Arendt, Maja

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1Improving teaching within veterinary clinicaloncologyMaja ArendtDepartment of Veterinary Clinical Sciences, University of CopenhagenIntroductionVeterinary clinical teaching includes many challenges that are not normallyencountered in classroom teaching.Due to the circumstances around clinical teaching there is an extra layerupon the didactical triangle, which needs to be considered in the teachingand learning situation. In addition to the interaction between the teacher,the student and the learning content, there are also other factors such as thepatient, the client (patient owner) and the hospital business, which need tobe taken into account (see figure 1.1). These additional factors complicateplanning of, and control over the teaching situation, as the teacher cannotcontrol which clinical cases come into the clinic, or how the owner(s) oranimal will respond to a teaching situation. As the hospital runs as abusiness there are elements that need to be taken into account, to avoid thatthe teaching situation damages the relationship between the client and theteacher, or the hospital. In the ideal setting the student’s engagement in theclinic should “maximize the efficiency of the clinical practice and optimizethe students educational experience, whilst not harming the relationshipbetween the care provider and the client” as described by Simon et al.,2003.4 Maja ArendtFig. 1.1. Interactive factors needed to be considered for clinical teaching. Theclassical didactical triangle is illustrated together with an additional layer of factorswhich are needed to be taken into account for clinical teaching.This project wanted to investigate how the clinical teaching in oncologycould be improved in order to not only enhance the learning experience forthe students, but also to take the other factors in the equation into account.The reason for wanting to improve the teaching on this rota is that thepatient flow, the patient material and the individual teacher’s preparationare variable between student groups. As this is the last clinical course beforethe students are qualified as veterinarians, there are certain essential skillsthat the students should be able to perform when they graduate which isknown as day 1 competences and hence there are some essential skills thatshould be practised or discussed during the rotation.Brief description of course: The course Advanced Companion AnimalTrack is a 26.5 ECTS points course. The workload for the student inthe course is 460 hours of practical experience and 269 hours of studytime or preparation. The course incorporates different clinical specialties1 Improving teaching within veterinary clinical oncology 5in the University Hospital for Companion Animals in Copenhagen andalso includes an external rotation period in private small animal practices.Around 60 students take this course each year. The part that will be discussedin this assignment, relates to the clinical rotation in veterinary clinicaloncology which includes 16 hours of clinical teaching for each group ofstudents divided into groups of 3-4 students at a time.There are general intended learning objectives for the course which aredivided into knowledge, practical skills and competencies. The intendedlearning goals cover the course as a whole and are therefore very broad,leaving the students a bit uncertain with regards to what they are expectedto learn in the different disciplines.Aim of this projectTo improve and standardise the clinical teaching in veterinary oncologybased on information gained from questionnaires filled out by studentsrecently completing this course, pedagogical principles and dialogues withthe clinical teachers.Materials and methodAn anonymous multiple-choice questionnaire was distributed by email to30 students on the day of completion of the course. The full list of questionsfor the questionnaire and the possible answers is shown in appendix A. Thequestionnaire was sent out by email and two follow up reminders were sentout to increase the completion rate. The questionnaire was left open for10 days after which it was closed for further participants. An identicalquestionnaire was then passed to all teachers on the oncology rotation andthey were asked to answer what they thought the majority of students hadreplied, to investigate if the teachers’ and students’ interpretation of clinicalcaseload, teaching content and understanding of the subject was comparable.A total of 9 multiple choice questions were formulated covering subjectsrelating to the preparation material for the course, the intended learning ob-jectives, the caseload in the clinic, alternative preparation methods, teachingsubjects and the ideal clinical rotation design. One question was left openfor students