Critical Psychiatry Debates; A Neglected Tool in Undergraduate Medical Education

This article was migrated. The article was marked as recommended. Background: Healthcare professionals must adapt to everyday clinical controversies using their critical thinking and communication skills. Educational debates nurture these skills producing a well-rounded clinician. Their value is well established in healthcare education, yet they are not commonly employed, and there is no literature on their use in undergraduate Psychiatry teaching. Methods: We planned and implemented a one-off educational debate lesson as part of the teaching program of fourth-year medical students on their Psychiatry clinical placements. We collected and analyzed the students’ feedback. Results: Although most students had no experience of debates, 79% found the learning event positive. The students also reported improvement in their confidence (58%), oral presentation skills (37%), critical thinking skills (71%) and the ability to cope with conflict (54%). In addition, there was a positive shift in their attitude towards Psychiatry (71%) and the chances of choosing it as a future speciality (33%). Conclusion: Our results showcase the benefit of using debates in shaping future doctors’ non-clinical skills and practice attitudes. In this paper, we discuss a thematic analysis of students’ feedback comments and reflect on several points in the planning and delivering educational debates. We also include practical recommendations for future applications.


Introduction
With motivation and appropriate skills, health care professionals can learn to address the controversies of clinical practice, and through educational debates, we can nurture such skills (Ganguli and Rancurello, 1990).Snider and Schnurer (2006, p. 6) defined debates as "structured communications on topics of interest".They facilitate adult learning via constructivist (Ang et al., 2019), social (Kennedy, 2007) and transformative learning theories (Kedraka and Kourkoutas, 2018).Moreover, they are an active learning process focusing the educational event on the learners (Ang et al., 2019).Their educational value is well documented in learners' perceptions (Bonwell and Eison, 1991 p. 45-46), educators' observations (Bonwell, 1996) and learning outcomes (Malone and Michael, 2018).
Educational debates improve communication skills (Doody and Condon, 2012), the ability to think critically (Doody and Condon, 2012), attitudes to complex fields (Malone and Michael, 2018), motivation (Hartin et al., 2017), leadership (Hartin et al., 2017), and general academic performance (Malone and Michael, 2018).They focus on high-level intellectual processes; Analysis, Evaluation, and Creation, thus achieving a more advanced level of knowledge (Scannapieco, 1997).Educators find debates more rewarding, exciting, and beneficial than orthodox lectures (Bonwell, 1996;Musselman, 2004).Moreover, compared with standard methods of active learning, such as problem-based learning (PBL) or group discussions, debates are considered less exhaustive of faculty resources (Omelicheva, 2006), and their structure gives an equal chance for all learners to participate (Dundes, 2001).
Debates have been applied in many fields of healthcare education, from ethics (Hanna et al., 2014) to dentistry (Darby, 2007) and pediatric surgery (Ong and Narasimhan, 2010).Moreover, their uses are not restricted to esoteric or controversial topics.They have been successfully extended to case-based discussions (Ong and Narasimhan, 2010) and journal clubs (Toor, Samai and Wargo, 2017).In Psychiatry, debates have been used in postgraduate teaching (Ganguli and Rancurello, 1990).And although Keynejad et al. (2017) involved medical students in their national psychiatry debate event, they did not focus on using debate in undergraduate teaching.
In this paper, we share our experience using debates in undergraduate Psychiatry teaching, outlining the structure used, students' perceptions, and instructors' reflections, including recommendations for future application.

Methods
We designed this activity to complement the experiential learning for fourth-year medical students at Barts and The London School of Medicine on their five-week clinical Psychiatry placements.We aimed to improve the students' communication and critical thinking skills and positively influence their attitudes towards Psychiatry.
A focus group of four students expressed enthusiasm for using debates as a novel learning method.Their opinions provided us with these guiding principles: Announcing the activity early with a detailed description.
Providing an introduction on how to debate.
Reducing workload by providing supporting evidence.
Reducing performance anxiety via formative self-assessed outcomes.
Choosing exciting debate topics.

