with by big dimension.

Table 3 - Number of students of responding medical schools *

(*n= 45)

Number of teachers

Results presented in Table 4 indicate that the number of teaching staff is quite variable. As expected, the number of teachers involved in clinical teaching is higher than in pre-clinical teaching.

Table 4 - Number of teachers of responding medical schools

Teachers tasks

Table 5 present the results of the different schools when asked about the percentage of time spent by teachers with the tasks they have to accomplish: education, research and clinical activities.

Table 5 Time spent by teachers in different tasks

(*n= 36 / ** n= 34)

Some interesting results emerge from Table 5, showing educational activities of teachers dont have highest priority (according to the criteria of time spent):

• On a high number of schools (28) teachers spent less than 40% of their time in education;
• Only on a few number of schools (7) teachers spent more than 60% of their time in education;
• On a significant number of schools (19) teachers spent more than 40% with clinical activities;
• Only in a very low number of schools (5) teachers spent less than 20% with research.

Teachers functions

Medical schools were asked to describe in percentages (20% - 40% - 60% - 80%) the time spent by teachers in different educational activities, i.e., how much time teachers dedicate to knowledge transfer, individual tutoring, curriculum development, educational innovation and assessment .

Given the above referred percentages it was supposed that medical schools rated their teachers time with the overall sum of 100%. When analysing the data it appears that only 17 schools respect this condition, i.e., the values found from the remaining schools range from 80% to 240%.

To explain this "impossible" values one may admit that teachers considered the given percentages values as indicator of order (or priority) instead of components of a total time spent by teachers (100%). Data were analysed, on the basis of this explanation, calculating the media for each task, in order to establish a rank order.

Table 6 Time spent by teachers with different educational functions *

(*n=40)

From Table 6 we easily understand that the core of educational activity is, still, mainly occupied with activities concerning the transfer of knowledge. Activities like individual tutoring, curriculum development, innovation on education and assessment of education seem to be components on the educational function occupying a much lower percentage of teachers time (less than half of the time spent with knowledges transfer).

Type of curriculum

Medical schools were asked if the type of curriculum they perform is mainly discipline oriented, thematically oriented, problem oriented, patient oriented or reflects other orientation.

Table 7 - Type of curriculum of responding medical schools *

(*n=44)

The majority of medical schools define themselves as having a discipline oriented curriculum and none of the schools present themselves as having a patient approach. Some schools (31,8%) showed an evolutionary curricular approach, i.e., discipline approach moving to a thematic curriculum, thematic oriented moving to a problem based curriculum or discipline oriented moving to patient centred curriculum. Those results seem to indicate that the majority of the schools, still, presents a "traditional curricular approach".

3.3 Characterisation of the professionalization process

As the concept of professionalization is far from being well defined it was decided to present the situation regarding two parameters: education practice and professional situation. Besides those aspects schools were also questioned on their view about the professionalization process within the institution and the existents barriers against him.

3.3.1 Practice in education

Medical schools were asked to describe their situation regarding the following professionalization indicators: selection criteria, qualification criteria, training programs and teaching evaluation.

Selection criteria

In 86,7 % of our sample a selection criteria is present for teachers entrance on the academic career. Using a Likert scale, medical schools were asked to rate the importance of the following criterias components: professional knowledge and skills, research experience, educational experience, teaching skills, degree in medical sciences and education training.

The given options, range from "very important" (+5) through "not important" (+1), allows the ranking of the different components according to the media (Table 8)

Table 8 - Importance of the different selection criterias components *

(*n = 39)

Research experience, professional knowledge and a degree in medical sciences, are seen as the most important criteria for becoming a teacher (media between 4 and 5). On the other sense, education experience teaching skills and education training are seen as moderate or almost, non important factors in the case of educational training (media 1,7).

Qualification criteria

In our sample, 43,2% of the schools declare to have a qualification criteria for teachers.

