Author Archives: Cathy

A long time between posts

When I started this blog, a colleague of mine said he liked the idea but surely I would run out of topics pretty soon.  Over fifty posts later, here I am, possibly about to run out of topics and with over a year since the last post.  I have probably dipped into most topics in a standard medical education textbook but, hopefully, in a more informal and concise way (and influenced by changing events).  I retired from clinical practice just before Covid struck so now feel that perhaps I am less in touch with on-the-ground clinical experience.

I am still involved with medical education in terms of having written multiple modules of a Certificate in Clinical Teaching and Supervision – General Practice over the last three years.  There are now ten modules (each in two parts) which can be found on Canvas online at the University of Newcastle website (or enquire at gpcertificate@newcastle.edu.au) . I am still delivering these modules and marking assignments.

Our medical and teaching environment has changed profoundly and unexpectedly in the last couple of years but basic educational principles tend to remain. The evidence probably doesn’t change as quickly as in clinical medicine – just think fomites versus aerosol regarding advice about Covid transmission over the last two years – but it isn’t all “common sense” or instinct either.  Being a good teacher is more than being a good doctor, even though this is rarely acknowledged in terms of career structures.

As all good comedians say “you’ve been a lovely audience” but I probably know fewer of you than I did at the start as the turnover in medical education staff in Australia has been considerable and the training environment remains unpredictable.

I was writing this blog at the same time as I ventured into learning botanical art (with coloured pencil) so I have been able to reflect on being a learner as well as a teacher.  It seems I learned some of these  skills in a similar way to engaging with CPD in medicine and medical education.  I attended occasional workshops and online courses (with and without feedback) and continued to practice.  I watched other people’s efforts and felt inspired by them.   I don’t have a qualification but family members have noticed a difference between my early and later attempts at grapes, amongst other things! 

Interestingly I started with an intention to do “botanical” art.  I embarked on flowers, then fruit and vegetables.  But then I moved on to birds and a few animals, even some landscape.  It’s the GP in me, being interested in many things and reluctant to specialise.  My GP career had moved, like many, with my patients.  From kids and women’s health to geriatrics and complex comorbidities.  The nature of general practice is such that it is too broad for everyone to be good at everything and one is always trying to improve and master new skills as required by patient needs.  I think being an educator is similar.  In both areas you may develop different skills at different times (and others in the educational team may be better skilled at some things) and you always see improvements that can be made in the way you might do things “next time”.  But that’s not a bad thing necessarily.  And now it appears to apply to botanical art also!


My conclusions after forty years of involvement in medicine and medical education are that you are kidding yourselves if you say that either medicine or education can be practised apolitically.  Everything is political. You can be the most enthusiastic supervisor but if you are struggling to meet the needs of a large patient load or the financial constraints of the practice then the quality of your supervision will probably not be as great as you would like it to be.  You may be a highly qualified and gifted educator but if the organisation coordinating the training is more concerned about the bottom line or the requirements of the funder then the educator to learner ratio may mean you lose the crucial interpersonal aspects of education.

A training organisation that engenders poor morale amongst its staff will result in greater turnover and therefore trainers with less corporate knowledge and experience.  Tertiary institutions may have staff with no job security, no time to “think” or support to attend conferences and this will obviously affect the learning environment. It may all work in terms of corporate outcomes but not in terms of quality training or the learner experience.  The recent decision to de-fund a well-used, evidence-based prescribing resource is also evidence of the effect of political decisions. All these issues of the broader context, the total learning environment, depend on policies made and implemented at a higher level and often by people with non-educational values and priorities.

If quality training is to continue there need to be passionate and skilled individual teachers but these teachers need to be encouraged by the system.  This requires some educators to venture out of their bubbles into the policy and political realm, despite not always being encouraged and even though this can sometimes be discouraging.  Sadly, institutions are less and less likely to be fans of people speaking out.

I suspect this chasm between management (and decision makers) and the professionals delivering the relevant service has grown larger across many areas and institutions (not just medicine or education) and is a tendency determined by specific ideologies.  There is a challenging divide to be crossed by the new generation of educators and this requires cooperation and respect rather than conflict and a set of new skills (in addition to medical or education skills).

