Category Archives: theory

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.  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   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. 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!

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.


To PPT or not to PPT – that is the question

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

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

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

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

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

The backlash

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

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

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

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

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

How do we learn?  

There are theories about how we learn and numerous specific studies about the factors influencing effective learning. This article is broader than just presentations: “Applying the Science of Learning: Evidence-Based Principles for the Design of Multimedia Instruction”

demonstrates how complex may be the underlying theories. The cognitive theory of multimedia learning states that people learn more deeply when they build connections between verbal and visual representations of the same material and this paper lists studies demonstrating the success of strategies predicted to enhance this. One of the practical messages is not to overload the visual channel. This is quite a specific study on visualisers and verbalisers and the main lesson is probably that it is very complex, there are individual differences and it is very hard to apply in practice.  It was interesting that only for visualizers was learning success substantially impaired if pictures or animations were missing. Certain professions scored differently on the spatial imagery scale, the object imagery scale and the verbal scale.  There was also a suggestion of a gender influence.

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

The synthesis / compromise – what works

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

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

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

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

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

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

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. 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 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 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)

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  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

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.