Methods of teaching evaluation

Thirty three medical schools (73,3%) declare to evaluate teaching quality trough one, or more, of the following aspects: students satisfaction, teachers satisfaction, intercollegiate audit, external audit, self evaluation and regular evaluation .

On those schools the most currently evaluation method seem to be the measure of students satisfaction (46,6%). Comparing to this high value, only a few percentage of schools measure teachers satisfaction (16,4%), or develops an intercollegiate audit (15,1%). An even lower percentage of schools implements external audit (8,2%) or self evaluation (6,8%), or regular evaluation (6,8%) for this purpose.

Columns on Table 9 show the different patterns observed in our sample regarding the evaluation methods used by medical schools. The more common pattern corresponds to those schools only measuring students satisfaction (28,9%) followed by those schools where none of the methods are employed (17,8%).

Schools where students and teachers satisfaction are evaluated appear in a lower percentage (11,1%). The frequencies regarding other patterns of methods range from one school (2,2%) to three medical schools (4,4%).

Table 9 - Patterns of evaluation methods

(*n =45) (P = present)

From the results two aspects deserve attention

• 18% of the medical schools in our survey were not using any of the referred teaching evaluations methods or any other method (an open-ended question was given as optional answer);
• students satisfaction seem to be most used method for teaching evaluation in our sample (28%) which contrasts with the lower percentages of schools where teachers satisfaction is evaluated (11%).

Training programs

Nearly half of the schools (48,9%) declare to have programs for teacher training. In 45% of those schools programs were mandatory, mainly, for young lectures, for new lecturers or for tutors, representing 22,2 % of all sample.

3.3.2 Professional situation

Several indicators may give us a picture of the state professionalization within the Institution.

Existence of a Department of Medical Education

Only 42,2% of the schools refer the existence of a Department of Medical Education (or a similar structure) to support the educational activities.

Rewards or incentives

Rewards to promote excellence are present in 38,6 % of our Medical Schools. They assume different formats: annual reward, financial complement or other non specified (n = 44).

Policy to promote excellence in teaching

More than half of the medical schools (53,3 %) declare to have a policy for promoting excellence in teaching. In 62% of those schools teachers know this policy, (33,3 % of all schools).

Policy or plan regarding (further) professionalization

From the 41 Medical schools who answered this question, only 18 declare to have a plan or policy for further professionalization ( 43,9%).

Promotions

Medical schools were questioned on the number of promotions, based on teaching activity, occurred on the last five years. In almost half of the schools no promotions occurred and only 3 schools assume to have had more than 10 promotions based on teaching (Table 10) which looks odd, given its student body size.

Table 10 - Promotions on the last five years *

(*n=36)

3.3.3 Professionalization process perceived within the institution

Asked about how professionalization is conceived within the institution, medical schools were given three optional answers, i. e.,

• "professionalization is not an issue in my institution", "
• "professionalization is in a developmental phase" or
• "professionalization is on an implemented or structured phase"

In a high percentage of medical schools (36,4%), " professionalization is still not an issue". For more than half of the schools (54,5%) "professionalization is in a developmental phase" and only for in 9,1% professionalization seem to be structurally implemented.

3.3.4 Barriers against professionalization

Unfortunately only 20 of the medical schools answer about the perceived barriers against professionalization. Data were classified through content analysis, in three perspectives: cultural, institutional and personal.

• Cultural barriers (25%): tradition, cultural, climate, etc.
• Institutional barriers (36%): financial, money, emphasis on scientific merit, structure of education, "professionalization is not an issue for the Institution", etc.
• Personal barriers (36%): low status, no incentives, resistance to change, lack of time competition with other tasks, lack of teachers interest, etc.

From the results, it appears that the personal and the institutional barriers are perceived as the most stronger factors against professionalization. We were curious on how the barriers were perceived by the respondents, i.e., did the respondent perceive only one perspective or are they perceived simultaneously within the same school. Table 11 shows the different patterns emerged when analysing the data.

