tag:blogger.com,1999:blog-85486486371101769262024-03-27T16:53:08.602-07:00Medical Education MattersRevisiting, re-thinking and reviving medical education.Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.comBlogger11125tag:blogger.com,1999:blog-8548648637110176926.post-57173209413664304912013-03-14T11:26:00.001-07:002013-03-14T11:26:07.168-07:00Observations on observation<div dir="ltr" style="text-align: left;" trbidi="on">
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<span lang="EN-US">A recent twitter exchange has stimulated me
to revisit the topic of ‘observation’ as a purposeful activity supporting
clinical teaching, learning and assessment. <a href="http://www.faculty.londondeanery.ac.uk/e-learning/feedback/files/T-L_through_active_observation.pdf" target="_blank">I first wrote about observation in 2003</a>, when contributing to some early web-based resources for clinical teachers
for the London Deanery (<a href="http://www.faculty.londondeanery.ac.uk/e-learning" target="_blank">now a well established suite of free on-line resources</a>). I argued that observation, at it's best, was<o:p></o:p></span></div>
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<span lang="EN-US" style="color: black; font-family: Arial; font-size: 10.5pt;">‘<i>an active,
purposeful task that stimulates deep learning and the development of
professional ‘know-how’. At worst it is a passive process that leads to either
heightened anxiety or total ‘shut down’ in the learner’</i>. <o:p></o:p></span></div>
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<span lang="EN-US" style="color: black; font-family: Arial; font-size: 10.5pt;">At the time, I was referring to a classic approach to clinical
teaching, where students are invited to observe the practice of qualified
professionals and engage in a dialogue about what was observed, afterwards. I
argued that it was important to maximize such learning opportunities, by making
the learning opportunities explicit, including the use of ‘advance- organisers’
to help structure student’s observations by signaling the types of theoretical
knowledge they might draw upon to make sense of the observed practice i.e. providing a framework to guide their observations. Drawing on the work of Karl
Popper, I challenged the idea that observation is somehow an objective or
‘neutral’ process, illustrating the ways in which experienced clinicians draw
upon experience and theoretical frameworks to analyse and interpret the
behaviours they witness. <o:p></o:p></span></div>
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<span lang="EN-US" style="color: black; font-family: Arial; font-size: 10.5pt;"><span style="mso-spacerun: yes;"> </span>“<i>Clearly the instruction
“observe!” is absurd. Observation is always selective. It needs a chosen
object, a definite task, an interest, a point of view, a problem</i>.” (Popper,
1972, page 46)<o:p></o:p></span></div>
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<span lang="EN-US" style="color: black; font-family: Arial; font-size: 10.5pt;">In the twitter exchange, I was vicariously part of a conference
session, and the observation referred to was not that of student observing
teacher, rather that of teacher observing a learner, in a simulated scenario.
The idea that captured my imagination was around the importance of the teacher drawing
upon ‘objective’ observations as the basis of a debrief conversation designed
to support further learning. I questioned the position that teacher observation
was objective, suggesting that all observation is subjective, in that it is
selective; the choice of what to observe is, I believe, influenced by what the
observer feels to be most important or pertinent at that particular time, or in
that particular situation. So, whilst it may be possible, as the teacher, to
provide a ‘factual’ account of what was observed (or indeed not observed) at a
behavioural level, there are limits to the usefulness of such observations. We
cannot see the situation with the same eyes as the person in the middle of the
action; what they notice and how they respond is something we can only infer. (
I am reminded here of a wonderful digital story called ‘Another person’s eyes’
on the <a href="http://www.patientvoices.org.uk/stories.htm" target="_blank">Patient Voices website</a> which beautifully captures what I am trying to
express here’.) <o:p></o:p></span></div>
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<span lang="EN-US" style="color: black; font-family: Arial; font-size: 10.5pt;">The complexity of professional activity lies in what is not
readily observable - the internal dialogue, the affective response, the
reflection-in-action arising when things do not go in the way we might
anticipate. The learning arising from engagement in observed work activity
(whether in vivo or in simulation) is often hidden from observers view. <a href="http://www.blogger.com/blogger.g?blogID=8548648637110176926#editor/target=post;postID=4682990861187897662" target="_blank">I have blogged before about the origins of debrief </a>being from the battlefield – where
the lived experience of one participant is used as a shared resource for others
around them. Asking the learner to talk you through the situation you have
observed (either from memory or shared viewing of a recording) will afford
