Category Archives: learning environment

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

We need to adapt

In the last few days there was an East Coast Low off the coast of NSW which caused amazingly high seas on our local beach. The bird (? Cormorant) at the top of this blog (or a relative of his/hers) had to adapt and take refuge on a lamp post. As educators we have to adapt to changing contexts.  As the tsunami of students ramps up the numbers, teachers may have to take refuge on their own pedestal of the lecture platform instead of wandering with small groups on the rock platform.  Or maybe distance requires online contact.  The other thing we have to do is to adapt resources for the audience. Teaching in and for the GP context, for instance, is not the same as in the hospital.

The learner

It’s often the case that we may invite a cardiologist to talk to GP registrars about atrial fibrillation or a gastroenterologist about the meaning of liver function tests. GPs may attend talks given by geriatricians or workshops run by Palliative Care Physicians.   In all these instances the listener needs to consider how the information is relevant to the GP context.  Similarly, when teaching in the clinical setting it is good to refer to EBM but often the evidence has come from studies done in hospitals and in different patient populations.  In the Welsh resource I referenced a month ago https://docs.wixstatic.com/ugd/bbd630_9068591ed32045ef9e10c04cdf3086a2.pdf

(about Care of The Elderly) there are some very good reminders about frail patients – but it is good to contextualise for the community context.  To utilise it appropriately for GP registrars, the differences need to be addressed.

The Teacher

As an educator you might research the relative importance of certain presentations in hospital patients versus GP patients. As a supervisor you could suggest your registrar reads the document and then discuss how they think it might apply to general practice. Or you could be more specific and read it in relation to particular patients.  The Welsh document has some Top Tips for geriatric medicine and on the first page are

Six Random Thoughts

Number five stated: For confused patient, a collateral history is vital – it is important to determine if the patient has dementia, delirium, or both.

This is a good starting point for a discussion on confusion in general practice. Delirium is less common in general practice – but on the other hand it is therefore likely to be missed, so the message is to think of it. Delirium is addressed on page 8 of the document. Discuss how it may present (especially quiet delirium).  The other relevant point in general practice is to discuss the possibility of delirium with a patient (and family or even surgeon) when they are facing hospital admission.  The GP can often identify when a patient has risk factors for development of delirium before they get there.   Of course, in general practice it is worthwhile also having Depression in your DDx.

The document quotes a great definition of frailty

“Frailty is characterised by a vulnerability to stressors which would not affect non-frail people. These stressors can range from a bereavement to septicaemia. These stressors can lead to a rapid decline in both functional status, and in some cases physiological deterioration. This decline may be reversible, but in many cases the person will not return to their baseline.”

GPs see patients earlier along the Frailty spectrum and are in a position to act when these stressors occur and to check on the patient and initiate actions that may help reverse or slow down the decline. Putting in place relevant supports at the appropriate time can help re-balance the scales in their functional status. Ask registrars how frail they judge a particular patient to be (and why) and brain storm with them about what services might benefit a particular patient with multimorbidity and polypharmacy, a recent hospitalisation, a recent fall or bereavement.

One section notes some very useful dos and don’ts of de-prescribing

 These are really worth discussing and a teaching session that involves reviewing a patient’s medications is always worthwhile. In general practice there is a smaller proportion of very frail patients and the clinical judgment required to make sound prescribing / de-prescribing decisions is challenging.  At what point might you discuss stopping preventive medications?  It will not necessarily depend on age.  Because we know patients over time they can sometimes decline imperceptibly and the prescribing decisions may need to change.  A registrar can cast new eyes over a patient so ask for their thoughts.

Often frailty scales are used more to keep patients out of hospital or decide if they need a palliative care approach or whether more resources are needed. My PhD was about developing a scale for general practice – to predict those at risk of frailty.  The importance of this is that you might make a difference at a much earlier stage.  The definition of frailty is very helpful but In the GP context I would suggest stating some of those hospital messages slightly differently.  Some points to emphasise might be:

  • A patient may become gradually more frail while you’re not looking
  • Carer or relative observations are important
  • What are some predictors you can pick up which might suggest a patient is more vulnerable -this might be information to pass on to the hospital when relevant
  • How can help be obtained in your geographic area in a timely fashion rather than leaving it too late? (bearing in mind that knowledge of community systems is crucial to being an effective GP)
  • Check for cognitive impairment
  • Frailty is a continuum rather than an either/or and care is also continuing rather than a one-off.

