Whose difficulty is it?

Preceptors

Preceptors are teachers who impart knowledge and skills to apprentices. Their individual objectives are influenced by their own life experiences. Their competence is determined not only by their actual knowledge and skills but also by their style of teaching. In reality, preceptors can only teach within the constraints of the system, drawing on available resources for optimal outcomes. Good preceptors evaluate themselves on how effectively they taught as vigorously as they evaluate how effectively the students learned. Nevertheless, there is no “natural-born” teacher, and one cannot assume that all preceptors know how to deliver knowledge or skills constructively and effectively. Preceptors lacking experience might either be too rigid in their style, or unable to recognize the weaknesses of the learners and inspire them to attain goals within their capabilities. I have also witnessed personality conflicts arising between preceptors and learners, and the ultimate onus should rest with the preceptors in having the experience and knowledge to resolve the situation.

Learners

Learners are apprentices who receive knowledge and skills from teachers, with a learning capacity defined by their education and their own personalities. In my experience, younger learners are more likely to conform to both the teacher’s format and the teacher’s style of delivery and are more easily molded, so to speak, by their teachers during preceptorship. Mature learners are often less pliable, as they have values and norms from previous experience, which tend to filter or colour any new information they receive. To complete the learning process, the apprentices are often evaluated against defined benchmarks to gauge their performance. Subject to constraints of the system and availability of resources, learners who have not met defined expectations need intervention and to be re-assessed.

Here is the snag: as for driving lessons, basic knowledge and experience can be acquired to pass the driving test, but thereafter, the driver’s road competence will continue to evolve with subsequent exposure and environmental variables. Aristotle called it phronesis, or practical wisdom.¹ New graduates from different medical schools might not differ much in their knowledge and skill sets, yet subsequent exposure to different clinical settings will diversify their individual phronesis. In a reverse scenario, international medical graduates intending to practise in Canada are inevitably more diverse in terms of phronesis. This poses immense challenges for our medical licensing bodies in assessment and evaluation. It is not uncommon for international medical graduates who have been practising competently in their previous locations to be rated as insufficient in the Canadian system, and they often perform less competitively in board examinations when compared with their Canadian cohorts.²

System

System comprises the administrative, executive, and financial frameworks at various levels that bring together the teacher, apprentice, and materials for teaching and learning. In real life, this system is often constrained by finite resources including time, space, facilities, and finances. One should never take for granted that the system must be optimized for teaching and learning in an educational institute. Often, it is not optimized. Inflexible allocation of time or space, poor mentoring facilities, and suboptimal mentoring environment³ can all compromise the efficiency of learning and teaching (Table 1).

Hardware

Implicit in the process of learning are measurable outcomes that often equate with some knowledge to be acquired or skills to be attained. As a preceptor, I see these measurable outcomes as deliverable hardware. From the learner’s perspective, they are items to be retained and reproduced in written format or simulated settings like the objective structured clinical examination. Most licensing examinations in Canada evaluate learners on 2 accounts: the Medical Council of Canada Qualifying Examination has both written and objective structured clinical examination components, whereas the Certification Examination in Family Medicine conducted by the College of Family Physicians of Canada has both a written module and simulated office orals. Such hardware, as I call it in the process of teaching and learning, is inevitably modified by geographic domains and paradigm shifts. For example, the knowledge and skills for performing a Papanicolaou smear are mandatory for every family medicine trainee in Canada. However, such hardware would not be essential in mainland China, where 99% of Pap smears are performed by gynecologists. When I worked as a houseman in England in the 1980s, I religiously followed the ABC mnemonic (airway, breathing, circulation) for external cardiopulmonary resuscitation; starting in 2010, the paradigm is now CAB (circulation, airway, breathing).⁴

Software

Imagine you have to deliver objects from one end of a long table to a person at the other end. There are a number of ways to do it: carry them over all at once or one by one; slide them across the table or throw them in the air hoping the person can catch; wrap them up in a box or just send them over without one; etc. Each method of delivery involves a different mind-set from the sender (preceptor) and the recipient (learner) regarding how well-packaged the goods (knowledge and skills) should be and how far the delivery (teaching) should go. Obviously there are no absolutes in these processes; their variations and modifiability are the characteristics of the software of the system. The software can be continuously rewritten until the goods are delivered safe and sound.

Dynamics

This term embraces interactions among all the variables that set teaching and learning in motion. These variables can be observed from different perspectives (ie, teacher, learner, and system) and are often evaluated in terms of efficacies and consistencies. If hardware is about what has been taught and learned, and software is about how the students have been taught and how they learned, then dynamics are about why it has worked or not worked. Not surprisingly, dynamics are the most crucial yet vulnerable variable, and often render the overall outcome of teaching and learning unsuccessful despite the presence of all the right players and ingredients.