Elective participation.
Restricted by resources, we offered this event as a single 120 minutes session as outlined in Table (1).In addition, we opted for a classic structure that allows for greater flexibility (Berdine, 1984).
We defined the participants' roles to guarantee maximum engagement and learning: The Debaters would be two individuals or teams of two, in which case the allocated time will be split.
The Audience would anonymously vote on each motion before and after the debate.They can also pose questions or comments during the rebuttal phases.
The Facilitator would safeguard the physical and emotional environments by stopping any form of aggression, keep the above structure, and manage the voting polls.Also, they conduct the feedback process and may make a closing remark.
We offered a choice of six motions, available in Appendix 1, that met Huber's (1964) ideal debate criteria; Debatable.

Clearly phrased.
Attractive to the students.
Relevant to the course.

Supported by evidence.
Achievable in the allocated time.
To reduce the students' workload before the debate event and increase their engagement in learning, we collated relevant resources supporting each argument in an online bank to share.We also provided a 30 minutes introductory session during the students' clinical placements' induction.

Results
24 out of 26 students participated in over three placements in the academic year 2019/2020.Two students opted out of attending the activity due to other engagements.All 24 students gave feedback using an eleven-item Likert-based form, available in Supplementary File 1, to express agreement or disagreement.Comments boxes under each item allowed them to expand on their responses.The quantitative results are shown in Table (2) below: As described above, the feedback/self-assessment tool invited the students to write comments under each question to help us capture their experience.The qualitative feedback indicated a positive response from the students, including reflections on their educational journey through medical school and suggestions for developing the activity further.The first two authors analyzed these comments individually, identifying themes and classifying them according to frequency; common (more than three times), repeating (two or three times), and miscellaneous (appearing only once).Thereafter, they amalgamated their findings into an analysis of common themes.The themes and a transcript of the students' feedback are available in Appendix 2 and Supplementary File 2.

