A Handbook for Medical Teachers (Fourth Edition)

Book reviews

Managing to do better:General Practice in the 21stCentury

Gordon Moore, Office of Health

Economics, LondonÆ 2000. ISBN: 1

899040 56 0, 62 pp. £7Æ50

Professor Gordon Moore holds the

Chair of Ambulatory Medicine at

Harvard University, USA, and is one of

the few American theorists who has

frequently visited the United Kingdom,

is well read in the European literature

and has a major interest in the National

Health Service. His views are therefore

of particular interest as the National

Health Service goes through a series of

unprecedented changes.

Moore’s starting point is that public

resource should be used to achieve the

maximum amount of public good. This

leads him to the view that preventive

medicine is more important than cur-

ative medicine and that the future of

health services will include the system-

atic application of modern knowledge to

defined populations and localities with

the prime objective of providing evi-

dence-based preventive care.

Moore believes that a radical trans-

formation is now needed in general

practice and particularly by general

practitioner leaders. He impressively

sketches out the new skills that are now

needed for modern primary care. These

include the acquisition of numerical

skills, particularly epidemiology, for the

primary care organisations and especi-

ally the doctors within it, to fully master

issues of provision and uptake and the

sensitivity and specificity of the different

preventive interventions. I have long felt

that the epidemiological influence was

lacking in general practice, and, like

Moore, still hope that new postgraduate

training programmes will be provided in

these subjects for future generalists.

Moore also skilfully spells out more

clearly than has been done before the

managerial implications of primary

care and the new responsibilities

which follow. Primary care organisa-

tions are growing and PCTs are sub-

stantial organisations. Primary care

staff cannot be expected to hold ma-

jor leadership and managerial roles

without proper training, when every

senior registrar in the NHS is provi-

ded by the NHS with courses in

management. It is extraordinary that

those doctors who are independent

contractors and already have substan-

tial management responsibilities for

employing staff, managing buildings

and developing dynamic organisations

should not be provided with such

training routinely.

Thirdly, Moore, as a senior academic,

values research and the need for

research to provide new knowledge and

the evidence base for change. Secondary

and tertiary care have long seen the need

to equip their future practitioners with

research training skills. The dearth of

medical generalists with higher univer-

sity degrees is evidence that primary

care still has a long way to go. In argu-

ing, therefore, for new forms of higher

postgraduate training, the acquisition of

key skills and the emergence in the

future of more professionally trained

generalists, Moore is on strong ground.

There are, however, limitations in this

analysis and in primary care there is

always a difficult balance to be struck

between the provision of preventive care

and the provision of personal care for

patients’ problems. It is at least possible

that the preventive programmes which

this booklet values so highly are not

always as cost effective as one would

like. The Edinburgh Unit, after screen-

ing 28 628 women over 14 years, re-

ported saving 11 lives.1 Epidemiolo-

gists, health economists and general

practitioners are not yet agreed on what

is value for money given limited re-

sources from the state.

Secondly, Moore underplays the

value of clinical care in general prac-

tice. Primary care is now the major

lifesaving machine in medicine. In is-

chaemic heart disease alone, the power

of aspirin, betablockers and statins, to

name but three drugs, probably has a

greater potential to save lives if prop-

erly prescribed and strictly focused on

appropriate patients than much of the

more expensive secondary care sys-

tem.2 Precisely because primary care is

becoming much more evidence based,

and because British general practition-

ers now prescribe as many as 71% of

drugs generically (far more than in al-

most all other countries), the effect-

iveness and efficiency of British pri-

mary care is steadily increasing. Even

in 1993, Garattini and Garattini3

showed that the prescribing efficiency

of British general practitioners was

greatly superior to those in France,

Germany and Italy.

But primary care is more than a pre-

scribing machine. It is still the first port

of call for patients who want to see

doctors and it still has an important and

Book reviews

682 � Blackwell Science Ltd MEDICAL EDUCATION 2002;36:682–686

underestimated role in providing reas-

surance and support for people with

serious illnesses or health concerns.

Given the extraordinarily low cost of a

GP consultation, currently about £15

(the same as a telephone consultation

with an anonymous nurse through NHS

Direct) the value of a frontline doctor

service still seems clear. The suggestion

that primary care is primarily a vehicle

for preventive programmes goes, to my

mind, rather too far in underestimating

the central role of family physicians as

clinicians.

