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.
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.