Author Archives: Cathy

Communities of Practice in MedEd

Post #50: This blog was started three years ago with the aim of providing some easy-to-read medical education content, mainly for starting-out medical educators some of whom had expressed the view that they felt unsupported in their new environment and, further, felt unfamiliar even with the language of medical education.

This is the sort of problem that should be ameliorated by the experience of belonging to a community of practice – a fairly recent concept and one with potential, which you probably know from learning theory.  It seems to be an appropriate discussion for this fiftieth blog now that some of those newish MEs, that I met initially, might now be more senior MEs and already mentoring younger educators.  I’m not going to get very academic regarding this topic except to say it arose in the writing of Lave (anthropologist) and Wenger (educationalist) in the 1990s.  Another related concept was that of Situated Learning.

What is a Community of Practice (CoP)?  It’s a group of people who share an interest in, and concern for, a specific area, and interact with each other in order to work out how to do it better.  It can be applied very broadly but is often applied to disciplines or professions although it has been applied in business settings. It is fairly easy to see how it can apply to a general practice whose staff meet together face to face regularly but it can also be a virtual community of practice – perhaps around special clinical interests such as sexual health or mental health for instance. Medical Education is obviously also a special interest within medicine and you probably feel you experience your community of practice when you attend a conference or workshop for instance.

Do you feel you are indeed part of a CoP? Is your CoP inward looking or outward looking?  Sometimes such a group might be fairly parochial and inward looking, focussing on the practicalities of the organisation in which you all work.  The most value from a CoP is probably when it is also outward looking, when you can interact and exchange ideas with those involved in “medical education” but who are working outside your specific context.  So, university tutors and lecturers might interact with GP educators and supervisors at a conference when they all attend a workshop on assessment for instance.  You might gain new ideas and knowledge from an international conference. This idea aligns with one of the rather philosophical “tensions” that Wenger went on to describe in relation to CoPs – that between local and global.  These tensions help contribute to development and creativity. You could explore these ideas further if you wish.

What sort of workplace are you working in – both clinically and in education?  Are there supportive relationships?  Is there challenge and growth?  Is there time for sharing knowledge and experiences? Who is responsible for nurturing all that within your CoP?  Remember that motivation for actively participating in communities of practice can be intrinsic or extrinsic.

Why bother with a CoP?  You can probably answer this yourself from experience.  Being involved in a CoP may have improved your professional knowledge or performance and also your morale in your job.  However, a couple of reviews of the effectiveness of CoPs in improving health care performance for instance have been a bit inconclusive.  Some of these were in terms of the goal of improving productivity in the context of funding shortfalls in the NHS – a fairly limited goal.

Just calling a group of people a CoP does not necessarily mean they function as one. You can read more about them here. http://www.linqed.net/media/15868/COPCommunities_of_practiceDefinedEWenger.pdf  Wenger described three characteristics of CoPs:

  1. A Community where individuals participate, commit and build collaborative relationships (NB in practice, there will be differing levels of participation).
  2. A shared Domain of interest
  3. A shared Practice

This article https://www.rrh.org.au/journal/article/4195   looked at the growth of a rural medical education CoP in the US which involved the development of relationships over time. One can see that this is a more tightly focussed topic.  It also has what members must feel is an important purpose, which is one of the facilitators of a CoP.  CoPs can also function to maintain and share the more tacit and less measurable aspects of the knowledge that is core to the community.  The concept has been much used and discussed in the business sector – but bear in mind that health and education are different in many ways.

A 2012 article looked at the literature on GP Training and virtual CoPs, speculating that such virtual communities might be useful in decreasing isolation for registrars. It utilised a framework from the business literature – and found differences in the way concepts were applied in the different sectors.

http://www.biomedcentral.com/1471-2296/13/87 They reported that, at that point, there were no studies on Virtual CoPs in GP Training. For trainees these would tend to be more in the area of clinical skills and knowledge rather than education.  For Virtual Communities of Practice, the technology was crucial, with consideration of blending of online and face-to-face. 

In medical education, in the context of constrained funding and resources (a phrase repeated in so many areas), Virtual CoPs may also be favoured but attention should be paid to the effect on the quality of relationships and collaboration.So there is a challenge for you – find space to develop and utilise Communities of Practice to develop your professional skills, to enjoy your career more and encourage the next generation!

On the smell of an oily rag: risks for teaching in a resource poor environment

From an educational perspective there has been much talk of the benefit of learning in the clinical setting.  In addition, the increase in the numbers of “learners” across the board and the shorter stays in hospitals has also created an imperative to divest some of the learning to the community context. As the numbers of students and registrars increase there appear to be expectations that more and more doctors will be trained in that generic environment called “the community.” But like many things transferred to the community, funds rarely follow.   The positives of learning in the community setting are huge but there are also challenges, especially where community practice is largely private practice. 

The benefits include the broad clinical scope and the chance to see earlier presentations and undifferentiated symptoms instead of the already diagnosed and streamed.  It also creates opportunities for experiencing prevention, continuity and seeing patients in their broader social settings.  And much more.  However, how do we ensure equivalence of clinical exposure across disparate settings and supervisors, maintain quality control across an environment over which we have little control generally and how do we generate enthusiasm for teaching when taking time out to teach is a financial loss?  I think there is general agreement that expectations are increasing but support, resourcing and funding are not keeping up (in Australia).