Discussion
In the next section, we will process the themes in the students' feedback.Each paragraph will introduce a new theme preceded by some relevant quotes from the students' feedback.For the sake of a logical narrative, we opted not to follow the exact order of questions included in the feedback.
'No other use of debate in MBBS thus far is enjoyable.'The most common theme in the feedback was the overwhelmingly positive experience that the students described (79%), consistent with other evidence (Darby, 2007;Doody and Condon, 2012).However, these comments might be influenced by the novelty of debates, which Darby (2007) described as an attractive feature.We hoped to reduce this bias by asking the students if they would like more debates in their MBBS curriculum.We hypothesized that students would be less likely to generate more 'work' for themselves.However, a significant majority of the students (70%) recommended introducing more debates to their curriculum.
'Excellent.Having done a prior degree, I was used to my own opinion being valued.In medicine from year one, this is completely shut down.' 'I have not done any debates since secondary school.' The students, who had previous exposure to debates (37%), had gained this before entering university, which supports the notion that modern medical curricula allow little room for exploration outside their structure.
'Do more.Once a week?' 71% of students reported a positive change in their critical thinking, and 37% reported a similar impact on their oral presentation skills.These findings are promising, considering that students only had a one-off debate event.However, it is documented that performance and confidence improve with repeating debates (Dundes, 2001;Hawkins, Fulford and Phan, 2019).We observed that some of the students who reported no improvement suggested that it could be due to the planned lesson being a singular unrepeated event.
'I think Psychiatry does bring up a lot more ethical issues which are extremely helpful to discuss.' 'The placement is more influential when considering psychiatry as a speciality.' The Royal College of Psychiatrists has advocated enriching activities as an essential strategy towards positively influencing medical students' attitudes towards Psychiatry and increasing recruitment into the speciality (Royal College of Psychiatrists, 2019).However, we were concerned that as debates highlight controversies, they might turn the students away from Psychiatry.Hence, we were keen to assess the degree to which educational debates helped or hindered this aim.The students' comments fit with the evidence that clinical experience is the most influential factor on future career choices in Psychiatry (Eagles et al., 2007).Only 1 out of 24 reported that the ensuing appreciation for the controversies and dilemmas of Psychiatry would deter them from choosing it.This supports using debates as innovative teaching tools that can positively influence attitudes towards complex disciplines leading to an increased interest in understanding them (Malone and Michael, 2018).
'Medical school is arbitrary and about passing exams where there are tick box right answers, so debating both sides of a question does not help this.' 'It is not well for exams, but there is knowledge value.' It is known that learners alter their behaviours to achieve the highest possible grade, even bypassing the planned learning experience (Alinier, 2003;Byrne and Smyth, 2008).Few students expressed a similar experience as they were very focused on the assessment, not the learning process.They questioned the value that this activity added to their journey towards passing the MBBS exams.However, such a limited view ignores that oral communication, conflict resolutions & critical thinking are integral tools in the inventory of physicians advocating for their patients and even everyday life (Snider and Schnurer, 2006 p. 9).Debates can challenge this assessment-focused culture as the student cannot bypass the learning experience.
'Love it -do not do near exams.' Debaters can exert themselves during preparation (Darby, 2007).We reduced this effort by providing the students with the evidence needed to construct their arguments.Nevertheless, the bulk of the negative comments tackled the timing of the activity.Due to several restrictions in the scheduling process and the framework we adopted, the debate event coincided with the end of the placements' assessments.Hence, some students felt more stressed during the preparation for the debates.Going forward, educational debates should be planned not to compound other exams stress (Hall, 2011).
'This was affected the most as I may be able to have an opinion and yet be able to vote for the opposite based on the arguments' 'Nice to have an environment where everyone listens and accepts you.' 'Helped analyze previously held beliefs more critically.''I understand how there is no right or wrong answer and psychiatry is not black and white.' One of the criticisms of debates is that they are inherently binary, which may reinforce dichotomous thinking (Tumposky, 2004).Contrarily, our students' comments highlighted an increased perception that Psychiatry is not 'black and white' in addition to challenging their personal beliefs.Debates encourage the participants to examine their biases and let go of them, even if temporarily (Schroeder and Ebert, 1983;Berdine, 1984).They also provide a protected opportunity to entertain less accepted views from the safety of arguing a motion that is removed from the judgement of others (Shaw, 2012).Musselman (2004) suggested mitigating this problem by introducing a 'conciliator,' who directly suggests alternatives to extreme positions.Garrett, Schoener and Hood (1996) mentioned that a post-debate discussion could also be helpful for this purpose.Thus, while the initial arguments of a debate are dichotomous, the ensuing rebuttal and discussion allow for analyzing a broad spectrum of views.
'It is a good mixture to promote discussion, but may not benefit everyone.' Dundes (2001) reported that learners preferred educational debates to lectures.However, Bonwell (1996) found that some learners are more comfortable with the latter since it requires less involvement.Similar responses echoed in our feedback as few students felt that this activity was not suited for them.Thus, we echo Hawkins, Fulford and Phan (2019) recommendation for elective participation in educational debates since the effort spent by participants requires some level of motivation.Increasing the allocated marks for this activity in the course would also increase this drive (Charrois and Appleton, 2013).
