Sunday, 29 July 2012

Lost in translation? Postgraduate Medical Training Curricula

In a previous blog on WPBA, I observed there has been a culture shift in postgraduate medical education, from that of a time-served apprenticeship, to one of time-measured training. This observation arises from my doctoral research part of which involved an analysis of 20 years of policy relating to the training of doctors. I was interested in tracing the ways in which NHS and postgraduate training reform had ‘dismantled’ medical apprenticeship. My analysis led me to observe a gradual decoupling of ‘working’ and ‘training’. at least conceptually. To explain…

Historically, in a time-served apprenticeship, work was the curriculum for medical training; through engaging in increasingly complex work activity doctors made transitions to greater levels of responsibility. Supported by their ‘firms’, to greater or lesser extent, transitions were made on the basis of readiness to progress, in the eyes of those closest to their work activity. There are close parallels here with Lave and Wenger’s (1991) accounts of communities of practice, where newcomers to a community are invited to engage in the shared work of the communities they join. The goal of training, in this case, is full participation in the work of the community.  

In more recent years, we have witnessed the move to a national curriculum for postgraduate training, expressed in terms of competences to be acquired, or outcomes to be evidenced. The modernized time-measured curriculum for medical education stipulates much more closely the anticipated length of time for each stage of training; those who do not progress at a predetermined point are at risk of being seen as ‘failing’. The tension here of course, is that certain posts may afford greater opportunities to learn than others, simply in terms of the scope and amount of ‘suitable’ work available. Failure to progress may be a failure of the workplace to support the development of the trainee. The ultimate goal of any stage of training is expressed here in terms of ‘sign off’; doctors in training have demonstrated the acquisition of pre-determined outcomes, competences, knowledge, skill or attitudes, however these are expressed. Those familiar with Sfard’s (1998) account of two metaphors for learning might see time-served apprenticeship in terms of ‘learning-as-participation’ and time-measured training as ‘learning-as-acquisition’.

Does this distinction matter, other than conceptually? I think it does. I believe that the postgraduate medical training curriculum introduced over the past 5 or 6 years got ‘lost in translation’. Ultimately, doctors, whatever stage they are in their career, learn through working: work is the curriculum. The challenge is ensuring that the amount, range and complexity of work activity undertaken is both within the trainee’s capability and stretches them to be more capable. One way to do that is to develop a curriculum map, that captures where they have been, where they are going and where they might go next. In this way, it is possible to make explicit and surface up the learning that arises while working and to make adjustments, where needed, to offer a richer learning journey (to keep the mapping metaphor going). The map does not need to be too prescriptive; there are, after all, many possible routes to the same destination. Some trainers have a natural sense of direction, have walked the journey with trainees on many occasions and only need check in, from time to time, to make sure they are both still on track. Others may prefer to plan the itinerary much more tightly, checking in on a regular basis that all is going according to plan. This kind of mapping process, overlaid on the workplace, had real potential to guide training. Unfortunately, the associated mechanics of the new curriculum models, workplace based assessments, compulsory ‘reflections’, log books, portfolios etc got in the way. These new ‘souvenirs’ from the journey too readily became the journey. 'Trainer-trainee' relationships became enacted through these tools of curriculum engagement. The training curriculum moved from being the trainees work, to additional work for the doctor in training.

So where next for postgraduate medical education? I take some comfort in the revised foundation curriculum, although I believe it has some way to go.

The move away from competences is encouraging, although the scuttle back to the security of outcomes statements is, for me at least, a missed opportunity. I think the discourse around EPAs (entrustable professional activities) is worth extending. It is much more meaningful to think in terms of what you are confident in delegating to a more junior colleague, than relying on the competences they have once demonstrated.

The move away from workplace based assessments to supervised learning events, conceptually at least, is also promising. The value of having a more knowledgeable other (in Vygotsky’s terms) observing your work and engaging in a meaningful dialogue about it has rich learning potential. I am not sure we need the forms to evidence these conversations have happened, but that is a topic for another blog perhaps.