Resources for medical education are variable.  When there is a new medical school opened to great fanfare there is often a welcome flush of funding.  In many instances the medical school proclaims a new approach to medical education and there may be a well-resourced medical education unit – for a while at least.  On the other hand, teaching within the hospital environment can also be very variable and dependent on local policies, funding and priorities.  Often there is time allocated (in theory) for the education and training which is written into many of the relevant standards for post graduate training.  Each country has its own systems.  The funding pool may come from universities, the national government or local health networks and those who are in training are often buffeted between systems operating in silos.

Doctors are supposed to be teachers, or so it is maintained when the etymological origin is noted in the Latin verb “docere”.  In the middle ages it meant “learned person” and “doctor of the church” and I guess we have moved quite a way from that.  There is also a handy assumption that if you are a good doctor you will be a good teacher or that it is something that is easy to pick up along the way and doesn’t require many extra skills.  And, of course, in practice, the demands of clinical professional development necessarily compete with those of teaching skills.  So how many doctors are indeed teachers?  It’s impossible to know really but certainly in the hospital context there is an expectation that the more senior doctors teach the more junior ones.  In General Practice, functioning as a small business, it is a choice as to whether to take it on.  Does everyone go into medicine or general practice expecting to teach?  And what is the motivation for teaching? The status of a teaching role varies across different systems – have a think about this – and this is perhaps reflected in the priority given to professional development in this area.   This has been brought increasingly to my attention as I am working on some modules on clinical teaching and supervisio

So how do you teach effectively in an increasingly resource poor and yet increasingly managerial environment?  Individuals, as always, squeeze it in to busy days while trying to maintain quality and funders and managers focus on efficiency. Do we put up with mediocre and variable, will it become bureaucratised or do we combat it by paying well and maintaining the standards or by somehow creating a supportive community of practice?  It is indeed possible that we are relying on a rapidly drying up source of good will and altruism.  GPs can just say “I’ve had enough” when the paperwork escalates or the resources decrease beyond a tipping point. 

Obviously institutions and policy makers will continue to take the most economic course possible as their own resources are stretched but those making the decisions need to know that the way the organisation functions may make the difference between enthused and engaged teachers and dispirited ones ready to give up.  A few “ifs” to consider: if policy makers want positive outcomes for patients and the community; and if the quality of the education influences the quality of the professional at the end of training; and if you want a sustainable educator workforce then perhaps you need to be looking at the implications of this and advocating at various levels.

In many parts of the health system, space is not made for teaching and training and in others, GP teaching is not always taken seriously.  Value can be added by providing appropriate support and professional development but it is a challenge.  Efforts can be made to make the total environment more positive for learning and utilise the whole health care team.  This blogpost really has no answers at the moment and is more of a warning. In some ways it will be up to the next generation.  There will always be enthusiastic and brilliant teachers but will their efforts be sustainable?  Will it be a rewarding career option?  Will it be enjoyable?

How will the next generation be trained – and will they indeed be trained rather than educated?

A few rhetorical questions: Do you value your educators and supervisors? Do you know them? Do you enthuse them? Do you support them?  These are places to start.

Teaching critical thinking – and other “soft skills”

I noticed this tweet and reply this week. When indeed did critical thinking become a soft skill? That response was by a medical researcher. No wonder we have to keep thinking about teaching it, if it isn’t given priority in the previous levels of education. Perhaps critical thinking is not welcome when it comes to voting but in the field of medical practice a critical mind is crucial. It’s obviously crucial in research and its crucial in all stages of applying evidence based practice.

I had previously had in mind to do a blog post of the “non-clinical skills” that are required to be taught in training. This was stimulated by a talk I went to in September at the EURACT conference which talked about the new capabilities framework in the UK https://www.gmc-uk.org/-/media/documents/Generic_professional_capabilities_framework__0817.pdf_70417127.pdf to be applied to all postgraduate training. The talk was by someone from the RCGP who described how the GMC have now mandated new domains to be continually assessed during training. These include, for example, capabilities relating to patient safety and quality, leadership, research, professional knowledge, education and training and so forth. So far so good.  It did not sound too different from the roles in the Canmeds framework (although the “continually assess” sounded a bit ominous). The speaker stated that these were to have equal emphasis with clinical knowledge and skills. They had enthusiastically embarked on teaching a research component in GP training which had been evaluated positively by selected and engaged supervisors and registrars. They reported they were now faced, however, with rolling it out to everyone and admitted there might be challenges with non-engaged supervisors and struggling registrars.

These non-clinical skills are obviously relevant for clinical people and perhaps even more so for those involved in education. I recall from my student days when students (and some staff) tended to give a bit of a nod and a wink to the equal weight given to the different domains in the curriculum. Similarly it is quite frustrating as an educator when learners object to spending time on “soft stuff” that we think is crucial and worthwhile. On the other hand it is quite understandable for learners to feel under pressure from an increasingly busy curriculum, the need to pass assessments and the perceived safety of patients if their clinical skills are not up to scratch.