insights into the ways in which they observe, read and respond to situations
encountered. Inviting them to provide <i>you</i> with an advanced-organiser, directing you to the aspects of their performance they would most value your help with, is a powerful learner-centred strategy. Together, these approaches can form the basis of the rich, developmental conversations
that support further development. By all means share your observations, drawing out
similarities and differences in perspective as a way to develop insights, but
be cautious about claiming objectivity! <o:p></o:p></span></div>
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<span lang="EN-US" style="color: black; font-family: Arial; font-size: 10.5pt;">As a footnote to this blog, I am left reflecting upon the exponential
growth in the use of workplace based observations as the basis for decisions
about competence. We observe a selected set of behaviours, at a given time, in
a given place, for a given purpose, interpret these behaviours and make and
record a judgment. This judgment is taken as an objective, portable measure of
competence, i.e. a judgment that tells us about not only what was done in the
observed moment, but what might be done in future comparable moments. In
recording these judgments on a form, or in a portfolio, we objectify the
subjective. <o:p></o:p></span></div>
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<span lang="EN-US" style="color: black; font-family: Arial; font-size: 10.5pt;">Reference: <o:p></o:p></span></div>
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<span lang="EN-US" style="color: black; font-family: Arial; font-size: 10.5pt;">Popper, K. (1972) Conjectures and refutations: the growth of
scientific knowledge’</span><span lang="EN-US"><o:p></o:p></span></div>
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Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com50tag:blogger.com,1999:blog-8548648637110176926.post-21145842196521208472012-12-16T12:31:00.004-08:002012-12-16T12:32:37.060-08:00On clinical teaching and learning theory...<div dir="ltr" style="text-align: left;" trbidi="on">
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<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">These past few weeks
have been all about clinical teaching. I have run a couple of workshops based
on the topic of <span style="mso-spacerun: yes;"> </span>'on-the-job teaching' for
a group of doctors and dentists studying for PgCerts in Medical and Dental
Education and <span style="mso-spacerun: yes;"> </span>I have also
had the joy of undertaking two workplace based teaching observations. One with
a dentist running a small group teaching session on dental implants for his
multidisciplinary team, the other an anaesthetist helping three FY2s understand
blood gasses. Both demonstrated the very best of clinical teaching, putting
shared concerns for patient care at the centre of their teaching activity,
working with their learners to develop their thinking and to shape their
practice. Neither involved whizzy learning technologies nor took the form of
slick, over-rehearsed 'presentations'...these were sessions based around
listening, dialogue, questioning (self and each other), prompting, guiding, rehearsing
ways of thinking and acting. They were authentic, democratic engagements with
colleagues.<o:p></o:p></span></span></div>
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<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
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<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
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<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I was reminded of
these teaching sessions, when I engaged in a brief twitter exchange with some
medical colleagues questioning the accessibility of educational theory. We
mused on its appeal (or lack thereof) and the ways in which it was possible to
put theoretical ideas to use, to ‘make sense’ of educational experiences in the
past or educational practices in the future. How might I make-sense of clinical teaching I observed, by drawing on educational theories and, in so doing, illustrate why I was so impressed?<o:p></o:p></span></span></div>
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<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
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<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
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<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Well, I might start
with <a href="http://www.avetra.org.au/abstracts_and_papers_2001/Billett_full.pdf" target="_blank">Stephen Billett’s conception of ‘workplace affordances’ </a>and consider the
extent to which workplace learning opportunities were evenly distributed in the
clinical settings I visited. My dental colleague did a fantastic session on
dental implants, engaging an experienced dental nurse just as equally as a
newly appointed dental receptionist. Here, learning opportunities were offered
to every team member, not just those with explicit learner status (student,
trainee) or particular professional roles (other dentists). Is this true of
every clinical workplace? Billett’s ideas lead me to question whether some
workers gain access to richer, more regular learning opportunities than others.