Table 11 Barriers against professionalization *

( * n= 20) (P = present)

No significant association seems to be present between the different perspectives of barriers. It was also looked for the possible association of the barriers perception and the professionalizations indicators within the institution and no association appeared between the barriers perception and the existence of training programs, Medical Education Department, incentives to promote excellence, policy or plans regarding further professionalization, qualification criteria or selection criteria.

3.3.5 Professionalization process: how does it develop?

It was important to understand how the process of professionalization is developing in European Countries: until now, these results only shed light on the presence or absence of those indicators.

We were interested in knowing if there is a level of association between the above mentioned indicators, i.e., if there is a pattern regarding teachers professionalization within the Institution or if each school.

In other words, medical schools with a department of medical education (42,2%) are the same where qualification criteria is present (43,2%), training programs exists (48,9%) and teaching is evaluated (50%)?

Results present on Table 12 indicate that an associations pattern seems to emerge between the different indicators.

Table 11 Association between indicators
(Chi-square p-values)

Approximate significance of the contingency coefficient: 
*** = p< .05: ** = p<.01; * = p<.001;

The following indicators seem to be associated:

• Department of Medical Education with training programs, policy to promote excellence, known policy, evaluation of teaching quality and future policy for professionalization;
• Qualification criteria with training programs, policy to promote excellence, known policy, evaluation of teaching quality, incentives, future policy, and professionalizations view within the institution;
• Training programs, with department of medical education, qualification criteria, policy to promote excellence, known policy, teaching evaluation, incentives and future policy.
• Policy for promoting excellence with department of medical education, qualification criteria, training programs, known policy, evaluation of teaching quality, incentives and future policy.
• Policy for promoting excellence with department of medical education, qualification criteria, training programs, known policy, teaching evaluation, incentives and future policy
• Known Policy with department of medical education, qualification criteria, training programs, policy for promoting excellence and incentives, future policy.
• Promotions with professionalizations view within the institution
• Teaching evaluation with Department of Medical Education, training programs, policy for promoting excellence and future policy.
• Incentives with qualification criteria training programs, policy for promoting excellence, known policy and teaching evaluation.
• Future Policy with department of medical education, qualification criteria training programs, policy for promoting excellence, known policy and professionalizations view within the institution.
• View on professionalization within the institution with qualification criteria, promotions and future.

It appears that a consistent pattern is present when the process of teachers professionalization is developing. Schools seem to adopt, more or less, the same initiatives regarding teachers professionalization although with a quite variable degree of co-existence.

Selection criteria and promotions seem to be the indicators showing a lower degree of association with the others. The department of medical education, training programs, qualification criteria, policy to promote excellence, future policy, evaluation of teaching quality appear to be those with a much similar pattern of emergence between the schools.

Curiously, professionalizations view within the schools contrarily to our hypothesis is only associated with a very small number of indicators: qualification criteria, promotions and future policy.³ We previously thought that the perception of the professionalizations situation within the schools would be associated with the existence of those indicators.

Although, as previous said, sample characteristics preclude us the use of sophisticated statistical procedures, it seems, looking at the associations found, that teachers professionalization is a process where upon a certain number of indicators emerge consistently.

³ Although no significant values were found for the coefficient of contingency, a tendancy is present when considering professionalization view and training programs (p<.0655), evaluation of teaching quality (p<0811.), policy known (p<.0663) and incentives (p<.0665).

4. Discussion

When medical teachers are selected not for the teaching competency but for their scientific or professional one, as it seems to be the case in a large proportion of our sample, it will be crucial to sensitise medical schools in order to increase the importance of educational experience, teaching skills and training certificate. The criteria assumed by the majority of the schools professional knowledge and research experience at the limit could indicate that those institutions assume that higher scientific/professional competency should mean better qualification for teaching which of course is not always true. It is important not to decrease the importance of the professional and scientific criteria but to increase the importance of the teaching competencies.

When looking for teachers educational activities we discover in the majority of schools the picture of a "traditional teacher" having as his essential activity the transfer of knowledge. Literature defends the drive towards learner centred learning which will equip doctors for the next century and encourage the exploration of alternatives ways of learning. (Thomas et al.1998) Placing students at the centre of their education is involving them with quality control organisation and development of curricula (Wisser et al.1998).