I think there are a few points that can be noted from this. There is a responsibility for educators to evaluate the curriculum and ensure it is not just comprehensive and responsive to various stakeholders (academic, political, legal or regulatory bodies) but also meaningful to the learners. We also need to convey why these other domains are important and how multiple competencies contribute to the performance of a clinical activity. From an educational perspective are these capabilities teachable and are they assessable? From a teaching perspective it is also preferable to teach in context. So, “critical thinking skills” are more effectively taught in a context meaningful to the adult learner (probably the clinical context for most medical learners) and not abstracted from the domain specific content which the learners are seeking to master. I addressed this aspect in an earlier post http://mededpurls.com/blog/index.php/2018/10/04/making-the-implicit-explicit-a-core-concept-in-clinical-teaching/  This may help prevent them from being siloed as a “soft skill” but this complexity does however make it more of a challenge to document and be accountable in a managerial sense – and this latter priority often predominates. Learning in the context involves articulating your thinking and this is particularly so for the clinical supervisor.

So, consider, with our increasingly impressive curricula and standards, is there a divide between what is stated, what we actually teach and what we test? And how is it perceived by the learners? We need to monitor the bigger picture of what we are doing in education. Bear in mind that some similar requirements may one day be coming to a training program near you.

 

Confound it! How meaningful are evaluations?

We generally state that we should evaluate our teaching. It’s a good thing.  But how meaningful are some of these exercises?

Just recently I saw a link on twitter to this delightful article entitled Availability of cookies during an academic course session affects evaluation of teaching” https://www.ncbi.nlm.nih.gov/pubmed/29956364  If this had been published in December in the BMJ I might have thought it was the tongue-in-cheek Christmas issue.  Basically it reported that the provision of chocolate cookies during a session in an emergency medicine course affected the evaluations of the course. Those provided with cookies evaluated the teachers better and even considered the course material to be better and these differences were reported as statistically significant.  Apart from making you think it might be worth investing in some chocolate chip cookies, what other lessons do you draw from this fairly limited study?

There were a few a few issues raised by this for me. Firstly it made me reflect on the meaningfulness of statistically significant differences in the real world.  Secondly it made me quite concerned for those staff in organisations such as universities where weight is sometimes placed on such scores when staff are being judged.  This is because, thirdly, it brought to mind the possible multiple confounders in attempts at evaluation.

When considering your evaluation methods, consider various issues: how timely is it if it is participant feedback? If you intend to measure something further down the track such as knowledge acquisition, at what point is this best done?  Question the validity and reliability of the tools being used.  Consider using multiple methods.  Consider how you might measure the “hard to measure” outcomes.  If programs (rather than just individual sessions) are being evaluated then ratings and judgments should be sourced more broadly.  I will not go into all the methods here (there is a good section in Understanding Medical Education: Evidence, Theory and Practice ed. T Swanwick) but the article above certainly raised points for discussion.

Surprisingly, student ratings have dominated evaluation of teaching for decades. If evaluations are in an acceptable range, organisations may unwittingly rest on their laurels and assume there is no need for change.  Complacency can limit quality improvement when there is an acceptance that the required boxes have been ticked but where the content of the boxes is not questioned more deeply.

More meaningful quality improvement may be achieved if evaluation methods are scrutinised more closely in terms of the relevant outcomes. Outcomes that are longer term than immediate participant satisfaction could be more pertinent and some quality measures may be necessary over and above tick box responses.  The bottom line is, consider the possible confounders and question how meaningful your evaluation process is.

Making the implicit, explicit – a core concept in clinical teaching

Learning in a work place such as general practice has its challenges. A student may give feedback that they feel the placement is a waste of time.  They sat in the corner of the consulting room observing the GP interact with many patients but did not feel they learnt anything.   A trainee may complain that their supervisor doesn’t seem to follow evidence-based guidelines in their management of patients.  It is a different learning context to the classroom and I have been thinking about this recently.

I have just attended the EURACT (European Academy of Teachers in General Practice/Family Medicine)  conference in Leuven, Belgium. It’s the first time I have been to this conference and, in fact, this is only the second of planned two yearly conferences. There were just over 200 attendees and this contrasted with the AMEE conference in Basel which had between three and four thousand participants. The other big difference is that AMEE caters for all those involved in medical (and other health) education and largely at the undergraduate level. That is a huge field.  EURACT was focussed specifically on teaching in general practice “in the real world” but it’s breadth lay in the diversity of countries represented, extending from Ireland to Turkey. I was the sole Australian and when queried about why I would attend a European conference I did liken it to Australia being in Eurovision!

I attended because I am currently involved in writing modules for a certificate in clinical teaching, geared specifically for GP supervisors of undergraduate students.

In at least three of the conference sessions I attended there was mention of making the implicit, explicit or the invisible, visible. This had already been an emerging theme as we developed the certificate modules.

