Category Archives: professional development

Communities of Practice in MedEd

Post #50: This blog was started three years ago with the aim of providing some easy-to-read medical education content, mainly for starting-out medical educators some of whom had expressed the view that they felt unsupported in their new environment and, further, felt unfamiliar even with the language of medical education.

This is the sort of problem that should be ameliorated by the experience of belonging to a community of practice – a fairly recent concept and one with potential, which you probably know from learning theory.  It seems to be an appropriate discussion for this fiftieth blog now that some of those newish MEs, that I met initially, might now be more senior MEs and already mentoring younger educators.  I’m not going to get very academic regarding this topic except to say it arose in the writing of Lave (anthropologist) and Wenger (educationalist) in the 1990s.  Another related concept was that of Situated Learning.

What is a Community of Practice (CoP)?  It’s a group of people who share an interest in, and concern for, a specific area, and interact with each other in order to work out how to do it better.  It can be applied very broadly but is often applied to disciplines or professions although it has been applied in business settings. It is fairly easy to see how it can apply to a general practice whose staff meet together face to face regularly but it can also be a virtual community of practice – perhaps around special clinical interests such as sexual health or mental health for instance. Medical Education is obviously also a special interest within medicine and you probably feel you experience your community of practice when you attend a conference or workshop for instance.

Do you feel you are indeed part of a CoP? Is your CoP inward looking or outward looking?  Sometimes such a group might be fairly parochial and inward looking, focussing on the practicalities of the organisation in which you all work.  The most value from a CoP is probably when it is also outward looking, when you can interact and exchange ideas with those involved in “medical education” but who are working outside your specific context.  So, university tutors and lecturers might interact with GP educators and supervisors at a conference when they all attend a workshop on assessment for instance.  You might gain new ideas and knowledge from an international conference. This idea aligns with one of the rather philosophical “tensions” that Wenger went on to describe in relation to CoPs – that between local and global.  These tensions help contribute to development and creativity. You could explore these ideas further if you wish.

What sort of workplace are you working in – both clinically and in education?  Are there supportive relationships?  Is there challenge and growth?  Is there time for sharing knowledge and experiences? Who is responsible for nurturing all that within your CoP?  Remember that motivation for actively participating in communities of practice can be intrinsic or extrinsic.

Why bother with a CoP?  You can probably answer this yourself from experience.  Being involved in a CoP may have improved your professional knowledge or performance and also your morale in your job.  However, a couple of reviews of the effectiveness of CoPs in improving health care performance for instance have been a bit inconclusive.  Some of these were in terms of the goal of improving productivity in the context of funding shortfalls in the NHS – a fairly limited goal.

Just calling a group of people a CoP does not necessarily mean they function as one. You can read more about them here. http://www.linqed.net/media/15868/COPCommunities_of_practiceDefinedEWenger.pdf  Wenger described three characteristics of CoPs:

  1. A Community where individuals participate, commit and build collaborative relationships (NB in practice, there will be differing levels of participation).
  2. A shared Domain of interest
  3. A shared Practice

This article https://www.rrh.org.au/journal/article/4195   looked at the growth of a rural medical education CoP in the US which involved the development of relationships over time. One can see that this is a more tightly focussed topic.  It also has what members must feel is an important purpose, which is one of the facilitators of a CoP.  CoPs can also function to maintain and share the more tacit and less measurable aspects of the knowledge that is core to the community.  The concept has been much used and discussed in the business sector – but bear in mind that health and education are different in many ways.

A 2012 article looked at the literature on GP Training and virtual CoPs, speculating that such virtual communities might be useful in decreasing isolation for registrars. It utilised a framework from the business literature – and found differences in the way concepts were applied in the different sectors.

http://www.biomedcentral.com/1471-2296/13/87 They reported that, at that point, there were no studies on Virtual CoPs in GP Training. For trainees these would tend to be more in the area of clinical skills and knowledge rather than education.  For Virtual Communities of Practice, the technology was crucial, with consideration of blending of online and face-to-face. 

In medical education, in the context of constrained funding and resources (a phrase repeated in so many areas), Virtual CoPs may also be favoured but attention should be paid to the effect on the quality of relationships and collaboration.So there is a challenge for you – find space to develop and utilise Communities of Practice to develop your professional skills, to enjoy your career more and encourage the next generation!