Finally, the new curriculum revives 'the firm', placing much more emphasis on the professional wisdom of clinical supervisors, educational supervisors and the clinical team in terms of guidance, support and decisions about readiness to progress.

20 comments:

  1. Can a curriculum revive 'the firm'? Surely if the firm was lost or diminished it was because of much bigger changes in the way that work was organised in hospitals because of factors such as EWTD, and not because of the FP programme curriculum? The new curriculum may place a greater emphasis on the role of clinical supervisors, but will current working practices support the development of these relationships.

    I speak as someone who has not worked in a hospital since 1999 so I hope some others who do will comment.

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  2. Good question - I guess revive is overly optimistic - but I do think the foregrounding of trainer-trainee relationships in the context of the work team (faculty groups, or whatever particular terminology is in vogue) at least reattaches trainees to those around them. If you see the curriculum as a way in which training relationships and activities are shaped and in acted, then maybe it is possible to make such a claim. You are of course, absolutely right about the dismantling of the firm...a starting point for my research in some ways :)

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  3. Also can we go back to people who have a medical degree being called doctor & not trainee! It is devalued g and disrespectful

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  4. Point well made Sally, no disrespect intended.

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  5. Dear Clare - excellent piece which hits right at the heart of the some of the issues in PGME at the moment.

    The intention of MMC was to in effect remove 'time' completely. You would progress according to your competencies rather than your years. I know of very few trainees who have 'jumped' years and no of many many whose training has been delayed as the paper evidence of the competency has become more important the duration of actually demonstrating the skill (i.e you have spent six months citing central lines on ICU but because you haven't found a consultant to see you physically do it you have no tangible evidence)

    I like your ideas on a curriculum map but do not believe we have sufficient quantity or quality of educational supervisors at present to deliver this. This idea should be taken to the GMC though as part of their trainer accreditation programme.

    The traditional firm is dead - how team dynamics can be re-discovered is vital to revive flagging moral and disillusionment in PGME

    Thank for this!

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  6. Thanks Damian, I appreciate your rapid response and insights which illustrate yet another 'lost in translation' issue . I am currently involved in a multi-academy trust, as a school governor, where we have a vision for a 'stage not age' curriculum for our young people. Parallels here!

    I guess there has to be a balance between the 'lost tribes' of old - forever meandering, never quite moving on, and the rather instrumentalist approach which seems to be a by product of reform. Interesting comments too on educational supervision - I think many have become disaffected as a result of curriculum reform. They are asked to train doctors in ways that are antithetical to their own learning histories (to quote my thesis) - and despair of the tick box mentality. The disconnect between service and training is mirrored in job planning which does not recognise the two are intimately entwined. I fear many opt out for these reasons and further regulation through accreditation, however well meaning, may make this worse. I speak as someone deeply committed to developing and supporting the educational development of doctors.

    Great to be involved in this dialogue with you :)

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  7. Hi Claire
    This is excellent!
    Just wonder if we suffer from rose tinted glasses re: time-served apprenticeship? Not sure I ever peripherally participated before being thrown in deep end - maybe my perception and memory though.

    Agree with comments that what we wish to achieve depends on the clinical and educational supervision. Think that the over emphasis on curriculum, blue printing and assessments has completely alienated the people who teach. What is irritating to me is that lots of people blame the educationalists - when they actually are the ones who talk about Lave/Wenger/Vygostsys - which makes sense. It feels to me that medical education has suffered from dabblers (and count myself in this) who have taken the easy way with this development - much easier to do stats, outcomes, mappings etc - or maybe as Hodges describes we are just on a journey moving through the different discourses chronologically.

    Just as an aside - I have trouble with the word trainee - I think the implication is as well that as a consultant you fail to train any further - but never liked the word junior either as when called it at 35 thought it was patronising. Not sure what the answer is.

    keep blogging!