It is described in the literature on learning theories (such as the cognitive apprenticeship model) where there is an emphasis on articulating what you are thinking.  We had discussed it at length when exploring how to teach clinical reasoning – a topic missing from many courses but one that is highlighted when supervisors later encounter trainees who appear to lack good clinical reasoning or fail exams because of this.  Clinical reasoning is a crucial skill for doctors (obviously) but there are nuances in the GP context.

At the conference the strategy of making the implicit, explicit was mentioned in several contexts – in relation to teaching both clinical examination and diagnostic skills and in the teaching of evidence-based medicine (EBM) in practice (rather than in a didactic series of lectures).  At the University it may be possible to didactically present content. The teachers may not necessarily be involved in the muddy waters of clinical practice (and may be dismissed as inhabiting the ivory towers of academia by those who perceive themselves to be at the coal face).  It is rarely so straightforward in practice.

We often claim that work-based learning is the most effective but it is also variable and unpredictable. The idea of making the implicit, explicit can be seen as a theoretical underpinning or as a strategy.  For instance, you have a clinician teacher who developed his or her skills during their training (in various ways) but these skills are applied (as experts do) almost automatically and unconsciously in the clinical situation. The underlying thinking or the way of putting the skills together does not seem obvious to the learner. Their consequent learning is laboured or hit and miss. The teacher’s application of their knowledge has also been modified by experience and context and it is a challenge for the learner to extract the principles from the wealth of detail in the clinical practice they are observing.  Thus it falls to the clinician teacher to articulate how they are thinking when puzzled by a diagnosis, to explain the complex influences that led them to prescribe a particular medication in this consultation or to justify their choice of examination or investigations at this point in the process.  It goes further than just listing the available evidence but puts it into context.  EBM is about applying evidence to the individual ‘s situation- but this is only realised in clinical practice, so students can make the most of this opportunity.  

How do we apply this in practice?  As an educator, remember to ask questions and expect the student to ask questions. Why do you think I did this?  Do you have any questions about what I just suggested?  What would you have done?  What is influencing my decision here?  Do others do it differently?  What is the latest on this according to what you are learning at University?

Get into the habit of asking yourself questions ie reflection.  Have I changed my management over time and why?  Am I up to date in this area?  In addition, it is the supervisor’s role to facilitate the learner to articulate their own thinking as they examine a patient or present a case. “I think I can guess why you did that but can you describe your thought processes that led you to it?”  Sometimes it is sufficient to be able to identify and describe the learning within the consultation so that it is recognised by the learner.

In the academic environment, clear principles and curricular content may be presented. In the real world of clinical practice we need to draw out the principles and curricular substance within  the complex human interactions – to make the implicit, explicit and to guide students on the path from novice to expert.

 

Slow Training

I’m generally not keen on analogies but it seems to me that the ideas implicit in the Slow Movement have a certain relevance for medical training.  Or have we missed the boat already?

“Slow” Education

I recently spent a week in Brittany on a Full Immersion French course.  This was not totally Slow Travel.  We travelled by plane and train and rented a car.  However, we stayed in a beautiful place (the bed and breakfast was a converted farmhouse with a lovely garden) where our lunches were created from food grown in the garden.  I went on excursions to the local towns with the teacher and learned about their involvement in the local community as we chatted over breakfast.

I deliberately slowed it down because I also spent time relaxing with the family.  It wasn’t onerous but I learnt more relevant French in that week than if I had attempted an online course or gone to weekly lessons (as I did previously).  It was very individually adapted to my learning needs – my knowledge base, my interests – and it was interactive and interpersonal.  Lots of educational concepts were incidentally observed as I experienced the excellent teacher!

Generally in life, I’m not good at being slow so it’s something I am forced to think about.  I like to get things done and ticked off.  I had two babies while going through medical school decades ago and felt obliged to take no time off.  I wouldn’t advise that now I suspect.

The Slow Movement


The Slow Food movement originated in Italy when a group of activists protested against a McDonald’s being opened in their area.  It’s now a global movement with positive aims to join up the pleasure of food with ideas about community and the environment.  Now, I am no Foodie and I am not ideologically averse to popping into McDonalds when travelling, but I can also see nutritional benefits in slow food. There are now Slow Travel and Slow Cities.
The Slow Movement overall makes the point that faster is not always better. The philosophy is about doing things at the right speed (not just the slowest speed) and as well as possible. It’s about quality over quantity and experiencing and savouring rather than just counting the time.   Can it apply constructively to education and training
?

Slow training?

It would seem that this might be an option in the context of Competency Based Education (CBE) where the important issue is not how long you take but whether you reach a pre-determined competency.  However, I’m sure educators will have noticed that CBE is generally contrasted with time-based education and the hidden agenda is often the possibility of getting learners through more quickly – if someone is already competent why should they have to “do their time”?  Fair enough.  The now disbanded possibility of “acceleration” in Australian GP Training embodied this concept somewhat.  Is it a problem (for whom?) if someone takes longer than average to “complete” training?  Some systems refer to “Less-Than-Full-Time” (perhaps to emphasise what is “normal”) but less-than-half-time was pretty flexible in terms of fitting registrars into stretched practices at variable times during a term rather than wasting time waiting for the next placement. It also enabled those who needed it to ease back in.  If this results in a happy trainee, a practice whose needs are accommodated and a competent GP who completes training, I would suggest this is preferable.  Forgive my polemic but I believe it is based on good sense and evidence.