Finally, there is a question worldwide,

and particularly in the UK, as to how

much doctoring doctors should do.

Implicit in Moore’s analysis is the sug-

gestion that primary care doctors should

withdraw more from the frontline and

devote more time to analysis, manage-

ment and the supervision of others. This

is already happening to some extent and

there may well be scope for more. There

are many general practitioners already

who are course organisers, trainers,

tutors, directors or general practitioner

academics, but there must be a limit and

there must come a time when the gener-

alist’s knowledge of his or her patient and

the ability to achieve real understanding

of the patients background, family, home

and values becomes threatened. Conti-

nuity has been shown to be associated

with the development of trust in doc-

tors.4 If continuity is too much reduced

will trust in doctors fall? This is one of the

central questions about the future of

primary medical care.

The Office of Health Economics has

produced an interesting thinkpiece. All

who are concerned with the future of

primary care will need to think hard

and reflect on Professor Moore’s diag-

nosis and prescription for our disci-

pline.

Denis Pereira Gray

Emeritus Professor of General Practice,

University of Exeter

References1 Alexander FE, Anderson TJ, Brown

HK, Forrest AP, Hepburn W, Kirkpa-

trick AE et al. 14 years of follow-up from

the Edinburgh randomised trial of

breast-cancer screening. Lancet

1999;353:1903–8.

2 Department of Health. National Service

Framework for Coronary Heart Disease.

London: Department of Health; 2000.

3 Garattini S, Garattini L. Pharmaceutical

prescriptions in four European coun-

tries. Lancet 1993;342:1191–2.

4 Mainous AGI, Baker R, Love MM,

Pereira Gray D, Gill JM. Continuity of

care and trust in one’s physician: evi-

dence from primary care in the United

States and the United Kingdom. Family

Med 2001;33:22–7.

Critical Reflection for Nursingand the Helping Professions:A User’s Guide

Gary Rolfe, Dawn Freshwater and

Melanie Jasper. Palgrave, 2001. ISBN:

0 333 77795 6, 194 pp. £16Æ99

The health education literature is full

of references to adult learning tech-

niques and how important they are for

developing professionals. Part of this is a

growing emphasis on reflection as an

important step in learning – a central

theme in core texts written by authors

such as Schon, Kolb and Knowles

amongst others.1–3 In theory this all

sounds very well but how do you do it in

practice? This volume makes a brave

attempt at trying to demystify the

reflective process. The book is written

primarily from the perspective of nur-

sing professionals who, as a discipline,

have probably explored and researched

reflection and reflective techniques such

as portfolios and reflective writing more

than other health professions.

The book starts with a promise to be

different, to include lots of practical

exercises and with a guide on how to

best approach it as a reader. Although

small, this work is excellently researched

and logical in its construction. This

seems to include every major reference

on adult learning and reflective theory

and this rich source alone makes it

worth its purchase. To my mind the

authors generally meet their aims, al-

though I feel that Chapter 1, which ex-

plores adult learning in detail and tou-

ches on the tensions between

reductionist and constructivist thinking,

is quite complex and uses technical

language and concepts which may not

be familiar to all. This feels slightly

contrary to the initial promises of the

book being different and easy to read.

Having said that, the complexities of

this chapter may be unavoidable given

the nature of the debate and the think-

ing behind it, and the chapter is well

written and deals clearly with the the-

ory. All the other chapters are much

more pragmatic and provide ideas and

ways of engaging in reflection and en-

couraging reflection in others. Much of

this is based around an emphasis on

reflective writing.

If I do have a criticism of this book,

it is due my perception that there is a

hint of a non-critical view that reflec-

tion is a good thing. The authors do

superficially mention concepts such as

different learning styles and the diffi-

culty of getting some people to write.

It would appear to me, however, that

many health professionals are activists.