Other topics are UTIs, falls and end PJ paralysis. For the GP, what are the strategies for encouraging and maintaining mobility in patients in the community? The last topic in the document is Advanced Care Planning.  There are impressive figures given about death rates of in-patients and those in residential care so it is a very relevant issue. General practice has many more healthy, resilient coping patients. Not many of our patients die in a twelve month period  (and meanwhile we are seeing babies, teenagers, young families etc, all requiring a different paradigm of care).  Registrars, in particular, might have a patient load of which only a small percentage is over 65. However, we do see those transitioning to frailty, at risk of frailty.  This makes it a challenging topic in general practice which is worth discussing.

It is always worth directing attention to up to date guidelines but, even then, it is worth a discussion about how you might need to adapt them in practice. Even if there is a screening tool which will work on data entered into the electronic health record it is important to discuss the relevant concepts and issues with the learners in the practice.  There are protocols and there is clinical judgment.

And the document finishes with some book reading suggestions – always a good idea!

Go with the Flow

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

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

What is Flow?

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

More recently it has been applied more broadly to the educational context with the assumption (and some evidence) that individuals learn better when experiencing Flow. However, much of the literature refers to the school classroom and I haven’t found much on postgraduate vocational training although it appears to be very pertinent.  However, there is a post by Daniel Cabrera on Flow and education on the blog for clinical educators https://icenetblog.royalcollege.ca/2016/09/23/the-tightrope-between-fear-and-futility/  It also includes Csikszentmihalyi’s more detailed schematic.

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

When does it happen?

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

Looking for references I found a nice summary article on the net http://www.niu.edu/eteams/pdf_s/CHALLENGE_FlowEducation.pdf

Facilitators of Flow

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

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

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

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

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

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

 

The Training Environment – micro and macro

Education and training does not just depend on the teacher / learner dyad in isolation. They are just part of a bigger training environment.  We are probably well aware of the micro environment of the practice or clinical setting which includes attitudes and involvement of the non-supervisor medical staff, the busyness of the service (in either direction), the variety of clinical cases, the supportiveness of non-medical staff and so forth.   These can be even more variable in community settings (compared to hospital) and can be harder to control.  However, they may often need to be accounted for.  If a particular practice has a patient load that is largely acute presentations, repeat scripts and medical certificates with little continuity of care (not uncommon in some settings) then educators should be aware of this and able to direct the registrar to a different type of experience in a later term  It can be more subtle within a practice where “female problems” are directed to a female registrar who then gains less experience in other areas.  A registrar may feed back that a supervisor is not very helpful  but yet the environment is conducive to learning because office staff are supportive and other medical staff are knowledgeable and involved.  The one thing you can say is that the issues are complex and a training system needs to take account of this.

There are a few points made in the following article (about education in residency training) regarding the importance of the “intangibles of the learning environment”.  The author claims that “At its best, the residency experience must be conducted as professional education, not as vocational training.” It goes further than mere training or credentialling and should focus on things that are obvious to many good supervisors : the assumption of responsibility, reflective learning, primacy of education and continuity of care.  http://www.jgme.org/userimages/ContentEditor/1481138241158/06_jgme-09-01-01_Ludmerer.pdf However, I do not agree with the negative interpretation of the limiting of work hours and suspect the principle of continuity should be addressed in other ways. A positive training environment can certainly encourage the learners to be curious about the outcomes of patients they see in the context of good handovers and teamwork.

He suggests there is a need to prepare “residents to adapt to the future, not merely learn for the here and now…excellency in residency training is not a matter of curricula, lectures, conferences, or books and journals…. Nor is it a matter of compliance with rules and regulations. Excellence depends on the intangibles of the learning environment: the skill and dedication of the faculty, the ability and aspirations of trainees, the opportunity to assume responsibility, the freedom to pursue intellectual interests, and the presence of high standards and high expectations.” You can sense his frustration at the increasing bureaucratisation in learning environments.  I am aware of many great supervisors in general practice who do all of this almost intuitively and we rely on their skills and commitment when broader systems are not adequate.