Longer training is not a problem for the individual if their practice options are not too constrained.  Similarly it is less a problem for the system if it is recognised that they are contributing meaningfully to the workforce.

A few years ago I presented in a Dangerous Ideas segment of a conference – arguing in favour of part- time training.  In many training programs it is a battle to get a part-time position and it is very rigidly defined. Realistically it is also challenging for large organisations (size is often a determinant of training style). At the end of the talk people came up to me saying they wished they could train in Australia where it seemed so flexible.  Most of the options I mentioned then, no longer exist.  This is despite the fact that measured outcomes, apart from “time to completion”, were not negatively impacted. Among these learners, who had made the most of flexible training, some had taken time out to do “electives” which included extra clinical work for twelve months or more (eg Obstetrics, paediatrics etc) or work with overseas aid organisations.  There were no easy statistical measures to explore how these experiences may have benefitted this small group of individuals and the communities in which they ended up working.  They were a small enough group to have negligible impact on overall completion figures. A more senior registrar used to advise new registrars to “take their time” because they would never again in their career have such an opportunity to learn.  But have we now missed that boat?

Benefits of Slow Training

Other benefits (in the context of general practice) were often increased continuity of care while working part-time (over longer attachments) – important learning for the registrars and a positive for their patients. Many registrars at the end of training said they wished they had a bit more time to consolidate their knowledge.  They didn’t feel quite ready after the rush at the end of training to pass exams.  I believe other training programs in other countries have experimented with elective terms at the end of training.  In other countries GP training is, in many instances, longer than in Australia so perhaps there is some leisureliness programmed into their systems. Issues have been noted with the tendency for systems to act as if one day you are not competent but the next day (ticked off and credentialled) you are now totally on your own. This is perhaps where the more recent thinking about graded levels of entrustment could be usefully applied.

It is also arguable, knowing that our “up-to-dateness” diminishes over time after graduation or Fellowship, that if we compared ex-registrar cohorts ten years down the track, that those who took longer to complete would be more current in their knowledge and management than those who exited in minimum time.  An interesting point to consider in terms of the community and the goals of GP training.

Another benefit of Slow Training for the individual is likely to be a decrease in burnout and therefore, for the system, less drop out and, for government funders, a more sustainable workforce.  But this requires longer term thinking.  The shorter term is often concerned with outputs – and numbers are certainly important to report.  Perhaps those of you on the planning side of medical education can realise how crucial it is to put significant and informed effort into meaningful KPIs.  Education is so much more than what is delivered on the day, online or even in one-to-one discussion.

The importance of time and place

I realise there is a different train of thought in procedural speciality training because of the perceived absolute number of hours needed to acquire expertise – in a required range of procedures.

But general practice is about breadth – and a breadth that keeps changing.  In theory GP Training (or at least, learning) continues until the day you retire.  There is never a day in clinical practice where I don’t go home thinking “I need to know more about…..”  There is not a finite list to master – although we may try to produce lists that define overall minimum competency in a particular way.  Some generic skills (eg communication) would be expected to improve during training but GP education is not just about an incremental and chronological improvement in a limited set of skills over a set time period (milestones).   It is about acquiring a range of knowledge and skills from each very different clinical placement and this path may be different for each trainee.  It is easier to apply milestones over a longer undergraduate course with a steep learning curve than to a shorter post graduate course with participants with varying degrees of commencing expertise.  The generic skills (capability) are applied to different content and competency may be acquired in one area early on (or already exist) and in another area later in training. Learning occurs in context, in communities of practice.

We already emphasise the presumed differences in “rural training” and the opportunities for learning in a rural environment.  In reality there are also nuanced differences across regions. Just as we aim for a nutritious diet but the source of the nutrients may be packaged differently region to region, so too, a basic curriculum is learned in different contexts.  But perhaps there are also benefits to regional training akin to slow food – an emphasis on quality, an enjoyment of the process, an emphasis on community and reflection.  Fast food comes pre-packaged but slow food promotes adaptability, thinking and flexibility.  Perhaps a McDonald’s in each town misses out on something. Or maybe even McDonald’s (not drive-thru) is seen as a haven of connectivity in a virtual world.

All training programs are on a continuum from minimal structure to tightly structured.  A tightly structured program may more easily ensure that prescribed content is covered in a shorter time period and may be more easily reportable. A less structured program may rely on (and encourage) more self-direction.  Some are more university and lecture based, some more hospital based and others largely in general practice.  One could compare, for instance, Canada, New Zealand, Germany and Norway.  All have their pros and cons but it is worth considering what may also be lost in being at either end of each spectrum.   Consider where we are on the spectrum from slow to fast training – how far we have moved along that spectrum and what that means for training.  OK, so the analogy isn’t perfect but it is perhaps worth reflecting on.

