This last week I noticed this encouraging headline in Australian Doctor in regard to GP Training.
It reinforced the sense that the apprenticeship model for training has a lot going for it and the GP Supervisors at the coal face are perceived to be doing a good job. It was only when I logged in to the full article that I noted the fine print under the headline – but some are dissatisfied with the support of their Regional Training Organisations. This satisfaction has apparently decreased significantly since the last government shake-up of training and I guess that reiterates the message of my last blog – that there are challenges facing the colleges as they resume oversight of training and that training programs are not just exercises in efficiency. Neither are they pure academic exercises. They are affected by politics and ideology and it is necessary to keep in mind that the learning environment we are setting in place now will affect future generations. Training systems are crucial in creating a positive learning environment and if you are involved in training it is good to keep this broader perspective in mind. Education is more than what you do in a lecture or small group or the feedback form you fill in for the individual learner.
Some dialectical choices for GP training
We could see some of the issues perhaps as dialectical choices facing future decision makers. The first obvious tensions are those of professionalism vs managerialism and collegialism vs corporatism. A managerial approach may have been seen as a solution to inefficiencies in education and training but it has also sidelined educational debate. It has been recognised in education for a couple of decades. Managerialism has itself gone through several incarnations with neoliberal managerialism emphasising competition and markets and now neo-technocratic managerialism focussing on metrics at the expense of other values. Here are a couple of interesting articles I read previously on this topic.
Even our way of speaking about health or education has been infiltrated by the managerial lexicon and thoughts and actions soon follow the language. Neo-technocratic managerialism reduces the technical expert to being a content provider while education is reduced to what can be measured and reported. We start to think only about what we can measure. The BMJ article I’m sure will spark surprising recognition. It’s a tongue in cheek article describing this whole process as Management Language Syndrome which has now become a chronic disease – and like obesity it is supported by the environment. http://www.bmj.com/content/359/bmj.j5661
This is why it is important to consider the personal vs metrics. It is very easy, when managerialism encourages priority of efficiency over other values, to be tempted by the panacea of IT and online solutions for everything. Sadly, experience in other countries has already demonstrated that the cons can be just as crucial as the pros. The related challenge to this is to keep reminding ourselves of the place of IT. Is it functioning as tool or master?
Having spent time in the UK I have observed a stretched health system where individuals are held responsible for system failures. There is an increasing international tendency to talk about teaching “resilience” (apparent in the recent AMEE conference) but we shouldn’t need to teach resilience so people can survive unhealthy systems. The issue of support for trainees and students is crucial to quality training. In fact, our systems should model the values we are trying to instil. If we feel it is important to produce GPs who are able to relate, to nurture, to have empathy, to take note of evidence, to communicate well, to respond to the whole person, to be curious and adaptable – then ideally the training environment should exemplify these values and attitudes. We are all aware of studies where experience in a hospital system can negatively affect values inculcated in early medical school.
In this corporate world it is almost mandatory for organisations of all types to claim to have “world best practice” and to have mission statements regarding quality etc. In the educational sphere we need to hang on to the reality that quality is not just about repeating “we are the best”. Brand and marketing are ubiquitous in today’s culture and we are not immune. It is obviously important in selling a product but we need to acknowledge that not all human activity can be reduced to selling products, people are not just consumers and education and health are not merely business. There is often a choice of brand versus substance.
How do we know we are “world class” if we are not outward looking enough to know what the rest of the world is doing and to evaluate it? This brings me to another dialectic of parochial vs global. I have recently been at AMEE with between three and four thousand medical educators from the rest of the world and there is much we can learn and from which we can benefit. A speaker in a session on feedback was describing studies on written versus audio feedback (the latter being preferred by students) and quoted from a 2014 study which still concluded that “It is only the relationships between the student and the instructor which can enhance learning.” A symposium on dilemmas in supervision raised many of the complexities of supervision and assessment and the fact that existing systems do not always support quality supervision.
A lot of these debates and dilemmas could be approached by keeping in mind that education is interpersonal. This is very much underlined by sociocultural theories of learning and the literature on the influence of mentors and role models. Do our systems, processes, methods etc facilitate or hinder the interpersonal aspects of education? What can be done to mitigate the threats? How can we support the learners if we don’t know them and they have become just numbers? If the personal is lost this will be to the detriment of good training and the quality of our future medical workforce. It is a challenge to be consciously faced in medical education by educators, policy-makers and managers.