to comment on further recommendations for how the clinicalrotation could be improved.6 Maja ArendtBased on the answers from the students and the teachers of the course,summary statistics were made to mainly look at differences between theteachers’ anticipation of student answers as well as particular areas wereanswers from the students indicated that there could be room for improve-ment.ResultsIn total, 14 out of 30 students completed the questionnaire whilst 5 out of5 teachers completed the questionnaire as seen in the flowchart figure 1.2.All data was summarized by analysing the frequency of each answer withinthe student and the teacher group as seen in appendix A.Fig. 1.2. Illustration of the questionnaire distribution and completion rate. The totallist of questions and answers is illustrated in appendix A.Interpretation of resultsBased on the questionnaire answers from the students there was suggestiveevidence for elements in the rotation which could be improved or altered.From the answers from question 1 regarding the preparation material forthe rotation, it was evident that 43% of the students felt that the preparationmaterial was either inadequate (29%) or they didn’t read it (14%). Likewise,from the answers in question 2, the intended learning objectives for therotation were either unclear (14%) or where not read (21%). This suggestthat there is room for improving the background information for the rotationmaking, and making it more appealing to read.1 Improving teaching within veterinary clinical oncology 7With regards to the clinical caseload; question 3, then 57% of thestudents felt that the caseload had been adequate whilst 29% and 14% feltthat it was too high or too low respectively. When asked about whether thestudents would prefer as high a caseload as possible versus fewer cases withmore thorough theoretical discussions in question 9, the majority 71% wouldprefer fewer selected patients with time for more theoretical background foreach case. From these answers, it was evident that individual studentsbeen exposed to different case flows during their rotation, however thatproviding a few good teaching cases with time for going through theoreticalknowledge and pathogenesis would be preferred by the majority rather thanbeing exposed to a higher case flow.The parallel running clinical rotation in cardiology provides the studentseach year with an information package, which includes details about learningobjectives, clinical case examples, examples of paraclinical test results anda short multiple-choice assignment. This information is used for studentpreparation but also used as case material during the clinical rotation inorder to discuss important clinical presentations, which might not havebeen seen in the clinic that day. In this sense, the theoretical material isused to substitute clinical cases in a controlled manner providing the teacherwith more control over the teaching situation. The oncology rotation hasabstained from providing similar material, as the teachers have thought thatthe students would not appreciate it, due to potentially extra preparationtime. From the answers in question 4 it is evident that only 20% of theteachers thought the majority of students would be interested in this kindof material whilst 80% answered that they though the majority of studentswould not appreciate a detailed information package. When looking at thefigures from the student answers, this shows the opposite, with 86% ofthe students replying that a more detailed information package would begreat and improve preparation whilst only 14% reply that they think thisadditional material will require too much preparation time. This question isa good example of teachers thinking that they know what the students want,however when asked, then the answer is quite different, which emphasizesthe importance of making a student-survey.When asked about the contents of the clinical teaching in question7, the four subjects of highest interest for the students where commontumour types, prognosis, grading and staging procedures. Interestingly,when looking at what the teachers thought the students would be interestedin, common tumour types, sensitive conversations with owners, stagingand grading procedures came as the 4 subjects highest on the list. In this8 Maja Arendtexample, there seemed to be relatively good alignment between what theteachers thought that the students wanted to learn more about and whatthe students actually answered that they wanted to learn more about, withsome exceptions. Though teaching should not be designed solely based onwhat students want, then this questionnaire was sent out, just as the studentfinalized their clinical rotation before becoming veterinarians and hencethis likely represents the skills that they feel they are