Education is interpersonal

This last week I noticed this encouraging headline in Australian Doctor in regard to GP Training.

https://www.australiandoctor.com.au/news/most-gp-registrars-happy-work-survey-reveals

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.

https://www.researchgate.net/publication/308012061_The_Death_of_Socrates_Managerialism_metrics_and_bureaucratisation_in_universities

https://www.opendemocracy.net/kathleen-lynch/’new-managerialism’-in-education-organisational-form-of-neoliberalism

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.

Threats, challenges and opportunities in planning programs of training

I was doing my due diligence as a College member, reading the statements from and interviews with candidates for the RACGP presidency and I noticed one saying that one of the most important issues was the college’s resumption of GP training.  He noted several issues including that the college “needs to defend and strengthen the apprenticeship model of training in the face of pressure from cheaper online or classroom-based teaching. Supervisors and registrars need to be supported and nurtured through the process”  http://medicalrepublic.comau/college-hystings-dr-bruce-willett/15384?utm_source=TMR%20List&utm_campaign=Of3d397085-Newsletter_June_30_06_18&utm_medium=email

This is certainly recognition of some of the threats to GP training (already in process) and of the challenge in the transfer of training – that is, if it is to be done well rather than assuming business as usual.  There are other things at the top of my list when I think of general practice as a whole but that is not the focus of my blog.  On the other hand, it is right up there when you think of the opportunities for the colleges and for training, at this juncture.

It would be good to build on previous quality and strengths rather than just on our laurels.  There is much that the College used to do in training twenty years ago.  Phrases such as “Education Evaluation” and “flexibility in training” come to mind.  They were also moving to regional training. It would be a step forward if the colleges (and the managers of training) were able to interrogate the concepts of quality and success more seriously (and in an evidence-based way) and to do this educationally rather than corporately – a distinction that still remains (just).  Numbers are not the only important outcomes.

Why is good training important?  I will go back to a point I made in a recent presentation that there is a connection between the way training is structured, the sort of GP we produce and the way they then go on to educate others.  This will then impact on the care received by patients and the health of the community.

The presentation was a Pecha Kucha I delivered at a medical education meeting (and which I mentioned a couple of posts ago when I was preparing it).  I learned a few things from the experience and had other impressions confirmed including (but not limited to): Pecha Kucha may pack a punch for one good idea or one short story; it’s probably good if we assume a short attention span of the audience; it’s good for engaging the audience but not so good for engaging WITH the audience; it’s not as good for getting across complex ideas; I am not primarily a performer; I’ve always struggled to learn lines and we strive to entertain rather than educate at times.  This was also supported by the written feedback I was handed!   Similar analysis should be applied to models of training – not all models and methods suit all contexts or all desired outcomes.

As my presentation was about the challenges for future GP training I might discuss a couple of the thoughts in subsequent posts.  The first point I made was that such transitions (such as the transfer of training) involve looking both back and forwards like the Roman God after whom January was named.  Some will want training to return to what they perceived as a mythical golden age and others will wish to move forwards with all the trendy disruption and technical innovation that is available.  Either approach should consider the evidence.  The greatest disappointment would be if there was no change at all and all the changes of the last 18 years (good or bad) were accepted as givens. 

This includes the move to corporatism. 

The most recent changes have resulted in a loss of corporate memory and knowledge in many areas.  As Santayana said “Those who can’t remember history are condemned to repeat it” or even as Hegel wrote “what we learn from history is that we don’t learn from history.”  Training programs are not just exercises in efficiency.  Neither are they pure academic exercises. They are affected by politics and ideology.  However, keep in mind that the learning environment we are setting in place now will affect future generations

Alliterative Attitudes for Medicine and MedEd

Recently on Twitter there was some discussion about what were the essential characteristics of a good doctor. The initial tweet said:

This was followed by replies suggesting other words beginning with C: “I’d add curious and concerned.” And “whatever synonym for humble that begins with c”. Others said “great mnemonic. I might add: Considerate.”  And  “Can I add a fourth C?  Communicative”.  All worth discussion. The occasional game tweeter suggested additional words beginning with A.

 

Someone else noted it reminded them of a poster for the 6 C’s (in the NHS) and a reply to that was “Interesting. “C” is obviously key.  The signs I put up in our department are “Caring, Clean and Courteous”.

 

My contribution was to note the three  words beginning with C that I used to quote, for many years, to GP registrars at the end of an observed session of consulting. When worried about the exam I tried to encourage them that, as long as they Cared, had Curiosity and were Conscientious they would be good doctors.  Why did I say this?

I wasn’t promising them that they would pass the exam on their first attempt. I wasn’t even promising that they would tick all the required competency boxes in the next twelve months. This was more about capability (when they need to keep learning), patient safety and future career satisfaction – maintaining enthusiasm and avoiding burnout.   It was more about continuing professional development than measuring a good doctor in the here and now.  More about attitude than current knowledge or skills.

About ten years ago I thought this off-the-cuff advice through in a bit more detail and with a bit more rationale to see where the options might lead.   The powers that be want those finishing training to be competent.  I took this as the starting point (at least as judged by various training assessments) and then looked at what might happen if they were also caring, curious or conscientious.  My exploration produced a few more words beginning with C along the way.  Perhaps a negative way to view this is to speculate on what happens if one of these attributes is not present.  If you miss one of these things, it can all go awry.   I guess I could have constructed the algorithm in a few ways but here is one version anyway (I’m sure you could come up with your own list to generate discussion).