Cathy Regan

Some reflections on medical education at the end of a plague year

 

A year ago I was in the UK.  Some years the cycles repeat themselves like ecclesiastical dates or  “terms” in the academic year but, sometimes, something happens and nothing is ever quite the same again.  I’m sure the daffodils are flowering again in Finsbury Park but medical practice and education are still in a state of flux.

This post was part written at the end of August and, like many things in this year of Covid, it got postponed.  August was an upside-down month for me.  My usual August for the last few years has involved attending the Edinburgh Fringe Festival (where my daughter performs) followed later by an event with a different vibe – the AMEE conference somewhere in Europe.  So, there I was with no presentation to prepare, saving money by registering online and hoping the technology worked.  I saw a few interesting sessions and came across some relevant online posters when browsing but the vibe was certainly different.  A few months later saw me having to change a 1.5 hour workshop at another European conference into a 45 minute presentation.  Not sure if anyone saw it.

I was indeed fortunate to continue being involved with writing and delivering some online modules for a Certificate in Clinical Teaching and Supervision during the year and I was able to do that from home.  Currently these can be found at https://bit.ly/3detS5S  and the twitter link is ModulesInClinicalTeaching @GPCertModules  The last module was on e-learning and teaching.  Later in the year we started some online live webinars – so a few new skills acquired!  Those deadlines provided some structure.   In fact the third Zoom online, on the topic of Feedback, is happening on March 9th (more information at gpcertificate@newcastle.edu.au).

In between, I read a lot, ensured I did more daily walks than usual and set myself some drawing projects.

What is happening to education and training in the glow of corona?  I guess the answer to that is not yet complete, it’s not the same in every country and probably will continue to change, depending on what is happening in each country regarding Covid-19 (and now the vaccinations).

This year has revealed (in Australia) the significance and extent of casualisation in Universities.  One might speculate in what ways this influences the quality of education, training and the morale of teachers and researchers.  It’s an issue that won’t go away but may eventually become unquestioned and something to just “live with” (as some say), but perhaps it warrants a few minutes’ thought.  Moving from face-to-face to online is different from moving distance learning to online.  At many levels the effect of the virus has been unequal and the enormous work of changing courses to online at short notice also fell unequally.  Of course, let’s not forget that more workers in the arts sector also lost their jobs and, for some, their careers in one fell swoop.

We all knew that we were moving slowly toward more online and less personal contact but this suddenly accelerated and I reflected on educational aspects of that in my last post in May.  It’s had its challenges but it’s also been interesting.  There will no doubt be lots of presentations at next year’s medical education conferences about what worked and what didn’t.  As educators we are hopefully moving from getting it done, to doing it well (but what are we measuring?)  There are lots of “tech” things happening and that provides opportunities to some.

We changed our ways of engaging and communicating and some words and phrases got used a lot more frequently or developed different meanings: zooming, you’re muted, podcasts, WhatsApp it, virtual conferencing, breakout rooms, asynchronous webinars etc.

Other training organisations were already losing funding in many instances, and is it possible that online training may be seen as a panacea, not just to the viral context but to the economic context?  However, it is not often acknowledged that to do online “well” is not necessarily cheaper.

Will education be changed for good (or for the better)?  Will we reassess the place of interaction and the interpersonal in health professional education – but also in the area of health care generally?

I have no answers to any of this but I confidently predict some interesting PhDs and books in the coming years.

Going viral: some lockdown thoughts on e-learning

And apologies for the overused pun in the title. When I recently returned from the UK it seemed like there wasn’t much to say on medical education at the moment.  Suddenly life and death issues were raising their heads instead.  At the time Covid-19 started to flare up I was on my way to the UK to help out with grandkids.  This suddenly became more complicated.  With family there involved at the scary front line of the NHS and the numbers predicted to rise, it suddenly began to dominate our thoughts even further.  So much so that we were persuaded to return to Australia ten days early in the expectation that things would be better here for someone in a relatively high-risk category.  The weekend we left, the reported deaths in the UK numbered 10 and within a month were in the thousands.  The rest is history – still in the making.