'Vital to do, but may need to be modified for people with anxiety or who hate public speaking.' 'I understand how it aims to make you consider the content of what someone says as opposed to taking things personally.' A 'healthy' dose of competition and stress may improve the learning experience in debates by guaranteeing preparation (Schroeder and Ebert, 1983;Saito and Fujinami, 2011).However, the competitive and confrontational nature, not to mention pre-debate and oral presentation anxieties, can hinder socially anxious students and those who are uncomfortable with conflict (Goodwin, 2003, Tumposky, 2004, Hartin et al., 2017).Hence, we designed our framework to reduce predebate anxiety & competitiveness.As a result, only 8% of students reported feeling 'a bit worse' in their confidence level after the debates.Furthermore, 58% of students reported improved confidence despite 63% of them having no prior debate experience demonstrating that debating with more experienced peers can be a confidence-building exercise.Also, 54% of students reported a positive change in their ability to cope with conflict.Thus, affirming that debates develop conflict tolerance and desensitize the associated anxiety (Bellon, 2000, Fisher, Lapointe andPeterson, 2001).
Planning the instructional debate experience is vital to make it a productive learning activity (Hartin et al., 2017).Below, we reflect on our experience, as facilitators, with the hope that these points make useful tips for future application: Faculty Resources: Setting up the initial structure and material was taxing, a frequent deterrent for faculty to consider new learning strategies (Bonwell, 1996).However, afterwards, our involvement was limited to analyzing students' feedback, providing pre-debate support and facilitating the event.
Class Size: Traditionally, debates are considered small group activities, but they can be adapted for larger audiences (Combs and Bourne, 1994;Musselman, 2004).To involve all our students, we sometimes had to allocate them into pairs and gave them equal speaking time to guarantee equal participation.
Debaters Selection: By giving students the option to choose from multiple motions, we balanced engaging them in a topic they found exciting yet had enough supporting evidence (Omelicheva, 2006;Malone and Michael, 2018).We allocated them randomly to supporting and opposing arguments to reduce the chance of defending an argument aligned with their personal views, which would reduce their gained insights (Budesheim and Lundquist, 1999).Also, we asked the students for suggestions for future debates.
Safe Learning Environment: Debating in front of an audience, naturally, creates social anxiety of being judged against the competing performer (Omelicheva, 2006).This anxiety and competition are useful to motivate performance but only to a certain level as instructional debates are educational, not competitive (Schroeder and Ebert, 1983;Musselman, 2004).Also, a focus on 'winning' communicates a learned behaviour that may negatively impact professional integrity (Tumposky, 2004).Thus, creating and maintaining a safe learning environment is vital in educational debates (Garrett, Schoener and Hood, 1996).The strategies below can help towards this aim; Before: During the introductory session, we provided a clear outline of the event and discussed different debate strategies (Jackson, 1990;Roy and Macchiette, 2005).We provided both sides with the same evidence for each debate and highlighted that the motions were chosen to have no absolute right answer.We affirmed that the activity is both voluntary and formative.We also made it clear that no criticism of each other's character will be tolerated, thus forming what we called 'the rules of engagement'.Pre-debate anxiety can be reduced further by giving enough preparation time, reducing the duration of each phase and arranging a mock debate to set expectations (Candela, Michael and Mitchell, 2003).
During: At the start of the session, we had a short presentation to cement the message of a safe learning environment.Also, we found it helpful to maintain a positive and slightly informal ambience.Having the flexibility between submitting a written versus oral argument can also help participants find the process overwhelming (Berdine, 1984).
After: We avoided facilitator or peer assessment.Also, after the feedback, we checked in with the group generally and privately with students who appeared to have a negative experience during the debates or requested this support.
Role of the Facilitator: Debates work best when the facilitator serves as a scaffold to direct the participants but letting them lead the activity (Musselman, 2004).Hence, the facilitator's involvement in the activity was kept minimal, except in three situations: Most commonly, we reminded participants of the time boundaries if they got carried away.
Less frequently, we interfered with maintaining a balance between the supporting and opposing arguments or correct any misinformation (Shaw, 2012;Hawkins, Fulford and Phan, 2019).We planned this during the closing remark.
Only once did we have to interrupt the students to reinforce the 'rules of engagement when a student got carried away and criticized the character of the opposing team in their rebuttal.However, they promptly apologized when reminded.
Assessment: We opted for self-assessment outcomes as suggested by our focus group and commonly used in literature for assessing debates (Ang et al., 2019).A summative assessment process might lead to unhealthy competition and anxiety, reducing the educational value of debates (Hartin et al., 2017).However, several solutions have been suggested; Employing a categorical result of 'Pass' or 'Fail' rather than a numerical score (Hartin et al., 2017;Hawkins, Fulford and Phan, 2019).
Assigning most of the grade to pre-debate preparation (Hawkins, Fulford and Phan, 2019).
Peer assessment using a rubric marking grid takes away control from the instructor (Smith, 1990;Lampkin et al., 2015).
Online Platforms: Although not employed here, the classic debate structure lends itself well to the online environment either synchronously via video conferencing (DeClerk, LaBorde and Smith-Olinde, 2020) or asynchronously via forums (Lin and Crawford, 2007).This flexibility is a crucial feature considering the challenges posed by the COVID-19 pandemic on traditional teaching strategies.