 

Curiosity

I agreed with some of the tweeters that curiosity is essential. If you’re not curious you can stagnate.  You might not seek out the new knowledge you need to manage problems, develop new skills or be intrigued by new presentations.  If you’re not curious about the people you see every day you are at risk of boredom.  You might still be caring and well liked but eventually you risk becoming incompetent without being aware of it.  Perhaps this picture demonstrates curiosity along with a bit of tenacity!

If you are curious about medicine and about people you will never be bored.

Conscientiousness

If you aren’t conscientious, safety goes out the door. If you are conscientious you will keep up your professional development (regardless of any carrots and sticks) and you will follow up patients and ensure their safety.  But without the curiosity and the caring this might become a soulless pursuit or even an anxiety ridden approach.

That over-used concept of caring

Caring is a bit of a vague (and over-used) concept but in some of its manifestations it modifies the other two attributes. If you care about the person in front of you, you will be more inclined to conscientiously follow up and be curious about what is happening to them.  Caring can imply compassion for the person or passion for medicine and the profession.  If you don’t care – you will find it difficult to develop a doctor patient relationship, you will lose interest and motivation to head into practice each day.  A curious and conscientious doctor is likely to still be competent (and safe) in ten years’ time but they may miss some of the rewards of general practice that come with caring.  If you care about people and care about your profession then you have motivation and passion that helps you hang in there.

Obviously, if you lack all three attributes things may not turn out well, regardless of the starting point, and I would acknowledge the growing relevance of collaboration (and perhaps collegiality) in the initial tweet.  it should be somewhere in an expanded algorithm!

Here is where I add a “Caveat”. Will caring always make you more content in your career and help you avoid burnout?  Not necessarily so.  Problems with boundaries or system constraints that limit how you can help patients may cause frustration and burnout so these are things to bear in mind.  You may be a good doctor for your patients but not for yourself!  A discussion for another day.

The above is just a discussion that attempts to go beyond the current focus on measuring competencies to what keeps us going in a challenging career. In rapidly changing times we need to be capable as well as competent.  The conclusion for me is that GP training and education should also focus on these other aspects.  A training program should encourage and reward curiosity. It should recognise that sometimes a focus on ticking boxes and the often perverse incentives of quality frameworks can decrease the intrinsic conscientiousness that is part of professionalism.  It should explore the importance and implications of caring and being compassionate.  Perhaps this may also lead into the recognition of broader system issues that affect our ability to be good GPs and providers of effective primary care.

To PPT or not to PPT – that is the question

Whether or not to use a (now almost “traditional”) PowerPoint (PPT) presentation when asked to run a session is certainly a good question but it’s not necessarily THE question.  There are many more important questions in education.  However, it is worth thinking about when you are asked to present on a topic to a large number of people.  In medical education, there are a minority of instances in which a single lecture is better (educationally) than a small group or a reality-anchored, case-based discussion in the clinical context.  However, there are increasing instances when budgets and logistics require it – either in person or online.

Should you use Powerpoint or not? Opinions are divided – and strong.  But sometimes the opponents seem to be opposing a straw man (the bad PPT).

With ideas or technologies (as with drugs) there is often a bit of a dialectic: a phase of enthusiasm, a phase of backlash and then a more reasoned compromise.

Powerpoint does have its proponents in education. One argument is that it helps the more modestly skilled performer to get their material across (rather than constraining them). The critics make the point that a lecture is actually a performance anyway (and should be a good performance).  I suspect those who are keen to ditch PPT probably have some natural performing skills already.

I have been around long enough to remember when the usefulness / appeal/ memorability of a lecture depended on how enthusiastic and charismatic the lecturer was. Some certainly weren’t worth going to. Others were most enjoyable and entertaining but the content dissolved into the mists of time and had no permanent impact.  This was the “BP” era – the days Before PowerPoint.  It was quite a relief when we were able to expect that a lecture would have a structure with bullet points and take home messages

The backlash

A Guardian article sums up some of the complaints about PowerPoint, claiming it is making us stupid.  https://www.theguardian.com/commentisfree/2015/sep/23/powerpoint-thought-students-bullet-points-information It has been around for thirty years and concern about it began early.  It is relevant to note how it followed on from the overhead projector and was initially geared toward desktop graphic projection in meetings.  Of course it has now moved on to the point where slides are compulsorily loaded onto websites and students feel no obligation to attend as all the information is assumed to be on the slides.  The Guardian article also notes that students have been known to demand it back when it is withdrawn.

Some critics feel it limits the way we think and oversimplifies issues. Some feel that the intrinsic nature of the design of PPT templates is to blame for poor presentations and others feel that the way information is put on slides can inhibit learning because humans are only designed to learn in a particular way. If you are interested in some of the neuropsychological arguments you could look at work by Stephen Kosslyn (book called Clear and to the Point) who has drawn more optimistic and detailed conclusions about how to structure presentations to achieve better learning outcomes.

