Monthly Archives: April 2017

Go with the Flow

A theory can make sense in several ways including: 1. when you have an “aha” moment and think “yes, that makes sense” or “that describes what I’ve been trying to do intuitively” or 2.when it gives you some concrete implications for practice. “Flow” did this for me.  I first came across the concept of “Flow” back in 2006.  My husband told me a colleague of his at the university (who worked in the music industry and was interested in creativity) was excited about the topic and it sounded interesting so I bought  a book called Finding Flow  by Mihalyi Csikszentmihalyi (1997).

I discovered he had been talking about it since 1975 and has since written numerous other books until the present – which I discovered when I revisited it. If you want to get an easy explanation go to Wikipedia and look up Flow or the author.  Anyway, I did a 10 slide PowerPoint for registrars on the topic in a segment we used to call “Thought For The Day.” I thought the concepts were transferable to learning in General Practice with its ongoing experiences of balancing challenge and skill (and the question sometimes of why we keep doing it!)

What is Flow?

Learning theories often mention competence. Sometimes they move on to “mastery” and often they are concerned with motivation.  Csikszentmihalyi’s work is allied to the positive psychology school and he was interested in situations where someone experiences happiness doing what they like, feels lost in the moment and in the zone.  What motivates individuals to keep on achieving?  He researched the phenomenological experiences of elite athletes and artists.

More recently it has been applied more broadly to the educational context with the assumption (and some evidence) that individuals learn better when experiencing Flow. However, much of the literature refers to the school classroom and I haven’t found much on postgraduate vocational training although it appears to be very pertinent.  However, there is a post by Daniel Cabrera on Flow and education on the blog for clinical educators  It also includes Csikszentmihalyi’s more detailed schematic.

Are there times when you feel like that? I think I am very susceptible to experiencing Flow and sometimes stay up way too late when doing something that is enjoyable but challenging.  I’m no skier or marathon runner unfortunately.  It sounds mundane but I used to experience it when doing sewing and craftwork.  Later on I started to feel that way when producing a presentation for registrars.  Or writing posts for this blog!  I’m fairly new to Scottish Country Dancing and the teacher nicely balances our skills and the challenge of particular dances.  I recently did a drawing course and did not get bored spending two days drawing four grapes – but realise I have a long way to go.

When does it happen?

This is the simple graphic representation that is used to illustrate the concept.  In practical terms, think of a GP in training. There are times when the challenge feels way too much and anxiety can set in.  If this persists it can become chronically stressful and perhaps lead to symptoms of burnout.  On the other hand there are times when the challenge is low (endless medical certificates, repeat prescriptions, the same types of problems) and boredom or apathy set in.  Another job might be seriously considered as motivation drops.  But, somewhere between these two states is the sweet spot when a person’s skills are fully involved in overcoming a challenge that is just about manageable, where learning occurs in a safe environment and the enjoyment of this state leads the learner to gradually challenge themselves further and extend their skills.  The theory suggests an immersion in the task, a sense of control, and an altered sense of time (maybe not always good in General Practice!).

Looking for references I found a nice summary article on the net

Facilitators of Flow

You can read about these in more detail in any articles on Flow but in brief flow seems to require

  • An activity with a clear set of goals to provide direction.
  • A balance between perceived challenges and perceived skills in relation to the task. This balance is obviously dynamic
  • Clear and immediate feedback (a very familiar concept to educators).
  • A focus on the task itself
  • It’s also likely that the importance an individual places on doing well in an activity (i.e., “competence valuation”) is pertinent. Is being a good GP seen as a worthy goal?

In GP Training the challenges are high for the early registrar and their skills need to improve to match the challenges.  However, the level of challenge is very much influenced by supervisors and educators, standard setters and policy makers and is often related to:  the number of patients you are obliged to see, the range of patients you are seeing, the standards required of placements, background knowledge and skills and the learner’s access to timely help.  Matching help, support and supervision to the registrar’s skills (and comfort zone) is a finely tuned process and is reflected in the RACGP standard that supervision be matched to competence.

Obviously this involves supervisors and educators knowing the registrar’s level of competence and this can be harder than it sounds. It is not just important to patient safety and registrar safety but also to the registrar’s learning experience.  “Flow” encourages intrinsic motivation to learn. Csikszentmihalyi develops ideas about how to make education (and life) more enjoyable.  Does our current system make learning more enjoyable (or less so)?

We want a learning environment (and a system) that facilitates learning, that makes learning enjoyable and that inspires the learner to extend themselves further – not just a box-ticking of competencies or passing an exam. In terms of learning “theory”,  if you and the learner are overtly aware of these parameters that surround the learning environment it might help you to implement Flow more effectively and appreciate it when it happens. We can facilitate registrar experiences that move toward flow (and are therefore rewarding and motivating).

This concept could perhaps also be applied to us as educators in our working and learning journey.


