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.
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.
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.
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
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.
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!
There have been many seasons in medical education. There was a long era of lectures and a shorter epoch of small groups. There has been an evolution of overhead presentation technologies and we have entered the age of performance in the TED (technology, entertainment, design) talk template. My daughter is a stand-up comedian and I observe similarity between the preparation for a six minute comedy set and a six minute Pecha Kucha. There have been other more innovative approaches and, for the researcher and presenter there have been books, libraries, index medicus, online journals and, praise be, Google. In terms of seasons, it is probably Spring heading into Summer for the use of various aspects of social media in medical education.
If we go far enough back there have also been dire warnings, at a society level, about TV replacing radio and cinema, screens replacing books and too much time spent on video games or social media. So it goes on. Perhaps the main issue is the end point – informed and reflective individuals – and there are stimuli aplenty to thinking and reflection in the whole range of media. Afficionados of one approach to education are very much inclined to bag other approaches but perhaps there is wisdom in the quote that started this post and which still resonates with me after all these years. “To everything there is a season and a time to every purpose under heaven”. It all depends on appropriateness (and there is professional judgment in that) and that may depend on purpose and context (in its broadest sense).
Take some time over the Christmas season to take in a good (or bad) film, an interesting book, concert, gallery, magazine or blog and exchange views on social media or in person. I hope we can all find some time to relax, reflect and relate (and start the new year revived).
The address was by Pasi Sahlberg and looked at Finnish lessons for education – stimulated by their consistently impressive ratings in the PISA results (in school education) from the OECD. These came to light initially in 2001 and it took a few years, apparently, for the Finns to take them seriously and actually believe them – and, therefore, to start looking at reasons behind this. The country’s school children performed well in literacy, then maths, then science.
but don’t give the full flavour of his talk (such as playing “Knocking on Heaven’s Door” and getting the crowd of several thousand to sing along). Of course the PISA rankings have produced their own problems and encouraged teaching to the test in many countries although they do now look also at broader equity issues. Finland’s top position has been taken recently by several East Asian countries with very different approaches. Some commentators note that, compared to Australia, all these high performing countries have much more homogeneous populations (which is now changing in Finland) – but, on the other hand, Canada has also consistently maintained a higher position than Australia. Whatever that means.
