Monthly Archives: February 2018

The learning environment and safety

This week, even in Australia, there has been discussion (on two ABC radio programs: Saturday Extra and The Health Report) about the Bawa Garba case which has stimulated so much discussion in the UK. I won’t summarise it except to say a paediatric trainee was ultimately struck off by the GMC after being convicted of manslaughter when a young patient died in 2011.  There has been much angst on Twitter and articles in the BMJ and lengthy discussion about workload, understaffing, whistle-blowing, the role of supervisors, the use of reflective journals in training and so forth. I could illustrate this blog post with any number of Tweets. There has subsequently been a justification of their position by the GMC on their blog (links below).  You can read the details yourself but the issues I feel it raises for educators are those of patient safety and a “safe” learning environment for learners.

For any educators responsible for work-based training it is important to consider what sort of learning environment is provided by the work environment. The GMC claim a strong emphasis on patient safety as do all health systems and training programs.  Their explanatory document maintains that clinical supervisors are required to adhere to high standards. The impressively titled document Promoting excellence: standards for medical education and training repeatedly notes that patient safety is the first priority but notes that Patient safety is inseparable from a good learning environment and culture that values and supports learners and educators.  I don’t work in the NHS but I am well acquainted with documents about training standards. In the Twittersphere many in the NHS are commenting on their current work load, even as they head in to a shift, and asking on Twitter, in effect, should I work today when it is not safe?  The GMC advises they should work and follow their algorithm for making complaints but other tweets make comments that this algorithm does not work in the real world.  Policies, standards, statutory regulations and accreditations seem only able to delegate accountability rather than to ensure the quality of the system.

The other recent popular response is to focus on producing “resilience” in doctors – yet again focussing on the individual for the solution, rather than on the system for some responsibility.

Discussion has progressed about strategies for maximising patient safety in various health system contexts. Professionals are trained within a health system which also provides the learning environment and this is a complex situation. How can the safety (for patients and learners) of this training environment be ensured and whose responsibility is it when issues occur?   Can you always be a good or safe doctor in an unsafe environment? A further question might be whether we can rely on increasing rules and regulations (and increasing delegation) to really ensure quality and if not, what does?  When is it the responsibility of the medical educator or supervisor to not only comply and tick the relevant boxes but also to speak up when the system is not functioning to facilitate the safety of the learner or the patient?  It is probably not enough to introduce a module on resilience in the hope that learners in future can cope with a dysfunctional system should it arise.  I am sure the debate will continue.


  • A very interesting account of what happened clinically by concerned UK consultant paediatricians.

  • The link for the GMC blog explanation is on,5ESIO,PGBN9B,KXV14,1

Happy Groundhog Day – some thoughts on innovation

I wrote this on February 2nd, a date for which I have a soft spot and which is officially known as Groundhog Day in the US. Some of you may remember the film of the same name made way back in 1993! It was sort of “deja vu all over again”. I hear it is now a popular musical by Tim Minchin.

I vaguely recall that Phil, the reporter/weatherman (Bill Murray) is forced to relive this day (and the assignment he disliked) ad infinitum but he eventually tries to utilize it to learn new skills and to change things bit by bit. In Groundhog Day Phil breaks out of the time loop eventually with no overt explanation in the film (all the better to provoke ongoing interpretation and speculation) but discussions speculate on issues of hedonism, self improvement and philanthropy apparently. Without getting all philosophical the idea of a repeating Groundhog Day has still entered the movie goers’ lexicon.

It reminds me of some educational delivery – but not in a bad way. You get up in the morning at the beginning of the academic year, or a new term, and there’s a feeling that it’s just the same thing again. And indeed it is to some degree, especially where the implementers and deliverers have no power to change things. And the larger the bureaucracy the more this is the case. The syllabus has, of necessity, been planned ahead; The curriculum is fixed by a particular body, the infrastructure is designed by some other administrative group, the standards are set and measured by the relevant groups and job roles are spelt out in employment contracts.

However, as in the movie, each day the protagonists try to make incremental changes based on the feedback from previous experience. Let’s change the way we teach this concept; let’s involve the learners more in this workshop or this day at the surgery; how about I try and ask more questions rather than giving easy answers. I mentioned incremental changes automatically – because I’m a fan of this sort of quality improvement – but also deliberately after listening to an ABC Future Tense podcast on “Innovation” (from 19th March 2017) on the way to a short break on the South Coast this week. It’s worth listening to but some of the random points that struck home to me regarding education included the following:

  • It noted that innovation has become all pervasive in the business and political lexicon ( and I’m sure it rings bells in all our educational vision statements)
  • It suggested that it has become too technology focussed and advises ensuring it maintains a people focus
  • It noted that it didn’t always have to be “disruptive” or involve a big new idea. Most effective innovations are incremental improvements on what exists already (like wheels on suitcases) and often ideas are taken from other countries and then applied at home.
  • A useful definition is “new ideas successfully applied” (which emphasized for me the importance of evaluation)
  • It might be a vague buzz word but it is still important
  • Successful ideas and processes in one sector are not always successful in a different sector (business is different from education)
  • Much innovation is transferred through informal relationships
  • Being adventurous can sometimes be necessary as can government funding
  • There was some final advice to “not try to impose innovation on everything that moves.” This was related to the attempt to put an economic value on everything including things that can’t be measured (eg the arts) and reducing things inappropriately to a simple formula.

These thoughts also linked, in my mind, to references that the Finnish educationalist, Pasi Sahlberg (recently relocated to UNSW in Sydney I believe), makes to the use of “small data”  Big data is everywhere and some managers are very excited by it. It’s a great tool and I have often chased bigger numbers and interesting correlations. But it has big limitations and correlation tends to be where it stops. Pasi mentions the human observations and critical reflection that make up small data. It is part of the crucial interpersonal nature of education. Small data at a local level helps illuminate what works best and why and, as educators, we do this on a daily basis.

So, whilst we are in the current time loop, let’s learn new skills and make incremental improvements that probably have a greater (if difficult to measure) effect for good in the training of the next generation of doctors. Pick up ideas from colleagues, conferences and journals, critically reflect and apply and evaluate to ensure they work.. This is innovation. But it would also be a plus if these changes could be communicated to others (for the benefit of all) and noticed and valued by those with decision making power. If you are (or become) an educator who is also responsible for policy then consider these aspects of how education progresses and improves and ensure they are integrated into the system. Keep the people focus, applaud the incremental improvements and value and encourage the small data.