Category Archives: policy

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.

Slow Training

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

“Slow” Education

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

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

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

The Slow Movement


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

Slow training?

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

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

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

Benefits of Slow Training

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

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

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

The importance of time and place

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

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

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

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

Education is interpersonal

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

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

It reinforced the sense that the apprenticeship model for training has a lot going for it and the GP Supervisors at the coal face are perceived to be doing a good job.  It was only when I logged in to the full article that I noted the fine print under the headline – but some are dissatisfied with the support of their Regional Training Organisations. This satisfaction has apparently decreased significantly since the last government shake-up of training and I guess that reiterates the message of my last blog – that there are challenges facing the colleges as they resume oversight of training and that training programs are not just exercises in efficiency.  Neither are they pure academic exercises. They are affected by politics and ideology and it is necessary to keep in mind that the learning environment we are setting in place now will affect future generations.  Training systems are crucial in creating a positive learning environment and if you are involved in training it is good to keep this broader perspective in mind.  Education is more than what you do in a lecture or small group or the feedback form you fill in for the individual learner.

Some dialectical choices for GP training

We could see some of the issues perhaps as dialectical choices facing future decision makers. The first obvious tensions are those of professionalism vs managerialism and collegialism vs corporatism. A managerial approach may have been seen as a solution to inefficiencies in education and training but it has also sidelined educational debate.  It has been recognised in education for a couple of decades. Managerialism has itself gone through several incarnations with neoliberal managerialism emphasising competition and markets and now neo-technocratic managerialism focussing on metrics at the expense of other values.  Here are a couple of interesting articles I read previously on this topic.

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

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

Even our way of speaking about health or education has been infiltrated by the managerial lexicon and thoughts and actions soon follow the language.   Neo-technocratic managerialism reduces the technical expert to being a content provider while education is reduced to what can be measured and reported.  We start to think only about what we can measure. The BMJ article I’m sure will spark surprising recognition. It’s a tongue in cheek article describing this whole process as Management Language Syndrome which has now become a chronic disease  – and like obesity it is supported by the environment.  http://www.bmj.com/content/359/bmj.j5661

This is why it is important to consider the personal vs metrics.  It is very easy, when managerialism encourages priority of efficiency over other values, to be tempted by the panacea of IT and online solutions for everything.  Sadly, experience in other countries has already demonstrated that the cons can be just as crucial as the pros.  The related challenge to this is to keep reminding ourselves of the place of IT.  Is it functioning as tool or master?

Having spent time in the UK I have observed a stretched health system where individuals are held responsible for system failures.  There is an increasing international tendency to talk about teaching “resilience” (apparent in the recent AMEE conference) but we shouldn’t need to teach resilience so people can survive unhealthy systems.  The issue of support for trainees and students is crucial to quality training.  In fact, our systems should model the values we are trying to instil.  If we feel it is important to produce GPs who are able to relate, to nurture, to have empathy, to take note of evidence, to communicate well, to respond to the whole person, to be curious and adaptable – then ideally the training environment should exemplify these values and attitudes. We are all aware of studies where experience in a hospital system can negatively affect values inculcated in early medical school.

In this corporate world it is almost mandatory for organisations of all types to claim to have “world best practice” and to have mission statements regarding quality etc.  In the educational sphere we need to hang on to the reality that quality is not just about repeating “we are the best”.  Brand and marketing are ubiquitous in today’s culture and we are not immune.  It is obviously important in selling a product but we need to acknowledge that not all human activity can be reduced to selling products, people are not just consumers and education and health are not merely business.  There is often a choice of brand versus substance.

How do we know we are “world class” if we are not outward looking enough to know what the rest of the world is doing and to evaluate it?  This brings me to another dialectic of parochial vs global.  I have recently been at AMEE with between three and four thousand medical educators from the rest of the world and there is much we can learn and from which we can benefit.  A speaker in a session on feedback was describing studies on written versus audio feedback (the latter being preferred by students) and quoted from a 2014 study which still concluded that “It is only the relationships between the student and the instructor which can enhance learning.”  A symposium on dilemmas in supervision raised many of the complexities of supervision and assessment and the fact that existing systems do not always support quality supervision.

A lot of these debates and dilemmas could be approached by keeping in mind that education is interpersonal. This is very much underlined by sociocultural theories of learning and the literature on the influence of mentors and role models.  Do our systems, processes, methods etc facilitate or hinder the interpersonal aspects of education?  What can be done to mitigate the threats?  How can we support the learners if we don’t know them and they have become just numbers?  If the personal is lost this will be to the detriment of good training and the quality of our future medical workforce.  It is a challenge to be consciously faced in medical education by educators, policy-makers and managers.

Threats, challenges and opportunities in planning programs of training

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

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

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

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

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

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

This includes the move to corporatism. 

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

What’s new, what’s old or what works (from AMEE)

Much of medical education today focusses on being “innovative” (or complaining that older methods cannot possibly be appropriate). A few weeks ago I was at the AMEE conference in Helsinki, looking for “what’s new” but was impressed by one of the keynotes addressing what actually might work in education. It was great to be challenged by some broader educational ideas (instead of just which particular testing method has temporarily replaced the previous one).

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.

Australia’s response to their own falling position in the rankings has been to introduce more testing.

Countries that don’t improve

 Sahlberg speculated on some characteristics of countries that don’t improve in educational outcomes: they emphasise competition and choice; they have test-based accountability; teaching is de-professionalised and they are addicted to reform.

What might have worked – in Finland

There is an emphasis in many areas on everything being “faster” but Sahlberg claims that, by contrast, Finland is into “slow learning”.  He characterised the education systems that perform better as including:

  • Collaboration
  • Teacher involvement in curricular development
  • Trust based responsibility
  • Teacher professionalism
  • Systems improvement rather than reform.

An emerging feature was the relationship between quality and equity.

He also raised the issue of using small data.  Big Data has certainly proved useful for global education reform by informing us about correlations that occurred in the past. But to improve teaching and learning, it behooves reformers to pay more attention to small data – to the diversity and beauty that exists in every classroom – and the causation they reveal in the present. https://pasisahlberg.com/next-big-thing-education-small-data/ In some other venues he has flagged the increasing use of technology as influencing educational outcomes but also now dictating the research agenda.

His slides are here https://pasisahlberg.com/wp-content/uploads/2017/08/AMEE-Talk-2017.pdf 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.

Sahlberg addresses the pros and cons of PISA including increasing commercialisation in this area https://pasisahlberg.com/the-leaning-tower-of-pisa/ but also notes there have been austerity measures in Finland since 2008: Finally, what Finland should learn from these recent results is that reducing education spending always comes with consequences. It is very shortsighted to think that high educational performance ….. would be possible when resources are shrinking.

Relevance for medical education

Schools are a long way from the medical education environment (which can be quite privileged) but sometimes it’s good to stretch our minds and consider some broader concepts. Besides which, it is probably also of interest if you have children or grandchildren.  Like all education, the possible variables influencing outcomes are myriad and even the outcomes themselves are debated.  I won’t draw particular conclusions but suggest that it might be interesting to reflect on your own teaching/learning environment and the system in which you work.  Consider which concepts have relevance, the direction in which your education system is heading and the implications of this.

We often encourage post graduate trainees to reflect and there is some literature on whether one can teach “reflection” so perhaps we educators should also be trying to reflect on concepts such as: collaboration, competition, professionalism of and respect for educators, opportunities to use small data to improve, the reasons for reform, resources and funding priorities, the use of tests etc – and whether “slow learning” might be relevant for post graduate GP training?  Maybe an interesting workshop topic.

 

(silver birches in Finnish forest and airport sculpture)