Launching the ACE

Abstract

Much focus has been placed on optimising training in obstetrics and gynaecology, with redesign of accreditation standards, expansion of training sites, curriculum reviews and the ever-present dilemma around appropriate surgical numbers for trainee logbooks. However, the time has come to consider the role of the unsung heroes of the training experience – the trainers. At the 2023 Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Annual Scientific Meeting in Perth, a group of interested Fellows, Proceduralists, Trainees and College staff met to workshop what a RANZCOG Community of Practice for educators might look like. The discussion centred around the potential aims of such a group, its purpose, and of course – its name. Thus was born the RANZCOG Academy of Clinician Educators – the ACE. The ACE was formally launched by RANZCOG President Dr Gillian Gibson at the RANZCOG Symposium in the Sunshine Coast in July 2024, and will be hosting its opening webinar on the subject of ‘What makes a good medical teacher?’ on 22 August.

The aims of the ACE born out of that first meeting in Perth are fourfold: (1) to foster excellence in medical education; (2) to provide professional development opportunities for medical educators through RANZCOG; (3) to promote sharing of resources and collaboration between education providers and the College; and (4) to create networking and support opportunities for current medical educators and for those with an interest in the area (Fig. 1).

To foster excellence in education we need to know what that looks like: what are the essential competencies for a medical educator in our speciality? The literature identifies multiple competency domains, with good concordance between different authors on the subject.^1-3 The consensus is that excellence in medical education comprises skills or attributes in the following five areas: teaching and facilitating learning, designing and planning learning, assessment and feedback, educational research and scholarship, and educational leadership. If the ACE are to accept and promote those five competencies, we must first understand them, including understanding how they are applicable to clinician educators in our own speciality of obstetrics and gynaecology. Let us consider them in turn, starting with the most obvious competency area for an educator – that of teaching and facilitating learning.

How to define competency in teaching is surprisingly difficult within the medical field, as there seem to be opposing views on whether clinical expertise is more important than the non-clinical skills associated with teaching when it comes to medical education. In 2008, Sutkin et al published a literature review on the subject ‘What makes a good clinical teacher in medicine?’.⁴ Sutkin identified 49 separate themes arising from analysis of the literature. The dominant theme was ‘Medical/clinical knowledge’ followed by ‘Clinical and technical skills/competence, clinical reasoning’. ‘Positive relationships with students and positive learning environment’ and ‘Communication skills’ were less dominant themes in Sutkin's literature review. Finn et al take a different stance, arguing that the non-cognitive traits of relationship skills, engagement with learners, and the creation of a safe but exciting interactive environment are the most important skills for a clinical teacher.⁵ Singh et al bridged the gap between Sutkin and Finn, in their 2013 survey of clinical academics, finding that the top three most desirable characteristics of a medical educator were knowledge of subject, enthusiasm and communication skills.⁶

If we can agree on the traits of an obstetrician and gynaecologist that make them a skilled educator, how will we know if our ACE members demonstrate those traits? Assessment of teaching traditionally relies on student or learner ratings, but these are known to be subject to bias and confounders. Junior medical staff appear to use surrogate markers of knowledge or expertise in their evaluation of surgical teachers, as illustrated in a 1991 paper by Tortolani et al.⁷ Twenty-three general surgery residents evaluated 62 senior surgeons using a ten-item Likert scale rating. Senior doctors who performed more surgeries, attended more department meetings, and published more research reports were more likely to receive higher ratings as faculty, while seniors whose patients required longer hospital stays, or who had higher rates of complications from their surgeries were more likely to receive unfavourable ratings. The authors concluded ‘excellence in patient care and activity in teaching and research, although not necessarily related, characterise the superior surgical educator.’ There is some evidence that RANZCOG trainees also perceive a relationship between clinical and teaching expertise. In a 2009 survey, consultants who were supervising during operations dealing with complications were least likely to be rated as excellent teachers when compared to supervisors teaching during general obstetric, abdominal, vaginal or laparoscopic procedures.⁸ An explanation for the relationship between perceptions of clinical and teaching expertise is the ‘halo effect’, whereby raters give higher scores to teachers with whom they have a good relationship, with high scores in one area positively impacting ratings in another.⁹ One of the most successful ways to improve learner ratings (as per randomised controlled trial evidence), is to provide chocolate cookies to the learners.¹⁰ Clearly more meaningful ways of evaluating teacher performance need to be found.