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    1. Hi Kirsty - sorry for delayed response - been away in the Auvergne for a few days :)
      You raise an interesting point here about educational thinking and how these offer ways of looking at medical learning. I like the Sfard paper because it distills two often competing discourses about the nature of 'learning'. In framing these as guiding metaphors (rather than learning theories per se) she argues that the deeply held views we hold about learning shape our teaching practices. If our guiding metaphor for PGME is learning-as-acquisition, it makes absolute 'sense' to spend energy deconstructing complex medical practices into component parts, to be taught and assessed (evidenced). The underpinning assumption here is, of course, that if we put all the component parts back together again, they represent the complex medical practice we first started with. If this is your guiding metaphor, the complex machinery around PGME makes sense too -finding the right tools, to capture the right behaviour, attitude, knowledge etc. However, if your guiding metaphor is learning-as-participation, then the current preoccupations make no sense at all. Complex medical practice is seen as just that - and so, in order to be able to make a meaningful contribution to that practice, you need the types of work experiences that socialise you into the ways of thinking,acting, behaving and 'being' that are necessary. The shift of gaze is therefore too the types of work activity that are delegated to doctors in training, how these are supported (scaffolded) and developed over time, towards full participation in the work of that community. As to whether we hold a rose tinted view of apprenticeship ...I feel another blog coming on :)

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  8. Very insightful post Claire.

    My particular specialty, radiology, has always had a good reputation for training. I think this is partly because it is such a different specialty, even with several years of postgraduate medicine under your belt, when you start radiology you are essentially starting from scratch and can offer little service value to the department. This is in contrast to some of the more traditional medical or surgical specialties where previous experience tends to mean that you are expected to fulfill a largely service provision role.

    Most of the first year of radiology is spent as supernumerary where the main goals are to learn and pass the first exams. With each passing year (and with each exam obtained), you are given more responsibility and at the same time are able to offer an increasing amount of service provision to a department.

    Radiology have recently (2010) introduced a new curriculum which is much more competency based and includes WPBAs, I think this is designed to complement, rather than replace the apprentice-like model of training. I have to say, in my limited experience so far, it all feels very 'tick-box-y'.

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    1. Thanks for these observations - they are a strong reminder, for me at least, about the situated nature of learning. I do not subscribe to a view that teaching skills /practices are generic, rather they are a set of social practices, developed over time, that are situation and 'culture' specific. Training to 'be' a radiologist is distinct from training to 'be' an anaesthetist, or psychiatrist, because working practices are quite distinct too. I wonder then, why we are so keen on a one-size-fits all approach to designing medical curriculum, borrowing and loosely adapting WPBA developed for one purpose (e.g. foundation training) to fit so many others?

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  9. Presumably, at least in part, this shift occurred when, with Tomorrow's Doctors, the GMC moved some of the burden of knowledge out of the undergraduate degree and into postgraduate training. It is inevitably that, with the change from what was an apprenticeship into a particular specialisation to an semi-apprenticeship that cuts across the medical specialities, there would be a greater presence of acquisitive learning and assessment (and we should remember that Sfard thinks we need both metaphors). We should remember that the 'true' apprenticeship into a medical speciality now occurs following the foundation years. I am not sure 'time-measured training' is itself a problem, the rotational nature of foundation years is always going to have this shape. The tick box approach however does seem very problematic, especially the way in which this conditions and constrains the training itself. This last puts me in mind of an 'audit culture,' a concept you might find helpful: http://www.amazon.co.uk/Audit-Cultures-Anthropological-Accountability-Anthropologists/dp/0415233275/ref=tmm_pap_title_0 (the .pdf of that book is floating around the internets).

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  10. Thanks for engaging with my blog Nathan, I appreciate that :)
    For me, the value of Sfard's paper is she does not make claims to how learning happens, or even that there are different types of learning per se, rather that the deeply held views we hold about learning shape how we approach our work as teachers, curriculum designers, educational researchers etc. I think there has been a culture shift in PGME where learning-as-participation has been unseated as a dominant guiding metaphor, by that of learning-as-acquistion. I agree that there is value of looking at the audit culture. For me, competency is being used more to audit than to assess - competency is being used as a proxy measure for learning, reassuring the regulators (and the public) that medical work is 'safe in their hands'. Thanks for the link to the book :)

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