The above is a phrase which I have often seen written on Teaching Visit Reports. The enthusiasm almost jumps off the page (/screen) and it comes across as a comment (feedback) by a colleague, recognising certain (not always clearly articulated) perceived attributes of the trainee. Similarly, medical educators frequently make a global judgment about whether a registrar is likely to proceed through training successfully. What are these experienced assessors seeing?
Assessors are always searching for valid methods to assure/measure/predict training outcomes and much of this is currently focussed on competencies. This is a topic for a later blog but this post is about a slightly more elusive topic. It is about “pre-competencies” or perhaps “beyond competencies”.
Three essential ingredients
Over the last twenty years or so I have come to the conclusion that there are at least three crucial attributes. If a registrar is obviously 1. Curious 2. Caring and 3. Conscientious then I think “this is the sort of family doctor I would be happy for my family to see” and I relax, to some extent, as an educator. These qualities assure me that the registrar will achieve that desired outcome of a safe and competent (and, dare I say, good) GP. Let me explain why I feel reassured that these global judgments predict and reflect some of the more atomized competencies that programs try to measure along the way.
- Curiosity as an intellectual/cognitive attribute is obviously important to a scientific approach but it can remain cold and objective without also the interest in the person that is central to general practice (http://curriculum.racgp.org.au/statements/philosophy-and-foundation-of-general-practice/ ) In practice, curiosity means that the GP will not have the intellectual laziness that is happy with easy answers. It drives self-directed learning and ongoing professional development. The curious GP can’t help asking questions and searching out answers.Curiosity ensures you search out what you need to know (ie the curriculum, in more formal terms)
- In terms of “caring” I am thinking more about a passion for the job not just the soft and fluffy emotion that is sometimes claimed for GPs. The registrar who cares is motivated about being a good GP, is concerned about the person as a whole (not just their disease) and cares about what happens to the patient in the health system. It is articulated somewhat in domain 1 of RACGP and in the widely applied CanMEDS framework
- Conscientiousness is representative of the ethical and professional framework that is so difficult to measure during training. It rates of course in various training frameworks (domains 4 & 5 in RACGP, ACRRM domain 6 and the Professional Role in CanMEDS http://www.cfpc.ca/uploadedFiles/Education/CanMeds%20FM%20Eng.pdf ). It contributes to patient safety and ensures the registrar commits to ongoing learning. These are the learners who get their paperwork done, meet deadlines and make study plans and who ensure that patients are safety-netted and followed up.
I am often tempted to add Communication Skills to the above three attributes but, although some people appear to be inherently better communicators, there is a sense in which communication is a skill which can be taught and learnt. Certainly training programs assume this although the debate continues. The attributes identified above precede the competency tick-boxes. It is hard to imagine a trainee with the above attributes who does not go on to acquire the required competencies unless some impossible obstacles hinder their progress. There are people who seem to have the above attributes in spades. As educators we just need to point them in the direction of what they need to learn.
I guess some would want to add other attributes such as insight or resilience and I wouldn’t argue with that. They are perhaps even more basic to life generally.
There have been attempts to describe and operationalise some of the occupational attributes of the GP (eg Situational Judgment Tests – a topic for another post) in the hope that these will have predictive validity.
The recipe – the benefits of a training program
Of course the main question for educators is whether such attributes can be taught or their lack compensated for. Some trainees commence training with these attributes evident and seem to grow organically. They make it through regardless. Other learners need to have a top up in one or more of the ingredients and some need a bit more stirring or leavening before being put in the oven. These ingredients need to be mixed together in appropriate quantities and cooked for the required length of time. This is the benefit of an appropriately-resourced training program that articulates the best recipe for success. Hopefully an effective program optimizes this process with less wasted trial and effort of the ad-hoc approaches of a generation ago. To push the metaphor however, shortcuts may also decrease the quality of the product so we should beware in the future.
A bit more necessary spice
These basic ingredients have always been relevant in the making of a good GP but perhaps historically the preferred flavour has changed over the decades – a basic sponge is not good enough for current needs and perhaps different spices are required in certain practice contexts. This means that specific curricular content and required skills change over time – and the curious, caring, conscientious doctor takes this on board. Over the years we have recognised and encouraged the crucial ingredients and added in some of the specifics needed to produce the outcome appropriate to the needs of our community at this point in time.
The garnish – exam technique
Although being a good GP is the ultimate goal, passing the relevant exams is obviously crucial so, as educators, we are required to add a collection of more or less exotic “garnishes” which represent the methods of assessment appropriate to each sub-culture. Thus the registrar who we believe will be a good GP also needs to ensure they are acquainted with the relevant exam strategies before their task is finished – be they OSCEs, KFPs, or MiniCEXes etc. The appropriate garnish may just make the difference in the reality cooking show metaphor of training!
I will look at other potential, more measurable, predictors of training outcomes later.