Discussion is fairly opinionated and, of course, it is notoriously difficult to get strong, replicable and generalizable evidence about educational methods that are guaranteed to work for you.

Critics also tend to focus on the obvious failures in some presentations. This presentation by Ross Fisher is titled “Everything you know about presentations is wrong” https://www.youtube.com/watch?v=8Cl0xskA9fM and brings up many useful points including tips for improving presentations. It’s a long but listenable-to presentation. He maintains presentations often fail because of “cognitive load”.  He is a paediatric surgeon and well known to many medical professionals involved in education. His “P cubed” framework focusses on story, media and delivery http://ffolliet.com/   The aim is to keep people awake and he comments that the value of a presentation is what the audience thinks it is.

There are some interesting assumptions about how we (all) learn which it would be great to test. If someone talks and has words on a slide does this help learning or does it impede it?   Does it help some learners but hinder others?  Is it better to have an engaging picture while someone talks or is that distracting for some people?

How do we learn?  

There are theories about how we learn and numerous specific studies about the factors influencing effective learning. This article is broader than just presentations: http://result.uit.no/basiskompetanse/wp-content/uploads/sites/29/2016/07/Mayer.pdf “Applying the Science of Learning: Evidence-Based Principles for the Design of Multimedia Instruction”

demonstrates how complex may be the underlying theories. The cognitive theory of multimedia learning states that people learn more deeply when they build connections between verbal and visual representations of the same material and this paper lists studies demonstrating the success of strategies predicted to enhance this. One of the practical messages is not to overload the visual channel.

http://onlinelibrary.wiley.com/doi/10.1002/acp.3300/full This is quite a specific study on visualisers and verbalisers and the main lesson is probably that it is very complex, there are individual differences and it is very hard to apply in practice.  It was interesting that only for visualizers was learning success substantially impaired if pictures or animations were missing. Certain professions scored differently on the spatial imagery scale, the object imagery scale and the verbal scale.  There was also a suggestion of a gender influence.

Let me confess something. I was probably a serious teenager and I used to attend church to hear sermons that were not short homilies. I enjoyed hour long lectures on topics I liked and had no problem concentrating but now we advise stopping after ten or twenty minutes because of the general issue of concentration span.  I assume a lot of it was to do with motivation, expectations and sub-cultural factors.  I can still remember  the title (but not the content) of a sermon of the 19th century preacher Spurgeon that I read in a rather lengthy collection:  “Hope yet no hope, no hope yet hope.”  I remember it because my great Auntie Ethel saw it over my shoulder when I was reading it and read it out in a broad Yorkshire accent commenting “It’s enough to give you brain fever!”  There are now similar concerns that Powerpoint, in a different way, is giving us “brain paralysis”.  We have certainly moved from a very wordy culture to a more graphic one – although prior to literacy there was much supporting illustration on church walls for instance. A perusal of 19th century newspapers or novels suggests the population was accustomed to more “wordiness” without pictures (even still ones).  When I reflect I realise that I prefer to read a book than listen to an audio version and I compulsively read ahead on PPT slides.

The synthesis / compromise – what works

I am never going to be a dynamic presenter. Just an adequate one.  But it shouldn’t be all about me anyway!  Perhaps we can still structure effective learning experiences.  There are some common themes that emerge from all the reading (and viewing) I have done – in terms of the principles for effective presentations.

This study on Presentation vs Performance: Effects of lecturing style in Higher Education on student preference and student learning  https://eric.ed.gov/?id=EJ959028 actually seemed to examine the differences between a “good” and a “bad” presentation.  The basic PPT presentation describes PPT at its worst.  The Performance approach included slides with much less text, more images, relaxed manner and varying tone of the speaker, use of personal anecdote and audience interaction.  Needless to say it was more popular and more effective.

Ross Fisher’s positive tips were not too different from the earlier advice for good powerpoint presentations or the article on presentation vs performance. He suggests the slide set, handout and script should be different, he notes the importance of story and suggests a “star moment” in a presentation. He alludes to font size, not being distracted by logos or too many words and he emphasises the importance of any performance: projecting to the audience and practising.

The following are two nice brief pages from University of Leicester of practical hints about presentations.

https://www2.le.ac.uk/offices/ld/resources/presentations/delivering-presentation

https://www2.le.ac.uk/offices/ld/resources/presentations/visual-aids

This readable article reviews some of the evidence regarding the learning outcomes of lectures with and without powerpoint. http://www.hagerstowncc.edu/sites/default/files/documents/14-fletcher-powerpoint-research-review.pdf  It indicates that PowerPoint has no significant impact on learning – but students like it.  However, the way it is used affects learning.     An assertion-evidence approach is best (read the article for the details) and with or without PowerPoint, lectures are less effective than methods using active learning. This is a good warning to not be seduced into providing only lectures, however good, and to assess your goals, the audience size, the topic, the venue and so forth as you choose an appropriate method.  It is an encouragement to continue the broader task of structuring  learning experiences in all the contexts of learning.

Currently I am preparing a PechaKucha presentation (a style originating in a Japanese architecture office) and trying to apply a few of the principles above – quite a challenge!