I consider the extent to which medical educators might (unconsciously) favour
those who they feel to be a ‘good fit’ to their chosen speciality, offering
more hands on experience, taking them under their wing to talk cases and in so
doing miss opportunities to invite others into their ways of thinking.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></span></div>
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<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span style="mso-spacerun: yes;"><br /></span></span></span></div>
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<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">I might also turn to
<a href="http://www.infed.org/biblio/communities_of_practice.htm" target="_blank">Lave and Wenger’s work</a>, looking for examples of ways in which ‘newcomers’ to
each setting are provided with opportunities for legitimate peripheral
participation. <span style="mso-spacerun: yes;"> </span>Their analytic viewpoint on
learning leads me to consider the extent to which students and trainees are
invited to become full participants in the communities they join, through
engaging in meaningful work activity.<span style="mso-spacerun: yes;">
</span>This extends beyond practical work to cognitive work, in other words,
opportunities to rehearse ways of thinking like doctors. </span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">A recent hospital
admission (as a patient) provided me with great opportunities for some
ethnographic activity! I saw nursing students, for example, lead drug rounds,
with the senior nurse at their shoulder to make sure all was in order. Here,
students were able to rehearse (with support) the types of work activity they
would shortly be undertaking as qualified nurses. I was left more troubled by
the day to day activity of the FY1s, who, a month in, seemed to be engaged in
medical work that was quite distinct (and often detached from) the work that
more senior colleagues were doing. FY1s took bloods, they chased after surgeons
(literally) writing up notes from the ward round consult, but they (unlike the
registrars) were never invited into the discussions about my care, nor invited
to ask questions (at least within my hearing).<span style="mso-spacerun: yes;">
</span>Thankfully, the observed teaching session of FY2s a few weeks ago was
quite different. A complex session based on calculating blood gasses had
wonderful eureka moments, when ‘paper cases’ of patient presentations offered
new insights into the importance of these calculations and inspired those present to go back onto the wards to try out some calculations on their own. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Every discipline has
its own language and invites particular ways of thinking, education is no different
to medicine in that respect. Every worker makes choices about the tools or
instruments they use to do their job. Educational theories are, for me at
least, rich analytical and conceptual tools, which shed light on learning. Challenging
to grasp? Yes. Worth the struggle? Undoubtedly.<o:p></o:p></span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">----------------------------------------------------------------------------------------------------------------------------------</span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span style="mso-ansi-language: EN-GB;"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><i>Footnote: for those interested in ways of <a href="http://www.faculty.londondeanery.ac.uk/e-learning/facilitating-learning-in-the-workplace" target="_blank">enhancing workplace based learning, visit the London Deanery website</a>. In the linked e-learning unit, I draw on socio-cultural ideas about learning (including those mentioned above) to suggest some ways of developing clinical teaching practices. </i></span></span></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment--></div>
Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com21tag:blogger.com,1999:blog-8548648637110176926.post-14172596540029674162012-10-11T12:20:00.002-07:002012-10-14T11:38:37.922-07:00Lecturing for learning<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: left;">
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<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">It’s that time of year again! Lecture halls
are filling with eager new learners and those a little less keen, having been
there before. Lecturers blow the dust of their slides (symbolically, if not
actually) and start a process of refreshing materials,<span style="mso-spacerun: yes;"> </span>in order to show that they are absolutely up
to date, have read all the right journals and are ‘experts in their field’.