In praise of conferences

I know of some educators who aren’t fans of conferences and others who are too busy with clinical work to make it to any. Many researchers would denigrate conference presentations compared to publications in high-ranked journals. However, the reality is that sometimes you can interact with a larger number of people at a conference than you ever would as a result of a journal article (even if it isn’t as good for your CV).  In addition some employing educational institutions are making it more difficult for employees to get to conferences as budgets shrink and, of course, if you are in private practice there is no-one to help you get there.  Nevertheless, let me encourage you.

In my experience, I have picked up the best (newish) ideas for my job as a medical educator from attending conferences. Sometimes I have returned with half a dozen interesting thoughts, discussed them with fellow educators and ended up implementing at least a couple.  I could just have read about the same topics on line but I would not have experienced the same interaction or gained an idea of where the idea stood internationally.  You can go to conferences on specific topic areas – as I did initially – but then I started attending the more educationally oriented sessions and soon gravitated to the educational conferences. The current deliverers of Australian GP training organise the GPTEC annually.

Don’t turn up your nose at the idea of going to a conference in a nice place! Choose your location as well as the topic and let it enhance family life rather than detract from it. In my first years in general practice I can recall presenting at a Women’s Health Conference on the Gold Coast.  It was ideal.  We stayed in a luxury hotel, I learnt a lot and my partner got to take the two kids to the theme parks.  It wasn’t cheap but it was something we would not have done otherwise.  The presentation was part of an RACGP Certificate in Women’s Health that I was doing.  I didn’t become a world expert (and no one invited me to give a keynote address) but for years I felt competent at Women’s Health and I followed up with various women’s health meetings and Menopause Congresses etc.

Early on I attended and presented at a combined College conference in Wellington, New Zealand – and my partner got to take the kids white water rafting.  On a couple of occasions we have both attended the same conference because he had helped me by writing software programs for teaching approaches.  Just once we both attended different conferences in the same city.  That took good luck and forward planning.  I guess I’m not the sort of person who has put family and work into discrete compartments but my work-life balance has tended to work by integrating the two where possible. After all, it’s all part of life.

Attending conferences is not the financial perk some people imagine. My previous employer paid my registration, usually if I was presenting, but not the airfares.  I have tagged conferences on to holidays (to make the travel effort worthwhile) so it has generally not been worth claiming a fraction of the big airfares as a tax deduction – just the local travel and accommodation if needed.  My kids live overseas so I’m not complaining.  Conferences I have found useful have been RACGP and WONCA (early on), Menopause Congresses, a few geriatric conferences (in Australia), ANZAHPE, Ottawa (when it was in Australia), ASME (in the UK) and AMEE – the largest medical educational conference annually.  There is nothing of the quality or breadth of this latter conference in Australia.

Choose your conference carefully. Make sure it’s on a topic you are interested in and, preferably, have some positive recommendations from colleagues.  It can be very off-putting to make the effort to go and then feel you have learned nothing new or relevant and that your time could have been better spent elsewhere.  It helps to approach it in a positive way and realise that the quality of sessions will be variable.  Choose your sessions carefully – there are often many to choose from.  For some topics I had already read about them and then chose to attend workshops or symposiums on the topics.   These included:  Progress Assessment, Programmatic Assessment, Entrustable Professional Activities, Portfolios, Script Concordance Tests and others.  Sometimes there is a greater smorgasbord of ideas to pick from if you attend short presentation sessions for some of the time.

I arrived back from these attendances more excited about my job (and with a broader perspective) which has to be a good thing. It was great to connect in person (sometimes over a meal) with colleagues who are on the other side of the country and happened to be attending. It was helpful to present something (usually a short paper) as that honed my thinking on a particular topic. I used to come back feeling encouraged that we were actually doing things pretty well in Australia at the time. Education is often about changing ideas and evidence and implementing them successfully and there is only so long that you can be happy with administering processes and encountering nothing to stretch your mind. It has also been stated that education is essentially interpersonal and interactions with others who share your interests can be more productive than merely reading something on line.

What can you learn from me in a more negative sense? Well, I didn’t network enough (academics can be a bit cliquey and often there is an “in-crowd”) as I ‘m not very assertive. Being in GP vocational training is a bit more of a “part-time” vocation than being in academia and the medical education conferences are dominated by undergraduate education and research.  I didn’t become (or put myself forward as) an “expert” on one topic – I tend to be interested in a broad range of things so I spread my interests too broadly.  In short, I didn’t leverage off the opportunities.  Maybe, like many GPs, I see myself as a jack of all trades.  But how you evaluate that depends on what you want to get out of the experiences and your philosophical framework.

I’m sure those in undergraduate education are still getting to some conferences and, since GP Training has been disrupted and reorganised, there is a great need for those in post-graduate vocational training to broaden their skills and perspective and increase their enthusiasm. We all need to have our initial passions reignited from time to time. In the broader scheme of things it is beneficial for Australian training, long-term, to have access to international experiences rather than being parochial. Take the leap, as many grass-roots GPs do, and take yourself (and family if appropriate) off to an interesting conference in a nice place.  Recharge your batteries. Stave off burnout.  Perhaps go with a colleague with whom you can debrief, chat and gain support from on your return as you plan those “innovations” that make your job more interesting, more worthwhile, more effective and more rewarding.