They react to what is thrown at them

and trying to persuade them to write

things down and find time to think

about their actions is not an activity

for the faint-hearted.4 If reflection is so

important, how do we address where

the need for this is in health care

systems which are becoming increas-

ingly demand-driven, where target-set-

ting drives activity and waiting list

lengths govern policy. There are also

significant tensions between service

and education for both training grades

and established practitioners of all

disciplines. So for me one of the

weaknesses is that there are not en-

ough tips or ideas on how to confront

the biggest obstacle to reflection and

that is the prevailing culture and how

to change it. Current certification

Book reviews 683

� Blackwell Science Ltd MEDICAL EDUCATION 2002;36:682–686

changes and the expansion of portfo-

lio-based learning ideas may change

this, but do we have any real evidence

of what people on the ground think

and what they really feel about trying

to create the time to reflect on their

practice and write it down? This evi-

dence is central to trying to find ways

of helping all to engage in reflective

learning processes within the current

contexts of health care environments.

So, should you buy this book? Well it

depends. If you are a student engaging in

reflective writing for assessments and

personal development, then yes, as it will

help you to work out how to do it. If you

are a teacher trying to help people reflect,

then also the volume would be a good

investment as there is plenty of informa-

tion and numerous ideas to support you

in how you help groups and others

reflect. If you are an educationalist, the

references alone are worth having the

book for. If you are developing policy or

managing educational change, then the

answers on how to go about shifting a

culture are not here, but are they any-

where?

David Snadden

Dundee, UK

References1 Schon DA. Educating the Reflective

Practitioner. San Francisco, CA: Jossey-

Bass; 1987.

2 Kolb D. Experiential Learning. Engle-

wood Cliffs, New Jersey: Prentice Hall;

1984.

3 Knowles MS. The Modern Practice of

Adult Education: from Pedagogy to And-

ragogy. New York: Cambridge Books:

1980.

4 Snadden D, Thomas ML. Portfolio

learning – does it work? Med Educ

1998;32:401–6.

A Handbook for MedicalTeachers (Fourth Edition)

David Newble & Robert Cannon.

Kluwer Academic Publishers, Dordrecht,

2001. ISBN: 0 7923 7092 9, 222 pp.

£27.00

This book is intended as a handbook

for medical teachers at a relatively

unsophisticated level in terms of their

experience in analysing medical edu-

cation and reflecting upon their

teaching practice. This will include the

great majority of medical teachers in

the front line. It must have been an

almost irresistible temptation to the

authors, as experts in the area in

which they are writing, to parade the

depth as well as the breadth of their

knowledge. This they most com-

mendably fail to do. The text itself is

extremely clear and well written and

the advice is sound and simple and is

referenced to supporting literature with

a light but perceptive hand. It cannot

be recommended too highly to all

institutions in which medical education

takes place, and indeed many individ-

uals will find they come to enjoy and

value a copy of their own.

This is the fourth edition of the book,

evidence in itself of its usefulness. In this

edition, the authors have chosen to

bring the small chapter on learning

theory to the beginning of the book.

This is a commendable decision and

again the content must not be judged by

the standards of a comprehensive review

in this area. What the authors have to

say is clearly expressed and germane

to medical teaching practice as opposed

to theory. There are chapters on teach-

ing in large and small groups and in a

problem-based learning environment,

on teaching practical and clinical skills,

on assessment and evaluation, and on

course design and preparation of

teaching materials, all of which provide

a valuable introduction to these areas

and will tempt the beginner onwards. A

chapter on making presentations at a

conference sits a little less comfortably

in the text and might have been more

appropriate in a text on postgraduate

studies, for instance. This area is not of

direct concern to teaching, and, given

the high and unreasonable value set on

research, most staff appointed to full-

time teaching posts will already have

some experience in it. Moreover, it is

difficult to imagine that anyone suffi-

ciently motivated to read this book

would not also have acquired sufficient

communication skills to ensure that

their slides were in order before their

presentation began.

It is a toxic practice of reviewers to

immediately turn to that area of the

book they are reviewing in which they

regard themselves as most knowledge-

able. Quite independently of the level

of reader for which the book is inten-

ded, they then ghoulishly pick through

the text, shaking their heads and

tut-tutting aloud (and, frequently, in

writing).

Acknowledging the error of this

practice is, I find, no preventative to

doing it, and as a result I was able to

identify a number of statements with

which I disagree. For instance, the dis-

cussion of negative marking and norm

referencing appears to ignore a number

of important considerations that might

usefully have been explored at greater

length.