Lectures are undoubtedly good for the lecturer’s learning, but what about the
often passive recipients of their academic prowess, beautifully displayed on
power-points up and down the country? </span></span></div>
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<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Are lectures good for learners’ learning? </span></span><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">What is the nature of the relationship between ‘a good lecture’ and ‘good
learning’?</span></div>
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<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
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<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><a href="http://www.tandfonline.com/doi/abs/10.1080/03075079312331382241" target="_blank">Kugel (2003)</a> provides an interesting
account of how professors develop as teachers, noting shifts from
teacher-centric to learner-centric behaviours over time. Novice teachers are
concerned about their own preparation and performance, preoccupied with the
content of their lecturers, and ways to put together audio visual materials to
impress and entertain! More experienced teachers however,<span style="mso-spacerun: yes;"> </span>start with their learners, seeking to
establish what they already know, what their learning needs might be and how they can make new ideas and information accessible– re-contextualising
knowledge so it can be put to use.<span style="mso-spacerun: yes;"> </span>In
other words, they are preoccupied with making lectures good for learning. <o:p></o:p></span></span></div>
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<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">If you are preoccupied with ways to make
lectures good for learning, I have a few suggestions.</span></span></div>
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<!--StartFragment-->
</span></div>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span lang="EN-US"><b><span class="Apple-style-span" style="color: blue;">Establish learners’ needs. </span></b><o:p></o:p></span></span></div>
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">
</span><br />
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span lang="EN-US"><br /></span></span></div>
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">
</span>
<br />
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span lang="EN-US">Don’t treat a group of 100 learners as if they were of one mind and
don’t assume that because something has been ‘taught’ it has been learned. This
was a salutary lesson for me, when I asked a group of speech therapy students
to quickly sketch a picture showing pre and post operative anatomy of a patient
having a total largyngectomy, as a basis for discussing voice restoration. 6 hours
of ENT lecturers left 5 out of 80 students able to complete the task! A quick
quiz with a show of hands at the start of a lecture, primes students for what
is about to follow and offers you some information about where to concentrate
your efforts. <o:p></o:p></span></span></div>
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">
</span>
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span lang="EN-US"><br /></span></span></div>
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">
<div class="MsoNormal" style="margin-bottom: .0001pt; margin-bottom: 0cm;">
<span lang="EN-US"><b><span class="Apple-style-span" style="color: blue;">Structure your lectures</span></b><o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US"><a href="http://pgche09.middlesex.wikispaces.net/file/view/930229_731366039_713686930.pdf" target="_blank">Brown and Manogue (2001)</a> share insights
into observed medical and dental lectures and the structures often used. How
often do you resort to the ‘classical iterative’ structure in clinical
teaching, following signs, symptoms, diagnoses, management and prognosis? It
may mirror how classic medical textbooks are organized, but does that mirror
how you think when faced with a new patient? The problem-centred /case-based
lecture, where you start with a clinical case as a trigger for thinking through
options engages students in diagnostic reasoning processes before they meet
patients on the wards and in clinics. In doing this, you are showing how
clinicians put knowledge to use in practice.<o:p></o:p></span></div>
<!--EndFragment--></span><br />
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="color: blue; font-family: Arial, Helvetica, sans-serif;"><b>Build in interaction</b></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<br />
<div class="MsoNormal">
<span lang="EN-US"><o:p><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"> </span></o:p></span><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">For me this is perhaps the most important
element in increasing the learning value of lectures, but is often avoided.
Learners need opportunities to think in lectures, to test out new ideas, to
explore their relevance and put them to use. Interaction can be in a variety of
forms.</span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span class="Apple-style-span" style="color: blue;"><i><br /></i></span></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span class="Apple-style-span" style="color: blue;"><i>Interaction with the lecturer </i></span>is most
obvious but not necessarily the best strategy. Too often questioning becomes a
series of one-to-one teaching interactions in a whole group. Those asked
questions go into panic /show off mode, the remaining 99 breathe a sigh of
relief and switch off. Only the brave dare ask questions, which may not reflect
where the whole group is. There are ways to get round this. Asking students to
talk to each other for a couple of minutes and come up with a really good
question to ask you works well. If they write them on a slip of paper, you can
gather them and get excellent in-task feedback about what they are
understanding (or otherwise).<o:p></o:p></span></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><i><span class="Apple-style-span" style="color: blue;"><br /></span></i></span></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><i><span class="Apple-style-span" style="color: blue;">Interaction with each other</span></i> works well too.