On the smell of an oily rag: risks for teaching in a resource poor environment

From an educational perspective there has been much talk of the benefit of learning in the clinical setting.  In addition, the increase in the numbers of “learners” across the board and the shorter stays in hospitals has also created an imperative to divest some of the learning to the community context. As the numbers of students and registrars increase there appear to be expectations that more and more doctors will be trained in that generic environment called “the community.” But like many things transferred to the community, funds rarely follow.   The positives of learning in the community setting are huge but there are also challenges, especially where community practice is largely private practice. 

The benefits include the broad clinical scope and the chance to see earlier presentations and undifferentiated symptoms instead of the already diagnosed and streamed.  It also creates opportunities for experiencing prevention, continuity and seeing patients in their broader social settings.  And much more.  However, how do we ensure equivalence of clinical exposure across disparate settings and supervisors, maintain quality control across an environment over which we have little control generally and how do we generate enthusiasm for teaching when taking time out to teach is a financial loss?  I think there is general agreement that expectations are increasing but support, resourcing and funding are not keeping up (in Australia).

Resources for medical education are variable.  When there is a new medical school opened to great fanfare there is often a welcome flush of funding.  In many instances the medical school proclaims a new approach to medical education and there may be a well-resourced medical education unit – for a while at least.  On the other hand, teaching within the hospital environment can also be very variable and dependent on local policies, funding and priorities.  Often there is time allocated (in theory) for the education and training which is written into many of the relevant standards for post graduate training.  Each country has its own systems.  The funding pool may come from universities, the national government or local health networks and those who are in training are often buffeted between systems operating in silos.

Doctors are supposed to be teachers, or so it is maintained when the etymological origin is noted in the Latin verb “docere”.  In the middle ages it meant “learned person” and “doctor of the church” and I guess we have moved quite a way from that.  There is also a handy assumption that if you are a good doctor you will be a good teacher or that it is something that is easy to pick up along the way and doesn’t require many extra skills.  And, of course, in practice, the demands of clinical professional development necessarily compete with those of teaching skills.  So how many doctors are indeed teachers?  It’s impossible to know really but certainly in the hospital context there is an expectation that the more senior doctors teach the more junior ones.  In General Practice, functioning as a small business, it is a choice as to whether to take it on.  Does everyone go into medicine or general practice expecting to teach?  And what is the motivation for teaching? The status of a teaching role varies across different systems – have a think about this – and this is perhaps reflected in the priority given to professional development in this area.   This has been brought increasingly to my attention as I am working on some modules on clinical teaching and supervisio

So how do you teach effectively in an increasingly resource poor and yet increasingly managerial environment?  Individuals, as always, squeeze it in to busy days while trying to maintain quality and funders and managers focus on efficiency. Do we put up with mediocre and variable, will it become bureaucratised or do we combat it by paying well and maintaining the standards or by somehow creating a supportive community of practice?  It is indeed possible that we are relying on a rapidly drying up source of good will and altruism.  GPs can just say “I’ve had enough” when the paperwork escalates or the resources decrease beyond a tipping point. 

Obviously institutions and policy makers will continue to take the most economic course possible as their own resources are stretched but those making the decisions need to know that the way the organisation functions may make the difference between enthused and engaged teachers and dispirited ones ready to give up.  A few “ifs” to consider: if policy makers want positive outcomes for patients and the community; and if the quality of the education influences the quality of the professional at the end of training; and if you want a sustainable educator workforce then perhaps you need to be looking at the implications of this and advocating at various levels.

In many parts of the health system, space is not made for teaching and training and in others, GP teaching is not always taken seriously.  Value can be added by providing appropriate support and professional development but it is a challenge.  Efforts can be made to make the total environment more positive for learning and utilise the whole health care team.  This blogpost really has no answers at the moment and is more of a warning. In some ways it will be up to the next generation.  There will always be enthusiastic and brilliant teachers but will their efforts be sustainable?  Will it be a rewarding career option?  Will it be enjoyable?

How will the next generation be trained – and will they indeed be trained rather than educated?

A few rhetorical questions: Do you value your educators and supervisors? Do you know them? Do you enthuse them? Do you support them?  These are places to start.

Alliterative Attitudes for Medicine and MedEd

Recently on Twitter there was some discussion about what were the essential characteristics of a good doctor. The initial tweet said:

This was followed by replies suggesting other words beginning with C: “I’d add curious and concerned.” And “whatever synonym for humble that begins with c”. Others said “great mnemonic. I might add: Considerate.”  And  “Can I add a fourth C?  Communicative”.  All worth discussion. The occasional game tweeter suggested additional words beginning with A.