When we got back – to self-isolation – I noted GPs getting themselves organised for the predicted onslaught with discussions about sourcing protective equipment and changing over to telephone or video consultations.  Within not too long a time the government gave this their imprimatur when they came up with a medicare item number for telephone consultations.  Suddenly they were “a thing”.   Meanwhile my university colleagues (in all faculties) were suddenly under the pump to change everything over to “online” in an incredibly short time frame as rules for social distancing, group gatherings and working-from-home came into effect.  I will not be attending AMEE in Glasgow this year, sadly.

Just now we all have a very volatile work and social situation which is very different from country to country and with negative economic implications still developing world-wide.

Meanwhile I was still working on the (already online) CPD modules for the Certificate in Clinical Teaching and Supervision (general practice) for which most modules had been uploaded on Open Blackboard.  All my social interactions turned into Zoom get-togethers.  As the weeks progressed and the country’s response seemed to have worked (as I write) in holding Covid numbers down, some GP colleagues actually noted practices being quieter as patients stayed away – no doubt a temporary hiatus as other presentations can no longer be deferred.  But there is talk about General Practice itself having changed for the future and who knows for the tertiary education sector. So, it was suggested we add a tenth module on “e-learning” (instead of leaving it as a parenthesis in some previous modules).

Thus, I have been pondering and reading the (not very extensive and not always very current) literature around the topic and here is my current, unfinished list of thoughts and queries which I’m sure will start being addressed by the next generation of educators

  • When we have sessions on “consultation skills” in the future we will have to have one also on the subset of “telephone consultation skills” and “video consultation skills”.
  • When we think about presentation skills and running small groups we may be adding in “Zoom Skills”.
  • We are well versed in some important pedagogical skills for medical education but how are these being put into practice in the online environment?
  • The move to “online” had been already happening – often with the managerial impetus of cost efficiency rather than educational value – but suddenly it has accelerated and become all pervasive and we are not all necessarily up to speed. There is little spare time to acquire the skills and management need to consider their responsibilities in this regard.
  • On the other hand, it will no longer be OK to be proud of being an eccentric Luddite, not knowing how to switch your computer on, how to download an app or the name of the latest social platform used by your students. The gap between teacher and student may widen.
  • Many of us subscribed to a view that education is emphatically interpersonal. How does that stand up now?  Previously we had perhaps turned to Blended Learning to make up in some areas for the growing lack of interaction in others.
  • On the other hand, let’s face it, not all lecturers related to their students, even in the “good old days”. So, let’s not idealise it and let’s move on to how we can interact in the brave new world.
  • A more generic Covid related educational issue that has come up (to which my husband alerted me) is the whole issue of health messaging to populations (with evidence from different countries, or even states, with different systems, cultures and politics) and by extension communicating with and educating of patients.
  • It will be nice to have some evaluation of what is actually effective in the new environment, not forgetting to research the actual experiences and wellbeing of learners and teachers.
  • Online learning is an interesting area where we need to apply some basic and long-standing principles with which we are very familiar to what is a very changed environment – a constantly changing context of tools, resources, platforms, apps, connectivity etc
  • A bigger challenge may lie in the previously expanding area of work-based learning especially in the community. This will be particularly in question for undergraduate health professional students, depending on what happens re Covid-19 in the near future with its implications for safety.
  • There are exciting ways to utilise technology to enhance education but this is likely to still be constrained by bureaucracy
  • Meanwhile we also need to not fall into the trap of being driven completely by the technology where we only value what can be measured in the newly constricted context or where any innovation is responded to with a “computer says no”.

I’m sure we will all think of a few more points over the coming days and months.

Empathy in medical education

I have been busy writing some modules for clinical teachers’ CPD and just got started on one about teaching communication skills.  I moved on a bit in the literature to “empathy”- that elusive quality that I recall being reported to decrease either through medical school or once graduates land in the clinical years and the hospital system (a 2011 systematic review of studies on the decline of empathy is here https://www.ncbi.nlm.nih.gov/pubmed/21670661).  There is often debate as to whether this is to do with, among other things, lack of specific teaching, devaluing of “soft skills”, work and training stresses or the powerful influence of role models and the “hidden curriculum”.  Some of the research also overlaps with the concept of patient-centredness.