Set them a challenge, a question to answer or give them some clinical material
to analyse (spot the fracture, identify the anomaly).</span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><span class="Apple-style-span" style="color: blue;"><i>Interaction with data</i></span> is important - a
graph to interpret, a dataset to consider a set of symptoms to think through.<o:p></o:p></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><i><span class="Apple-style-span" style="color: blue;">Interaction with their own ideas </span></i>is seldom
included but really valuable. Offering students 3 minutes to write down their
key learning points from the lecture so far keeps them on track and allows you
a moment to gather your thoughts. <o:p></o:p></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="color: blue; font-family: Arial, Helvetica, sans-serif;"><b>Provide a clinical context</b></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Finally, and perhaps most importantly,
offer your learners what a text book can’t – your experience and professional
wisdom. We know medical students are incredibly bright, they have shown their
capacity for book learning long before they reach you. They can distill and
regurgitate facts much quicker than those of us with aging brains can. What
they can’t do quite so readily is put their knowledge to use. You can bring the
clinic into the classroom through your use of examples, of clinical situations
and scenarios, through stories of patients and patient care. <span style="mso-spacerun: yes;"> </span>Bring lectures to life by sharing your lived
experiences.<o:p></o:p></span></span><br />
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span>
<span lang="EN-US"><span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></span>
<div style="text-align: center;">
<span lang="EN-US"><span class="Apple-style-span" style="color: blue; font-family: Arial, Helvetica, sans-serif;">-------------------------------------------------------------------</span></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="color: blue; font-family: Arial, Helvetica, sans-serif;">Addendum: in response to twitter chat, some other 'tips'</span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="color: blue; font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="color: blue; font-family: Arial, Helvetica, sans-serif;">'Managing' lectures</span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="color: blue; font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Always set the scene so learners know what to expect. If using interactive methods, explain why (goal is to encourage them to develop understanding of subject matter, not memorise) and what will happen when (a road map). </span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Set ground rules about when 'talk' is ok and how you will get them back on track. I use 'blank' screen - so if powerpoint goes blank (press b or w on keys) this means silence. You can also have row monitors who have to pay attention and 'sh' the rest of their row. You can use bells, whistles too!</span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="color: blue; font-family: Arial, Helvetica, sans-serif;">Further examples of interactive strategies</span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Quiz /voting - use show of hands if you don't have whizzy technology. You can do hands up with the 'right answer' or use likert scales and ask them to put hand up to show strength of agreement/disagreement. </span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Ask a question post its - all students collect a post it note on way in, which they can use to ask a question at any point. They write their question and pass to end of row. You collect when they are doing another interactive task, then answer most popular questions in a plenary.</span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Buzz groups - you don't have to take feedback / comments from every group, rationale is to get them talking, thinking. You can offer to take comments from a certain number of groups who think they have a brilliant contribution to make.</span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;">Interactive handouts. i.e handouts with deliberate gaps to fill. Use these creatively! I use these for clinical topics where I am using a problem based structure. A single side of A4 with an empty table. Along the top put diagnosis, down the side put boxes for signs, symptoms, investigation findings, management options, prognosis etc. As the lecture reveals similarities and differences between 'case' being discussed and two differentials, students populate the handout. This way they have a classical handout at the result of a problem based lecture. </span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
<div style="text-align: left;">
<span class="Apple-style-span" style="font-family: Arial, Helvetica, sans-serif;"><br /></span></div>
</div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment--></div>
Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com16tag:blogger.com,1999:blog-8548648637110176926.post-14086933155563749102012-09-23T14:35:00.003-07:002012-09-23T14:35:55.192-07:00What's the point of faculty development?<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: left;">
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<span lang="EN-US">In recent weeks, <a href="http://www.gmc-uk.org/education/10264.asp" target="_blank">the GMC have laid out their implementation plan for the recognition and approval of medical educators and trainers</a> working in academic and clinical contexts. In future medical