 

Someone else noted it reminded them of a poster for the 6 C’s (in the NHS) and a reply to that was “Interesting. “C” is obviously key.  The signs I put up in our department are “Caring, Clean and Courteous”.

 

My contribution was to note the three  words beginning with C that I used to quote, for many years, to GP registrars at the end of an observed session of consulting. When worried about the exam I tried to encourage them that, as long as they Cared, had Curiosity and were Conscientious they would be good doctors.  Why did I say this?

I wasn’t promising them that they would pass the exam on their first attempt. I wasn’t even promising that they would tick all the required competency boxes in the next twelve months. This was more about capability (when they need to keep learning), patient safety and future career satisfaction – maintaining enthusiasm and avoiding burnout.   It was more about continuing professional development than measuring a good doctor in the here and now.  More about attitude than current knowledge or skills.

About ten years ago I thought this off-the-cuff advice through in a bit more detail and with a bit more rationale to see where the options might lead.   The powers that be want those finishing training to be competent.  I took this as the starting point (at least as judged by various training assessments) and then looked at what might happen if they were also caring, curious or conscientious.  My exploration produced a few more words beginning with C along the way.  Perhaps a negative way to view this is to speculate on what happens if one of these attributes is not present.  If you miss one of these things, it can all go awry.   I guess I could have constructed the algorithm in a few ways but here is one version anyway (I’m sure you could come up with your own list to generate discussion).

 

Curiosity

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!

If you are curious about medicine and about people you will never be bored.

Conscientiousness

If you aren’t conscientious, safety goes out the door. If you are conscientious you will keep up your professional development (regardless of any carrots and sticks) and you will follow up patients and ensure their safety.  But without the curiosity and the caring this might become a soulless pursuit or even an anxiety ridden approach.

That over-used concept of caring

Caring is a bit of a vague (and over-used) concept but in some of its manifestations it modifies the other two attributes. If you care about the person in front of you, you will be more inclined to conscientiously follow up and be curious about what is happening to them.  Caring can imply compassion for the person or passion for medicine and the profession.  If you don’t care – you will find it difficult to develop a doctor patient relationship, you will lose interest and motivation to head into practice each day.  A curious and conscientious doctor is likely to still be competent (and safe) in ten years’ time but they may miss some of the rewards of general practice that come with caring.  If you care about people and care about your profession then you have motivation and passion that helps you hang in there.

Obviously, if you lack all three attributes things may not turn out well, regardless of the starting point, and I would acknowledge the growing relevance of collaboration (and perhaps collegiality) in the initial tweet.  it should be somewhere in an expanded algorithm!

Here is where I add a “Caveat”. Will caring always make you more content in your career and help you avoid burnout?  Not necessarily so.  Problems with boundaries or system constraints that limit how you can help patients may cause frustration and burnout so these are things to bear in mind.  You may be a good doctor for your patients but not for yourself!  A discussion for another day.

The above is just a discussion that attempts to go beyond the current focus on measuring competencies to what keeps us going in a challenging career. In rapidly changing times we need to be capable as well as competent.  The conclusion for me is that GP training and education should also focus on these other aspects.  A training program should encourage and reward curiosity. It should recognise that sometimes a focus on ticking boxes and the often perverse incentives of quality frameworks can decrease the intrinsic conscientiousness that is part of professionalism.  It should explore the importance and implications of caring and being compassionate.  Perhaps this may also lead into the recognition of broader system issues that affect our ability to be good GPs and providers of effective primary care.

In praise of conferences

I know of some educators who aren’t fans of conferences and others who are too busy with clinical work to make it to any. Many researchers would denigrate conference presentations compared to publications in high-ranked journals. However, the reality is that sometimes you can interact with a larger number of people at a conference than you ever would as a result of a journal article (even if it isn’t as good for your CV).  In addition some employing educational institutions are making it more difficult for employees to get to conferences as budgets shrink and, of course, if you are in private practice there is no-one to help you get there.  Nevertheless, let me encourage you.

In my experience, I have picked up the best (newish) ideas for my job as a medical educator from attending conferences. Sometimes I have returned with half a dozen interesting thoughts, discussed them with fellow educators and ended up implementing at least a couple.  I could just have read about the same topics on line but I would not have experienced the same interaction or gained an idea of where the idea stood internationally.  You can go to conferences on specific topic areas – as I did initially – but then I started attending the more educationally oriented sessions and soon gravitated to the educational conferences. The current deliverers of Australian GP training organise the GPTEC annually.