Limitations
We can identify four limiting points in our work; 1.The short duration of the activity.
2. Limited employment of research skills in pre-debate preparation.
We believe that the first two limitations were much-needed adaptations to fit this learning activity into our students' teaching program.Moreover, we found that even with these restrictions, the value of using debates in medical education was evident.The small sample size was an arbitrary interference of the COVID-19 pandemic, leading to cancelling all face-to-face clinical placements.We followed Ang et al. (2019) in opting for self-assessment outcomes to reduce participation anxiety.However, we believe that an effective integration into the MBBS curriculum will require applying more objective assessment methods.

Conclusion
Our students' feedback and our observations support the evidence of the value of using debates in undergraduate healthcare education.They are ideally suited for preparing learners to be well-rounded healthcare professionals who can advocate for patients and lead change in healthcare policies (Faust and Paulson, 1998;Hall, 2011).Unfortunately, unfamiliarity with using debates for learning and over-estimating the difficulty of implementation turns away students (Goodwin, 2003) as well as educators (Omelicheva, 2006).We hope this paper will motivate and guide others in adopting and adapting the powerful and ancient but neglected adult learning practice of educational debates.

Take Home Messages
Educational debates are collaborative, not competitive.
Educational debates help future clinicians develop their non-clinical skills of communication, critical thinking and coping with conflict.
Educational debates positively influence medical students' attitudes towards psychiatry and can help increase recruitment into the speciality.
Education debates can be flexibly adapted to different fields and platforms.In this interesting paper the authors report on the value of structured debates as part of the learning process for undergraduate students during their 4th year Psychiatry placement.They describe the use of debate to improve communication skills and critical thinking in students, and piloted and evaluated a 2 hour debating session based on 6 motions that meet ideal debate criteria.24 students out of a cohort of 26 participated.The evaluation was an 11 item questionnaire with free text comments.The authors also provide their reflections on their experiences as educators and facilitators and provide helpful practical advice.The results are positive with students enjoying the experience and reported an increase in their confidence, presentation skills, critical thinking, managing conflict skills and in addition having a more positive attitude towards Psychiatry and a future career in Psychiatry.The paper is well written and easy to read and provides the questionnaire and free text comments and analysis as supplementary files.As a reader I would have like to see details of the six motions that were used in the debates also included.The paper reports the descriptive statistics from 7 of the 11 questions presented in table form, and data from 2 of the other questions.The order of data in the table is different to the sequence of the original questionnaire and 2 questions are commented on and the final question about future topics for debates is not provided.This slightly confusing (but perfectly logical) and could perhaps be explained in the paper.Not all readers might download the supplementary files -and I wondered if there is a way to present the free text comments and analysis in the actual paper.The free text comments for each question are dealt with by thematic analysis -which might better appear in the results section.I felt that this part of the paper was quite complex and as thematic analysis had been completed then more detail of how this was carried out and quality assured should have been provided.There were a large number of themes (31 for 100 comments) and while comments were matched to a theme -there seemed like a risk of getting comments out of their context.An example would be using the comment "I have not done any debates since secondary school" to discuss the wish for more debates -when this comment was in response to the question about previous debating experience.Perhaps the free text comments might have been used to further illustrate the results seen in each question.The authors experiences and recommendations for others wishing to set up such debates was very helpful -and perhaps should have been included in the abstract.As a minor point, I was not clear about what was meant by a limit to the study being limited employment of research skills.I think this paper will be of interest to all involved in undergraduate teaching and is a positive and helpful addition to teaching methods.

Centre for Medical Professional Development and University of Newcastle
This review has been migrated.The reviewer awarded 4 stars out of 5 I find this article interesting and innovative.We need to change the attitude of students towards psychiatry by making them active learners.Whilst doing this , the project also improved their confidence, communication , and critical thinking skills .It would have been interesting to see the topics for these debates .

Table 1 :
Phases of each debate motion

Table 2 :
Quantitative results Dr Ahmad Allam is a core trainee in psychiatry in the NHS in the North-East London Deanery.ORCiD: https://orcid.org/0000-0002-7428-9965Mr Ashvin Kuri is a third-year medical student and the head of the debates club at Barts & The London Medical School.ORCiD: https://orcid.org/0000-0003-0125-4806DrAli Ajaz is a forensic consultant psychiatrist in the NHS and a senior clinical lecturer in Psychiatry at Barts and The London School of Medicine and Dentistry.Dr Saman Ahmed is an old age consultant psychiatrist in the NHS and the Dean of Undergraduate Medical Education at North East London Foundation NHS Trust.Dr Peter Carter is a general adult consultant psychiatrist in the NHS and the Director of Medical Education at North East London Foundation NHS Trust.Professor Ania Korszun is a liaison consultant psychiatrist in the NHS and a professor of psychiatry & education at Barts and The London School of Medicine and Dentistry where she is also the lead at the Centre for Psychiatry.