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.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.
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. 
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!
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.
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.
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.
This is my fortieth post so I thought I would veer away from the serious and look at some visual distraction. 
And here is a polymorphic eruption, on a less than clear day.
In the past I have asked those finishing a gastro term for suggestions on abnormal LFTs or a student with a previous life as a physio for advice on musculoskeletal problems, but this is still seeking answers. The patient I have in mind is where we are still puzzled and are trying to work out how to proceed. This brings in the opportunity to make clinical reasoning skills a bit more overt. This calls to mind when I had a patient with an itchy annular lesion that wasn’t quite “classic”(barely visible scale) and was getting worse. The registrar and I discussed the top-of-the-list differential diagnoses and the most useful investigation to do as the next step. It raised the issue of tinea incognito (which skin scraping confirmed).
I thought I would use this approach a couple of weeks ago but then the patient went off on holidays so I had to adapt. The patient had already given me permission to take a photo and use it to discuss with colleagues or for teaching. In fact she was happy for this to happen since we didn’t have a diagnosis as yet. It was on a nicely unidentifiable part of the body. The evening before the session I put the picture into a power point and structured the slides historically with the questions that arose as the case unfolded. I put questions at appropriate points and printed out the half dozen slides. I had also sent a question around my colleagues at the practice asking their opinion and one of them said it reminded her of an article she had just read in AFP on skin biopsies which I printed off and gave to the student to read later 
Twittersphere many in the NHS are commenting on their current work load, even as they head in to a shift, and asking on Twitter, in effect, should I work today when it is not safe? The GMC advises they should work and follow their algorithm for making complaints but other tweets make comments that this algorithm does not work in the real world. Policies, standards, statutory regulations and accreditations seem only able to delegate accountability rather than to ensure the quality of the system.
When is it the responsibility of the medical educator or supervisor to not only comply and tick the relevant boxes but also to speak up when the system is not functioning to facilitate the safety of the learner or the patient? It is probably not enough to introduce a module on resilience in the hope that learners in future can cope with a dysfunctional system should it arise. I am sure the debate will continue.
However, as in the movie, each day the protagonists try to make incremental changes based on the feedback from previous experience. Let’s change the way we teach this concept; let’s involve the learners more in this workshop or this day at the surgery; how about I try and ask more questions rather than giving easy answers. I mentioned incremental changes automatically – because I’m a fan of this sort of quality improvement – but also deliberately after listening to an ABC Future Tense podcast on “Innovation” (from 19th March 2017) on the way to a short break on the South Coast this week. It’s worth listening to but some of the random points that struck home to me regarding education included the following:
So, whilst we are in the current time loop, let’s learn new skills and make incremental improvements that probably have a greater (if difficult to measure) effect for good in the training of the next generation of doctors. Pick up ideas from colleagues, conferences and journals, critically reflect and apply and evaluate to ensure they work.. This is innovation. But it would also be a plus if these changes could be communicated to others (for the benefit of all) and noticed and valued by those with decision making power. If you are (or become) an educator who is also responsible for policy then consider these aspects of how education progresses and improves and ensure they are integrated into the system. Keep the people focus, applaud the incremental improvements and value and encourage the small data.
In the last few days there was an East Coast Low off the coast of NSW which caused amazingly high seas on our local beach. The bird (? Cormorant) at the top of this blog (or a relative of his/hers) had to adapt and take refuge on a lamp post. As educators we have to adapt to changing contexts. As the tsunami of students ramps up the numbers, teachers may have to take refuge on their own pedestal of the lecture platform instead of wandering with small groups on the rock platform. Or maybe distance requires online contact. The other thing we have to do is to adapt resources for the audience. Teaching in and for the GP context, for instance, is not the same as in the hospital.
It’s often the case that we may invite a cardiologist to talk to GP registrars about atrial fibrillation or a gastroenterologist about the meaning of liver function tests. GPs may attend talks given by geriatricians or workshops run by Palliative Care Physicians. In all these instances the listener needs to consider how the information is relevant to the GP context. Similarly, when teaching in the clinical setting it is good to refer to EBM but often the evidence has come from studies done in hospitals and in different patient populations. In the Welsh resource I referenced a month ago 
GPs see patients earlier along the Frailty spectrum and are in a position to act when these stressors occur and to check on the patient and initiate actions that may help reverse or slow down the decline. Putting in place relevant supports at the appropriate time can help re-balance the scales in their functional status. Ask registrars how frail they judge a particular patient to be (and why) and brain storm with them about what services might benefit a particular patient with multimorbidity and polypharmacy, a recent hospitalisation, a recent fall or bereavement.
Thus there was music (from an era I love, especially when it features period instruments and recorders) and paintings (from a school I really like) and this was accompanied by three dancers who also introduced an element of physicality and humour. There were even some background noises suggestive of a Dutch seventeenth century streetscape (but not the smells). At the end we had a further fifteen minutes to browse the exhibition. This was an event that recruited multiple senses.
I wondered if I learnt more this way. So here is some immediate feedback from a sample of N =2 (I include my husband who noted he appreciated the ability to focus on several different things). It was initially a little disconcerting to hear applause for the dancers in the previous space while the musicians were playing in the next one. It certainly wasn’t boring. It wasn’t too long and I appreciated being able to walk, stand or sit on the portable stool as needed. I wasn’t therefore distracted by physical discomfort (brief snack could be had beforehand). There was certainly an ambience.
We might sit in our comfy arm chairs of an evening and share some interesting titbits of information that lead on to further discussion (and maybe a Learning Plan involving Google). I have also recently started a botanical drawing course so I took a deeper interest in the Dutch still-lifes. Sometimes the full impact of a learning event can be broader than you think.
Prior to the concert we walked through the Botanical Gardens and I enjoyed the height-of-summer cottage garden flowerbed. It reminded me tangentially that there often seems to be added value if you attend a conference in a pleasant place. Such things are hard to measure but maybe should be a topic for further research!