A recent article in the August 2019 edition of Medical Teacher was a little less pessimistic and not so conclusive when it described a meta-analysis of empathy studies and noted that significant negative changes were noted, but mainly with one particular tool, that studies relied on self-report and that the various tools may not even be measuring the same thing.  So, as is often the case, methodology issues and more research needed!

Over the years there have been various suggestions (and attempts) to expose medical students to humanities subjects on the assumption that this can engender empathy.  Of course, if these observations are true, it could be a chicken and egg situation.  Are potentially empathic people more drawn to the humanities?  And how often do rather unempathic staff “prescribe” such solutions, with students responding in the way they usually do to unwanted curricular requirements? 

This article in The Conversation lobbed into my email inbox earlier this year https://theconversation.com/empathy-in-healthcare-is-finally-making-a-comeback-113593 .  It comes from “The Oxford Empathy Programme.”   It’s a very readable summary and notes that studies have suggested that “empathic communication” can be taught.  The article notes the connection to Communication Skills which are mandatory in curricula now.  The author even raises the question of the cost-effectiveness of empathy.  Some of the comments on the article noted the effect of resources on empathy, the decline in GP:patient ratios, the increasing use of telephone consultations, less holistic approaches and the “avoidance techniques” used with patients to cope with time factors. 

Other articles relate decreasing empathy to concepts of burn-out as in this blog https://www.kevinmd.com/blog/2019/03/whats-happened-to-clinician-empathy.html Two years ago I attended a play at the Edinburgh Fringe which basically described GP burnout in the UK (the picture shows the blurb about it) and I discussed this in a previous post http://mededpurls.com/blog/index.php/2017/08/30/self-care-in-the-curriculum/ .

It is therefore of note that perhaps the time pressures in the UK system are now requiring consultations to be more “efficient” and with a subtle move away from the patient-centred idealism of a few decades ago.  The Consultation Hill Model described here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2894394/ summarises some of that in the registrar context.  There is a bit of cognitive dissonance here when we think of the exhortations to greater empathy inherent in much of the training.

Another Conversation article, from 2017, https://theconversation.com/are-our-busy-doctors-and-nurses-losing-empathy-for-patients-68228  also has the common caveat that “With more demand on doctors and nurses and a push for quicker consultations, clinical empathy is being dwarfed by the need for efficiency”.  This article focussed on the impact of technology lessening direct patient contact time.  Here are two recent articles on how technology may be affecting empathy in health care – although unfortunately they are behind a paywall https://journals.sagepub.com/doi/abs/10.1177/0141076818790669 and https://journals.sagepub.com/doi/abs/10.1177/0141076817714443?journalCode=jrsb

I would suggest it is good to have a look at the literature and see what evidence there might be about empathy training if you are going to try and insert it into the syllabus. There seems to be a Cochrane Review in process.  It is a complex topic and there has been interesting research on its place in general practice, including how perceptions of empathy vary according to measures of economic deprivation http://eprints.gla.ac.uk/104350/ . Of course, there is a much broader collection of opinions on how social media may be affecting empathy in society.

I would also suggest there is another influence on developing empathy which has a parallel with the effects being felt in the health system.  It is worthwhile noting the similar changes occurring in the medical education sector:  a decline in the ratio of lecturers/educators/tutors to students/registrars; more reliance on technology than interpersonal communication (do you get to know the learners?); simulation and online delivery of teaching; more emphasis on exam results and paperwork; more rigid rules and box-ticking for accountability and so forth.  Again, a type of cognitive dissonance is experienced.  We find arguments convincing that explain the behaviour of some adults because of the environment in which they grew up so perhaps it isn’t too much of a stretch to imagine that the environment and role models that learners are experiencing will have an influence on the sort of doctors they become. Ticking learning outcomes may not be quite enough.  There are various responses that can be made to the tensions in a potentially dysfunctional system and it’s good to make these in a conscious way.  It’s worth thinking about in relation to empathy and medical education.

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.