Regarding the most common curricular approach " discipline approach" usually more focused on knowledge gains, a major change is needed because this is not the only educational goal (Kolars1997). Professional attitudes, values, self skills, interpersonal skills are other salient components of medical curricula probably easily attained upon other curriculum approach. A tendency is to base curricula more on the education needs in order to optimise the learning process of student and to create a stimulating and active learning environment (Wisser1998).

A lot of work should, also, be done in what concerns training programs, only present in half of the schools, if we want to follow international recommendations on this topic: " .... to assure teachers trained as educators (WSME 1993) and "... to establish programs on the Medical schools in order to improve staff quality. We have reasons to believe that bad learning habits may be related with the lack of educational competency of the teachers" (CCME1992).

A high percentage of schools is still not evaluating their teachers quality although the Edinburgh Declaration and other international reports seem very clear on that point: "...to establish a system allowing the evaluation of teaching in each Faculty" (WFME, 1988).

It is reasonable and desirable that each institution take the responsibility for the evaluation of teaching because only through evaluation institutions could check if their objectives were really achieved. Measuring student satisfaction seems to be the most used method for teaching evaluation in our sample. If evaluation of students satisfaction is certainly an important tool it would be important to sensitise schools for a more valid evaluation using a combination of methods. The objective should be not only to measure the students satisfaction but also the efficiency of teaching.

Last but not the least, some remarks regarding future studies: First, although an effort was made to keep the language as clear as possible, we have reasons to believe that certain questions were not very easily understood by the respondents.

Another important point to have in mind for the future is how to motivate medical schools to answer the open-ended questions and to add material to document the undertaken initiatives, a starting point for other schools.

Lastly, it would be interesting to look for some questions not considered in this first exploratory survey:

• how to define a professional teacher (methods, activities, status);
• how is conceived a professional institution;
• what kind of actions (priorities) should be undertaken in order to accelerate the process of professionalization.

In the future Medische hulpbron reference group on teachers professionalization must improve the data bank, not only in quantity but in quality (reliability and validity), in order to be a good network.

5. Conclusions

Teachers professionalization must be one of the challenges in Medical Schools if we want competent and accountable teachers capable of preparing doctors for the needs and expectations of society. The dramatic change needed in the structure and process of Medical Education could not be achieved if the professionalizations process is not a high priority in Medical Education

This survey give us the idea that although the present situation in medical schools is far from ideal, there were signs pointing to a process in development. There is still a considerable amount of progress to be made in order to give teachers professionalization the quality and the importance that it should have.

We believe that although the on-going movement within the institutions seem to adopt a consistent and coherent pattern with literature, international organisations as Medische hulpbron may and must play a crucial role as a facilitator of this process.

Medische hulpbron should contribute by collecting and exchanging information.

Medische hulpbron must be a forum of discussion in order to develop awareness of the importance of the professionalization of the medical teachers.

6. Bibliography

• Consultif Committee for Medical Education (1992). Report and Recommendations for Medical Training. Document III/F512773792- PT. Brussels.
  
• Kolars, J.C. et al (1997) The effect of student - and teacher centred small goup learning in medical school on knowledge acquisition, retention and application Medical Teacher, 20, 53-57.
  
• Thomas, M.L, Snadden, D. Carlisle, S. (1998) When the talking starts. A framework for analysing tutorials Medical Education, 32, 502-506.
  
• Wisser, K., Prince, K.J.A.H., Sherpbier, A.J.J.A., Van Der Vleuten, C.P.V.D., Verwijnen, G.M. (1998) Student participation, educationl managemant and organization. Medical Teacher, 20, 451-454.
  
• World Federation Medical Education (1988) Edinburgh Declaration. World Conference, Edinburgh.
  
• World Summit on Medical Education (1993). Changing medical profession. Edinburgh.