In faculty development terms, the solution to the problem of providing meaningful feedback on teaching performance possibly lies in the use of multiple rating tools by multiple raters, in addition to focused self-reflection for the improvement of teaching skills by junior educators.¹¹ Peer observation of teaching can be a powerful tool to aid reflection and guide faculty development.¹² In order to achieve the first goal of the ACE, fostering excellence in medical education, the ACE website therefore links users to faculty development tools that can be used by novice or experienced teachers. The tools can be used for learner ratings, as peer observation tools or as self-assessment tools in the setting of bedside clinical teaching, or in small group teaching sessions. They aim to provoke and support self-reflection and to aid in skill development in teaching.

Designing and planning learning is an endeavour that occurs at local, state, and national levels, with curriculum development an ongoing area of focus for the College in 2024 and 2025. The current focus for curriculum development is on advanced training, including the formation of a new training pathway for rural specialists. Multiple opportunities exist to get involved with curriculum development, including via the College website where feedback on the 4th edition of the FRANZCOG Curriculum can be given via email as a ‘live’ process.¹³ The encouragement of active feedback and participation in curriculum planning allows all Fellows and trainees to participate in, and thereby learn more about, this critical area of medical education. The inclusion of curriculum design into the mandatory units of the Education Advanced Training Module is in acknowledgement of the importance of this as a foundational skill for a clinical educator.

The third medical education competency area, assessment and feedback, comprises a critical element of the practice of a clinician educator, with adequate feedback provision a clear enabler of clinical competency development for RANZCOG trainees.¹⁴ The problem with feedback in medicine is that it has the potential to be rejected, or even to be harmful to the performance of the recipient if delivered in a way which is unsafe, threatens self-esteem or lacks credibility.¹⁵ Our system of three- and six-monthly feedback provision can lead to a major erosion of credibility as feedback is commonly given separately to the event, and by an individual acting through hearsay and second-hand information rather than as a result of personal, near-contemporaneous observation.¹⁵ Giving on-the-spot feedback is more likely to be credible but is challenging to do safely in our fast-paced clinical environments. Indeed, as newly minted Fellows, even our sub-speciality trained junior consultants may lack confidence in feedback provision and balancing of teaching with clinical commitments.¹⁶ The ACE website includes links to online resources which members can use to improve skills in feedback provision. The implementation of mini-Clinical Evaluation Exercise assessments is likely to provide opportunities for supervisors to hone feedback skills which may be transferrable to other areas of our education practice as we start to embed feedback into our daily practice with trainees.

While even the most skilled clinical educator might be competent with teaching, educational design, assessment, and feedback, what of educational research skills? Nuthalapaty et al provide an excellent introduction to research practice and methodology in their 2012 article, ‘To the point: a primer on medical education research’.¹⁷ Educational research frameworks are similar to those used in clinical research. Most concepts, such as the use of the PICO (patient/population, intervention, comparison and outcomes) framework to design and interrogate a research question, or the use of a standardised rubric in journal club discussions, can be transferred painlessly into medical education research. The ACE website provides just such a journal club rubric, and it is hoped that users will find that their familiarity with the medical education literature will rapidly grow alongside their ambition to add to it. Using these resources will also encourage networking and connecting to peers with an interest in medical education – another major goal of the ACE.

Lastly, but not of least importance, the fifth competency area of leadership in education is required for RANZCOG to achieve a sustainable future in the provision of training. In their 2022 article Ruge, Pedroarena-Leal, and Trenado mount a passionate and powerful argument based in ‘dignity neuroscience’ for the importance of good leadership, stating that ‘It is not affordable to waste the dignity and talent, skill and insight, knowledge and valuable lifetime of one person’ through the consequences of poor leadership and bad decision-making in medical education.¹⁸ Faculty development programs in leadership in medical education have been shown to promote gains in leadership skills and positive changes in leadership behaviour.¹⁹ Such a program can be accessed via the Academic Leaders Institute, the link to which can be found on the ACE website.²⁰ The Academic Leaders Institute defines visionary leadership in medical education as including the ability to ‘embrace a possibility mentality’, to ‘anticipate the future of the discipline’ and to ‘reflect the culture of service leadership with heart for and willingness to serve’ – lofty ideals indeed and ones to which the members of the ACE can certainly aspire.

The aims of the ACE are clearly broad, its scope undeniably ambitious. But to whom should we entrust the vaulting ambitions of our speciality, if not its educators? For too long we have accepted that teaching has been a second thought, coming far behind clinical care on our daily priority list. It is time that we celebrated our clinician educators as the most important asset we have, investing as they do in the future of our profession. The ACE will take a central role in coordinating activities, curating resources, fostering collaboration, and raising the bar for all of us in this vital endeavour. You are all already doing amazing work in teaching, training, and supporting learners every day. Welcome to the ACE, you are already a member.