trainers should</span></div>
<div class="MsoNormal">
</div>
<ul style="text-align: left;">
<li>be ‘appropriately trained’ for their
educational roles,</li>
<li>evidence their competence against the seven
standards originally put forward by the <a href="http://www.medicaleducators.org/index.cfm/linkservid/C575BBE4-F39B-4267-31A42C8B64F0D3DE/showMeta/0/" target="_blank">Academy of Medical Educators</a> and</li>
<li>engage in appraisal processes specific to
educational roles.</li>
</ul>
<br />
<div class="MsoNormal">
<span lang="EN-US">The intent behind these new processes is to
improve the quality of training and patient safety. Laudable goals, but how
confident can we be that investing in trainer approval processes has a direct
effect on the quality of training and ultimately patient care? Equally
importantly, what does ‘appropriate training’ look like? <span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><span style="mso-spacerun: yes;"><br /></span></span></div>
<div class="MsoNormal">
<span lang="EN-US">Given the proliferation of masters level
courses in medical education and the rise of faculty development activity
within deaneries, royal colleges and higher educational institutions, you might
imagine we already know what ‘appropriate training’ looks like and the impact
it has. However, the research base is very limited and the discourse around
faculty development very narrow. The long chain of assumed causal relationships
(<i>faculty development</i> leads to <i>better training </i>leads to <i>better learning</i> leads to
<i>better clinical practice</i> leads to <i>better patient care</i>) has not, to my knowledge
at least, been the subject of any large-scale research study. <o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">I should perhaps declare an interest here!
For the past 15 years I have been engaged in a range of work activity, which
falls into the loose category of ‘faculty development’ within medicine,
dentistry and health. I lead a masters’ programme in medical education and
support a range of faculty development activity within and across NHS Trusts
and Deaneries. I believe faculty development can ‘make a difference’ – but
making a difference starts from having a clear sense of purpose and a
repertoire of practices that goes beyond typical generic ‘teaching the
teachers’ workshops. <o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US"><b><i>What is the point of faculty development? </i></b><o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">This is a question I explored in a study
tracing the demise of medical apprenticeship and the rise of faculty
development in PGME. In the post MMC era, claims about the transformational
potential of faculty development were embedded within the ‘professionalisation
of medical education’ discourse. As part of my study I had the opportunity to
interview medical educators from within and outside medicine, taking forward
the faculty development agenda in one deanery. In these professional dialogues
with colleagues, a range of orientations towards faculty development emerged
and a rich range of development practices revealed. The ways in which
colleagues made sense of faculty development, and the practices they adopted, were
shaped by the theoretical and biographical resources they drew upon. In my
analysis, I traced a continuum of responses to the professionalisation agenda,
ranging from conforming, through reforming, to transforming.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">A <b><i>conforming</i></b> response was one where the
need to professionalise medical education through faculty development went
unquestioned. Seen largely as a regulatory need (linked to PMETB initially and
GMC more recently), faculty development took the form of short workshops, or
e-learning modules, focused on ‘core’ or ‘generic’ teaching skills, that
participants could acquire and take back to their own workplaces.<span style="mso-spacerun: yes;"> </span><span style="mso-spacerun: yes;"> </span>Teaching
here was perhaps seen as a technical enterprise or craft. <o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">A <b><i>reforming</i></b> response was seen where the
professionalisation agenda was accepted, but faculty development practices
modified to meet the needs of certain professional groups and to be responsive
to particular workplace practices. Here, it was recognized that whilst there
are perhaps some generic principles, teaching on a ward round is not the same
as teaching in theatre, or in general practice, or out patients. Teaching here
is perhaps seen more as a social practice, shaped over time in ways that are
sensitive to context and practices. Workshops were adopted, but often for certain
professional groups (i.e. for surgeons), but other practices, such as workplace
based teaching observations were used.<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">A <b><i>transforming</i></b> response meant adopting a
critical stance to the professionalisation agenda and to faculty development
itself. Here there was a recognition that training practices of the past could
not be sustained as a result of NHS reform, and that a radical re-think of
training practices was required. Here, faculty development involved ‘listening
to the voices on the ground’, bringing colleagues together to examine and
develop training practices in ways that were sustainable in their local