missing, when theystart working as small animal practitioners, and hence the request shouldbe considered when planning the teaching. When asked specifically aboutdiscussing ethical dilemmas in the teaching in question 6, then the studentsdivided equally into two groups of students who felt it would be relevant todiscuss ethics more and who felt that ethics was discussed enough elsewhereduring their veterinary degree.Question five asked the student about whether oncology was mostlyabout chemotherapy and hence mostly related to specialist clinics or whetherit was more about diagnosing and staging and hence very relevant to firstopinion practitioners. Unfortunately, only 64% of the students answered thelatter. Around 50% of geriatric animals will develop cancer and thereforeoncology is a very relevant subject for any small animal veterinary prac-titioner. Ideally all students should feel that the subject would be relevantfor clinical practice, and hence there should be more focus on the studentsunderstanding what skills they are learning, and relating this to generalpractice. Question eight asked the students if they were ready to handleoncological patients after the clinical rotation. None of the students feltthey could do this independently however 79% felt they could do this withthe assistance of existing literature. Twenty-one percent felt that they werenot ready to handle oncological cases. Ideally 100% of students should feelready to approach oncological patients after the course.In general, the teachers’ anticipation of the student answers was re-latively well in alignment with the students’ answers, with a couple ofexceptions as seen in appendix A.Conclusion drawn from the questionnaireThe conclusion from the questionnaire results was that providing a moredetailed information package for the clinical rotation including well definedintended learning objectives, practical information and theoretical cases issought by the students. There should be focus on applicable skills and the1 Improving teaching within veterinary clinical oncology 9students understanding the clinical work. Based on the answers from thisquestionnaire and taking base in examples from literature on case basedlearning and problem based learning (Irby, 1994; Krogh et al., 2015; Krogh& Wiberg, 2015) it was decided to make improvements to the clinicalrotation with the aim to improve teaching for the students whilst also easingthe work for the clinical teachers.Improvements made to this course based on the findings inthe questionnaire which will be implemented in the clinicalrotation fall 2019Improved course information and teaching information on Absalon• Description of the clinical rotation.Defined intended learning objectives for the clinical rotation (whichare within the frame of the overall course description).Clear time table describing the different planned practical activitiesfor the rotation each week.• Theoretical oncology cases for discussion of most common tumourtypes, staging and grading schemes, paraneoplastic syndromes, evalu-ation of blood results and prognostication.• Multiple-choice test for testing of basic knowledge. Test will be usedas a discussion point between students and teachers to catch knowledgegaps, but the students will not be judged on their performance.• Improved literature list, including updated literature on common cancersand indications for chemotherapy.Improved clinical supervision:• Assignment of two clinicians to the rota on teaching days to assure thatthe clinician teaching has time for case discussion with the studentswhilst the second veterinarian manages other clinical activities mainlyrelating to chemotherapy treatment and external phone advice calls.Control of patient bookings:• Increased control with regards to the number and the type of patientswhich are booked during student course days to assure a sufficientnumber of good quality cases.10 Maja ArendtDiscussion of results with teaching colleagues:The results and implementations from this project report was discussedwith two teaching colleagues from the clinical oncology teaching group. Thechanges suggested were welcomed as both could see the clear advantage ofstandardizing the teaching and making learning objectives better defined tothe students. Additional case summaries and literature was suggested to beadded which was implemented. The use of the multiple choice questionnaireas a discussion point with the students, was thought of as a good idea tocatch knowledge gaps before the completion of the rotation. The suggestedchanges were thought to be able to make the teaching more similar betweengroups, provide more confidence to the students as well as helping theclinical teacher controlling some of the teaching content.Conclusions made from the assignmentThe main conclusions