As is often the case, there is some

slight difficulty in identifying the audi-

ence to which the book is addressed.

Many readers will have had the experi-

ence of attending a staff development

course on teaching only to discover that

their fellow course participants repre-

sent the best teachers of their

acquaintance, and that many of them

would be capable of running the course

rather than merely attending it. Con-

versely, those individuals who would

benefit most from even the lightest

exposure to courses on teaching meth-

ods (or to considerations other than

those of their own research or ego) are

unlikely to attend such courses. In the

same way, those who are likely to pick

up this book and attend thoroughly to

its advice are by nature probably already

Correspondence: Dr John C McLachlan,

Peninsula Medical School, ITTC North,

Tamar Science Park, 1 Davy Road,

Plymouth PL6 8BX, UK. Tel.: 00 44 1752

764296; Fax: 00 44 1752 764226; E-mail:

[email protected]

Book reviews684


familiar with many of its precepts and

have employed them in practice. The

authors indicate that previous editions

of the book have been used in manda-

tory staff development courses, and

these would indeed represent a highly

appropriate context for its use. It may

nonetheless be possible in future

editions for the authors to step up the

complexity of their analysis and

the range of reference materials very

slightly.

Having said that, this is not a book for

experts. It is unashamedly and properly

directed at interested novices. In this

role it is an essential text, and, as a

model of clear writing, it will in itself

serve as an exemplar for everyone

engaged in communication.

John C McLachlan

Peninsula Medical School, UK

Multi-Professional Learningfor Nurses: Breaking theBoundaries

Sally Glen & Tony Leiba (eds.)

Palgrave, Basingstoke, ISBN 0 333

98590 71, 147 pp. £15Æ99

Although multi-professional learning

is not a new concept, successive

government policy documents have

highlighted the need for health care

professionals to review their position on

it in order to move this agenda forward

at a quicker pace.1,2 The publication of

this book is therefore timely. Multi-

professional learning consists of more

than sharing the same learning envi-

ronment as others: it involves acquiring

an understanding of the knowledge

base, values and ethos of like-minded

individuals and developing mutual

respect for each other’s contribution to

the learning process. How can we

achieve this when different groups of

students study with differing curricula,

separate time-tabling arrangements and

distinct historical backgrounds? Some

potential resolution of the issue lies in

the commitment and drive of individu-

als who believe that multi-professional

learning will make a difference to pro-

fessional practice and, subsequently, to

the delivery of patient care.

This book describes the experiences

of such individuals. It is edited by two

experienced nursing academics with

current experience of working in a health

care education environment where there

is an interface between the realities and

theories of multi-professional working.

It is paradoxical, however, that the

book’s title contains the word ‘nurses’,

as its subject material is applicable to

all health care professionals. The title

alone may limit its audience, which in

turn reinforces the barriers, perceived or

otherwise, that hamper the cause of

multi-professional working.

All contributors to the book are

employed in higher education, the

majority in nursing and midwifery edu-

cational programmes. However, a

broader sample of expert experiences,

incorporating other health care profes-

sionals, would have widened the discus-

sion.

Each editor has contributed a

chapter to the book, providing an

overall perspective on the topic from

an historical and political point of

view. The government’s agenda on

cross-boundary working is explored

and critiqued in a balanced and con-

structive style.3

Tony Leiba explores the definitions

and assumptions of multi-professional

learning in such a way that his own health

care profession is not discernible. The

text is informative and questioning and

explores the opportunities, assumptions

and theories of multi-professional edu-

cation. Leiba’s chapter raises questions

on the possible effects on users of multi-

professional education and proposes that

this area would make a good topic for

research. He believes that multi-profes-

sional learning requires extraordinarily

skilled organization, a theory that has

been reinforced by Salmon & Jones

(2001) in their work at the University of

the West of England.4

Sally Glen concentrates on the polit-

ical agenda likely to impact on the

future progress of multi-professional

learning. Her chapter discusses, with

some authority, the potential division

between multi-professional learning

which takes place in higher education

environments and is essentially con-

cerned with changes in attitudes and

acquisition of knowledge, and that

which is concerned with work-based

learning. Glen’s concerns centre on the

danger of defining these two learning

environments as two separate issues

rather than as two complementary parts

of the same educational process. Her

chapter is informative and thought-

provoking and summarizes the messages

delivered in both government and pro-

fessional reports.

