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.
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.
He suggests there is a need to prepare “residents to adapt to the future, not merely learn for the here and now…excellency in residency training is not a matter of curricula, lectures, conferences, or books and journals…. Nor is it a matter of compliance with rules and regulations. Excellence depends on the intangibles of the learning environment: the skill and dedication of the faculty, the ability and aspirations of trainees, the opportunity to assume responsibility, the freedom to pursue intellectual interests, and the presence of high standards and high expectations.” You can sense his frustration at the increasing bureaucratisation in learning environments. I am aware of many great supervisors in general practice who do all of this almost intuitively and we rely on their skills and commitment when broader systems are not adequate.
If the varying stakeholders (government, colleges, standard setters, accreditors, funders) emphasise outcomes and competencies, this can move the learning environment towards one that focusses on assessment and box ticking. This may have benefits but there may be intangible losses which are not acknowledged. If efficiencies are sought through larger institutions and faculty mergers, then the interpersonal nature of education may be lost.
Standardisation may increase the quality of training or lead to a lowest common denominator approach and the implementation of IT platforms is extremely unpredictable in its outcomes. At its worst, educational quality ends up at the mercy of unresponsive systems and learners and teachers feel they are part of an industrial process. At its best, resources become more accessible to learners and reflective and self-directed learning can be enhanced.
There are other learning environments which include the “workshop” setting. There is more to it than standing up in front and presenting relevant or required content to a group of learners. The focus of evaluation is often on the presenter but a fantastic performer or an attractive collection of slides does not always ensure the most effective learning. Similarly, pre-prepared learning objectives may have limited relevance to the learning that is actually occurring. The size of the group will affect how active or passive the process is (300 is very different to 30). Consider the members of the particular group of learners – are they at the same level, do they already know each other, do the presenters know them, have they travelled far? What about the size of the rooms and the acoustics? Are the small group facilitators well prepared? Which of the educational staff takes note of (or has power to influence) these “small” but important issues.
Consider the learning environments that you are part of and the factors that are influencing its educational quality. I suggest discussing these with colleagues and considering the broader issues when you are evaluating your teaching sessions and the experience of learners. We want learners to bloom (not shrivel up like the pot plants on my windy and salty balcony) and for that they need the right environment! Bear in mind that you can make assumptions about the factors that create a positive learning environment but, ideally, it would be best practice to actually try to measure this. The validity of educational methods is very context dependent.