made from this assignment were that a more elab-orate ‘ ’information package’ ’ for the rotation including defined learningobjectives, time plans for set activities and theoretical case material couldimprove the rotation. This material is not meant to substitute the clinicalcases but to compliment them. The changes to this course will be imple-mented in the fall 2019 and evaluations from the students exposed to this willbe interpreted in the Spring 2020 to see if the implementations improvedthe teaching and learning situation for the students and teachers.ReferencesIrby, D. (1994). Three exemplary models of case-based teaching. AcademicMedicine, 1994;12, 947–953.Krogh, L., Stentoft, D., Emmersen, J., & Musaeus, P. (2015). Case-basedlearning. In L. Rienecker, P. S. Jørgensen, J. Dolin, & G. Ingerslev(Eds.), University Teaching and Learning. Samfundslitteratur.Krogh, L., & Wiberg, M. (2015). Problem-based and project-organisedteaching. In L. Rienecker, P. S. Jørgensen, J. Dolin, & G. H. Inger-slev (Eds.), University Teaching and Learning. Samfundslitteratur.Simon, S., Davis, D., Peters, A. S., Skeff, K. M., & Fletcher, R. (2003). Howdo precepting physicians select patients for teaching medical stu-dents in the ambulatory primary case setting? Journal of GeneralInternal Medicine, 2003;18, 730–735.1 Improving teaching within veterinary clinical oncology 1112 Maja ArendtAQuestions and answersTeachers	percent	answersStudents	percent	answers Queastion	and	answersRegarding	the	information	on	Absalon,	choose	the	answer	which	completes	the	sentence	best:	I	feel	the	information	on	Absalon	regarding	the	oncology	specialty	clinic	is0 14 Very	good,	I	read	it	and	felt	well	prepared	for	the	clinical	rotation60 43 Good,	I	read	it	but	felt	that	information	was	missing	0 29 Inadequate	and	not	useful	as	preparation	for	the	clinical	rotation40 14 I	did	not	read	the	materialQ1Regarding	the	intended	learning	objectives	for	the	clinical	roation	in	oncology.	I	feel	the	intended	learning	objectives	in	the	roation	are:	0 21 Well	defined,	it	was	clear	what	I	needed	to	achieve	on	the	rotation40 43 Reasonable,	but	it	was	not	clear	what	I	needed	to	achieve	on	the	rotation20 14 Inadequate,	it	was	not	possible	to	see	what	I	should	achieve	from	the	rotation40 21 I	did	not	read	the	intended	learning	goalsQ2The	patient	flow	on	the	days	I	was	in	oncology	can	best	be	described	as	20 57Adequate,	with	many	different	good	cases	which	meant	that	I	got	a	good	insight	into	clinical	oncology40 14 Inadequate	with	too	few	cases	for	me	to	feel	that	I	got	and	insight	into	oncology0 0 Adequate	but	the	cases	were	too	similar40 29 Too	high,	we	did	not	have	enough	time	to	go	through	the	cases	in	plenaryQ3The	cardiology	spacialty	clinic	has	made	a	very	detailed	information	package	with	examples	of	cases	and	clinical	test	results.	I	feel	a	similar	approach	in		the	oncology	clinic	would	be	:	20 86Great,	I	would	feel	better	prepared	and	sure	that	I	would	be	exposed	to	the	most	important	concepts	in	oncology0 0 I	dont	think	it	is	relevant	as	I	felt	that	I	got	through	all	important	elements	during	my	rotation80 14 	I	think	it	would	be	good	but	that	it	would	require	too	much	preparation	time	for	the	studentsQ4After	my	rotation	in	oncology	I	feel:	0 36Oncology	is	mostly	about	treatment	and	chemotherapy	and	is	therefore	not	relevant	for	first	opinion	practitioners100 64Oncology	is	mostly	about	diagnosis	and	workup	and	to	a	lesser	degree	about	chemotherapy	and	is	therefore	very	relevant	for	first	opinion	practiceQ5Regarding	ethichs.	Since	many	cases	can	include	ethichal	dilemmas	I	feel100 50 It	would	be	relevant	to	discuss	ethics	as	part	of	the	teaching0 0 It	would	not	be	relevant	to	discuss	ethics	as	part	of	the	teaching0 50 Ethics	are	discussed	on	many	other	occasions	and	hence	it	is	not	nessesary	to	repeat	hereQ6I	would	like	more	focussed	teaching	on60 64 Grading of tumors80 64 Staging procedures20 43 Oncological principles40 50 Treatment options20 43 Reasons for referral 20 71 Prognosis0 14 Chemotherapy100 36 Sensitive conversations with owners100 86 Most common tumor typesQ7After	my	roation	in	clinical	oncology	I	fell	that	I	am0 0 Ready	to	handle	and	diagnose	oncological	cases	independently80 79 Ready	to	handle	and	diagnose	oncological	patients	with	some	help	from	books	and	notes20 21 Not	ready	to	handle	and	diagnose	oncological	patientsQ8For my iddeal oncology rotation I would wish:0 29 I	would	wich	as	high	as	possible	patient	flow	during	my	rotation100 71I	would	wish	a	few	selected	patients	with	more	time	to	discuss	and	go	through	the	theoretical	background	for	each	case			Q9

Improving teaching within veterinary clinical oncology

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Improving teaching within veterinary clinical oncology

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