Don’t turn up your nose at the idea of going to a conference in a nice place! Choose your location as well as the topic and let it enhance family life rather than detract from it. In my first years in general practice I can recall presenting at a Women’s Health Conference on the Gold Coast.  It was ideal.  We stayed in a luxury hotel, I learnt a lot and my partner got to take the two kids to the theme parks.  It wasn’t cheap but it was something we would not have done otherwise.  The presentation was part of an RACGP Certificate in Women’s Health that I was doing.  I didn’t become a world expert (and no one invited me to give a keynote address) but for years I felt competent at Women’s Health and I followed up with various women’s health meetings and Menopause Congresses etc.

Early on I attended and presented at a combined College conference in Wellington, New Zealand – and my partner got to take the kids white water rafting.  On a couple of occasions we have both attended the same conference because he had helped me by writing software programs for teaching approaches.  Just once we both attended different conferences in the same city.  That took good luck and forward planning.  I guess I’m not the sort of person who has put family and work into discrete compartments but my work-life balance has tended to work by integrating the two where possible. After all, it’s all part of life.

Attending conferences is not the financial perk some people imagine. My previous employer paid my registration, usually if I was presenting, but not the airfares.  I have tagged conferences on to holidays (to make the travel effort worthwhile) so it has generally not been worth claiming a fraction of the big airfares as a tax deduction – just the local travel and accommodation if needed.  My kids live overseas so I’m not complaining.  Conferences I have found useful have been RACGP and WONCA (early on), Menopause Congresses, a few geriatric conferences (in Australia), ANZAHPE, Ottawa (when it was in Australia), ASME (in the UK) and AMEE – the largest medical educational conference annually.  There is nothing of the quality or breadth of this latter conference in Australia.

Choose your conference carefully. Make sure it’s on a topic you are interested in and, preferably, have some positive recommendations from colleagues.  It can be very off-putting to make the effort to go and then feel you have learned nothing new or relevant and that your time could have been better spent elsewhere.  It helps to approach it in a positive way and realise that the quality of sessions will be variable.  Choose your sessions carefully – there are often many to choose from.  For some topics I had already read about them and then chose to attend workshops or symposiums on the topics.   These included:  Progress Assessment, Programmatic Assessment, Entrustable Professional Activities, Portfolios, Script Concordance Tests and others.  Sometimes there is a greater smorgasbord of ideas to pick from if you attend short presentation sessions for some of the time.

I arrived back from these attendances more excited about my job (and with a broader perspective) which has to be a good thing. It was great to connect in person (sometimes over a meal) with colleagues who are on the other side of the country and happened to be attending. It was helpful to present something (usually a short paper) as that honed my thinking on a particular topic. I used to come back feeling encouraged that we were actually doing things pretty well in Australia at the time. Education is often about changing ideas and evidence and implementing them successfully and there is only so long that you can be happy with administering processes and encountering nothing to stretch your mind. It has also been stated that education is essentially interpersonal and interactions with others who share your interests can be more productive than merely reading something on line.

What can you learn from me in a more negative sense? Well, I didn’t network enough (academics can be a bit cliquey and often there is an “in-crowd”) as I ‘m not very assertive. Being in GP vocational training is a bit more of a “part-time” vocation than being in academia and the medical education conferences are dominated by undergraduate education and research.  I didn’t become (or put myself forward as) an “expert” on one topic – I tend to be interested in a broad range of things so I spread my interests too broadly.  In short, I didn’t leverage off the opportunities.  Maybe, like many GPs, I see myself as a jack of all trades.  But how you evaluate that depends on what you want to get out of the experiences and your philosophical framework.

I’m sure those in undergraduate education are still getting to some conferences and, since GP Training has been disrupted and reorganised, there is a great need for those in post-graduate vocational training to broaden their skills and perspective and increase their enthusiasm. We all need to have our initial passions reignited from time to time. In the broader scheme of things it is beneficial for Australian training, long-term, to have access to international experiences rather than being parochial. Take the leap, as many grass-roots GPs do, and take yourself (and family if appropriate) off to an interesting conference in a nice place.  Recharge your batteries. Stave off burnout.  Perhaps go with a colleague with whom you can debrief, chat and gain support from on your return as you plan those “innovations” that make your job more interesting, more worthwhile, more effective and more rewarding.