It is not so immediately obvious that the macro environments also have a significant influence on the learning culture.  These can include the ethos of a hospital, training organisation or government policy frameworks.

If the varying stakeholders (government, colleges, standard setters, accreditors, funders) emphasise outcomes and competencies, this can move the learning environment towards one that focusses on assessment and box ticking.  This may have benefits but there may be intangible losses which are not acknowledged.  If efficiencies are sought through larger institutions and faculty mergers, then the interpersonal nature of education may be lost.

Standardisation may increase the quality of training or lead to a lowest common denominator approach and the implementation of IT platforms  is extremely unpredictable in its outcomes.  At its worst, educational quality ends up at the mercy of unresponsive systems and learners and teachers feel they are part of an industrial process.  At its best, resources become more accessible to learners and reflective and self-directed learning can be enhanced.

In the clinic setting a positive learning environment is encouraged when the learner feels free to ask questions and when they observe a culture of learning in their colleagues;  where all staff acknowledge the importance of education and the learning task; where the supervisor is able to admit when she doesn’t know something and where the learner is treated with respect.  Learning is facilitated when there is sufficient challenge matched by the appropriate level of support – the concept of “flow” (another topic of its own) – which is not always easy to achieve and is a shifting dynamic.  The learning environment must also be safe for learner and patient and this often relates to the quality of supervision.

There are other learning environments which include the “workshop” setting. There is more to it than standing up in front and presenting relevant or required content to a group of learners.  The focus of evaluation is often on the presenter but a fantastic performer or an attractive collection of slides does not always ensure the most effective learning. Similarly, pre-prepared learning objectives may have limited relevance to the learning that is actually occurring. The size of the group will affect how active or passive the process is (300 is very different to 30).  Consider the members of the particular group of learners – are they at the same level, do they already know each other, do the presenters know them, have they travelled far?  What about the size of the rooms and the acoustics?  Are the small group facilitators well prepared?  Which of the educational staff takes note of (or has power to influence) these “small” but important issues.

In the bigger picture, consider the effect on the learning environment if service delivery is always prioritised over teaching or if the educational staff have minimal professional development to develop their skills. The “intangibles” of the learning environment that lead to excellence include the unintended consequences of policies and rules.   Learners are enthused to extend their knowledge and skills when they are inspired by mentors, when they can communicate with their educators and interact with their peers, when they feel supported by their supervisors and when the parameters of training include sufficient flexibility to allow for individual needs and rates of progression.

Over the last couple of decades there has been talk of both vertical and horizontal integration in teaching and learning environments. Some of this has been ideological, idealistic or pragmatic. It is affected by the size of institutions, the remoteness of training locations and the training requirements of various health professions. It has been influenced somewhat in Australia by the waxing and waning of funding for the PGPPP (pre-vocational general practice placement program) and it is no doubt also affected by practice economics, student numbers and reimbursement (or otherwise) for teaching.  The GP supervisors group has written about this from a supervisor viewpoint http://gpsupervisorsaustralia.org.au/wp-content/uploads/GPSA-Vertical-and-Horizontal-Learning-Integration-in-General-Practice-Apr2014.pdf  (before the more recent significant changes to the structure of Australian GP training) and there are some notable examples of practices who make a conscious effort to create a learning environment.

Consider the learning environments that you are part of and the factors that are influencing its educational quality. I suggest discussing these with colleagues and considering the broader issues when you are evaluating your teaching sessions and the experience of learners.  We want learners to bloom  (not shrivel up like the pot plants on my windy and salty balcony) and for that they need the right environment!  Bear in mind that you can make assumptions about the factors that create a positive learning environment but, ideally, it would be best practice to actually try to measure this.  The validity of educational methods is very context dependent.

Educators may have limited power to influence decision making at many levels but we have a professional responsibility to inform decision makers when the learning environment can be improved and, especially, when it is under threat.