The remaining chapters describe ex-

amples of multi-professional learning

by providing first-hand accounts of

operational issues. These are described

honestly and in enough detail to in-

volve the reader in the reality of each

situation. Although they represent a

series of accounts, the chapters also

present discrete case studies that may

be studied independently or as a whole.

Some of the accounts, such as in the

chapter entitled A Perspective of Shared

Teaching in Ethics, include examples of

critical analysis, thereby clarifying for

the reader some of the strengths and

weaknesses of multi-professional learn-

ing. The chapter entitled Joint Training

for Integrated Care shifts the spotlight

from collaboration between medical

and nursing professionals to nursing for

people with learning disabilities in a

context of social care. The recommen-

dations of this particular initiative are

similar to those made by a study un-

Correspondence: Rosalynd Jowett, Institute of

Health Studies, University of Plymouth,

Somerset Centre, Wellington Road,

Taunton, Somerset TA1 5YD, UK. Tel.:

00 44 1823 366900; Fax: 00 44 1823

366901; E-mail: [email protected]

Book reviews 685


dertaken at the University of Liverpool,

where the perceived benefits related to

changes in knowledge, skills, attitudes

and beliefs.5

The book has eight chapters in total,

which together present an informed

opinion on the context, definition,

practicalities and learning and teaching

implications of multi-professional

learning in practice, as well as providing

real examples of the process.

The text does not expound the virtues

of multi-professional learning as provi-

ding a solution to deficits in the current

educational process of preparation of

future professionals. Instead, it asks

which practices might be effective and

why. The book’s descriptions of student

views on multi-professional learning are

interesting and are worthy of compar-

ison with those in similar studies, such

as in Horsburgh et al.6

The book’s intended audience

includes those responsible for provision

of education in health and social care,

and, in particular, those interested in, or

sceptical of, multi-professional educa-

tion. It is not, as the title suggests,

applicable only to nurses. It could, in

fact, serve as an interesting resource for

students by developing their under-

standing of what constitutes multi-pro-

fessional learning.

The book succeeds in its aim to ‘bring

together current experience and future

developments in multi-professional

education’ and contributes to the agen-

da of developing multi-professional

initiatives in the rapidly evolving envi-

ronment of health and social care

education.

Rosalynd Jowett

University of Plymouth, UK

References1 Department of Health. The NHS Plan.

London: HMSO; 2000.

2 National Audit Office. Educating and

Training the Future Health Professional

Workforce for England. London: HMSO;

2001.

3 United Kingdom Central Council for

Nursing Midwifery and Health Visiting.

Fitness for Practice and Purpose. UKCC;

London.

4 Salmon D, Jones M. Shaping the inter-

professional agenda. A study examining

qualified nurses’ perceptions of learning

with others. Nurse Educ Today

2001;21:18–25.

5 Cooper H et al. Developing an evidence

base for interprofessional learning: a

systematic review. J Advanced Nursing

2001;35:228–37.

6 Horsburgh M et al. Multi-professional

learning: the attitudes of medical, nur-

sing and pharmacy students to shared

learning. Med Educ 2001;35:876–83.

Practice into theory

Can you recall a moment in your career when your under-

standing of medical education was informed, transformed or

even deformed? If so the Journal would like to hear from you.

We are looking for short pieces of about 200 words which

briefly describe an event, incident or interaction, either posi-

tive or negative, which profoundly affected your views on how

medical or health professional students should be educated.

We will publish accounts that go beyond description and

relate the incidents to underlying principles of teaching,

learning and assessment. We are interested in your analysis of

the event and how it affected you in your subsequent work.

We encourage you to demonstrate how the specific incident

illustrates a general principle or theory.

Contributions should be clearly labelled as a Practice into

theory contribution and forwarded to the Editor for review.

You should provide five copies and include your name, title

and institutional affiliation. We will publish these details in

successful submissions. We would expect you to preserve the

anonymity of participants as appropriate.

We look forward to your contribution to relating practice to

theory in medical and health professional education.

Book reviews686


Documents

A Handbook for Medical Teachers (Fourth Edition)