context. Here creative faculty development approaches, such as trainer forums,
team based teaching observations (involving trainers and trainees) were being
developed in order to find solutions to problems arising following
implementation of new PGME curriculum. Here too, doctors were engaging in
masters programmes in education and educational leadership in order to have
access to theoretical tools that would help craft such solutions. <o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Which leads me back to the question, what
is the point of faculty development? If it is merely to satisfy a regulatory
need, processes of approval and recognition will suffice. They put education on
the agenda, they raise awareness of educational practices and they make
trainers accountable for their actions. If however, it is to develop training
practices that are sustainable in a reformed, and reforming, NHS, something
more educationally sophisticated and meaningful is required. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<!--EndFragment--></div>
Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com4tag:blogger.com,1999:blog-8548648637110176926.post-33634636746101201332012-08-21T14:17:00.003-07:002012-08-21T14:17:53.003-07:00Activity theory, agency and medical education reform<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span lang="EN-US">This post was stimulated by an interesting
twitter exchange today, about using activity theory in research and, in
particular, how issues of individual agency are addressed. I am interested in activity theory (and, </span>in particular, Engestrom’s 3<sup>rd</sup>
generation activity theory ) having drawn upon it in my doctoral studies. In the first study, I analysed medical
student learning on attachments, seeking to make sense of the ways in which
they engaged with the learning cultures of the medical school and the
workplace. In the second study, I set out to make sense of the emergence of
‘faculty development’ as a new set of practices within secondary care medicine.
I was interested in the discourse around the so-called ‘professionalisation of
medical education’ – for me an interesting phrase, given that medicine is one
of the oldest professions with centuries old traditions of apprenticeship. </div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
In
this study, I analysed 20 years of government policy and the grey literatures
of professional bodies (eg GMC, PMETB) in three areas – the NHS, Postgraduate
Medical Education and Undergraduate Medical Education. This led me to conclude
that constant reform of the NHS had systematically dismantled medical
apprenticeship, leaving doctors in a position where they were asked to adopt
training practices that were antithetical to their own learning histories. In
particular, I noted the growing disconnect (conceptually, practically) between
‘work’ and ‘learning’, no longer seen as mutually constitutive. The shift to
formal curriculum in PGME, with ‘competences’ to be gained, tools to evidence their
acquisition etc, signaled a profound culture shift, discussed, in part, in
previous blog postings.</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">My analysis led me to argue that there had
been a shift from time-served apprenticeship to time-measured training, creating
a series of structurally accumulating tensions. For example, an increasingly
risk averse culture (with consultant led services) sits uncomfortably with
training practices which rely on the delegation of medical work to those in
training grades. My analysis left me concluding that the medical profession
found themselves in a contradictory positioning (an activity theory concept). Training practices of old were
unsustainable in a reformed NHS, yet the solution put forward by the
regulators, to ‘professionalise’ medical education, was unlikely to offer the
creative, expansive solutions necessary to reconcile these tensions.<span style="mso-spacerun: yes;"> </span>Compulsory, regulated, faculty development
activity was offered up as the means to professionalise medical education, with
the ‘curriculum’ being focused on rather instrumental trainer-trainee
interactions e.g. the use of WPBA tools, how to give feedback, ‘managing the
trainee-in-difficulty’ and so forth. The question for me, was how would
deaneries respond to this positioning? Go with the grain (ensuring all trainers
were ‘trained’) or seek more creative solutions that would genuinely help
trainers find ways of sustaining high quality training practices in a reformed
NHS. This is where, for me at least, the question of agency sets in.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">My research led me to an analysis of one
deaneries response and a series of in-depth interviews with a new ‘faculty
development workforce’. I explored their sense making, talked to them about
their faculty development practices, and the types of theoretical and
biographical tools they drew upon in their work. In so doing I was able to
trace a range of responses to the call to professionalise. For some there was a
‘conforming’ response, meeting the regulators requirement to ensure that all
trainers were trained. Typical methods involved short, central workshops,
across all specialties, covering key aspects of educational supervision
practice. Others were a little more creative in their response (which I label
as a ‘reforming’ response). They worked with doctors in a range of ways, always
seeking to offer/elicit a medical context to their work, working with teams on
site, offering up teaching observation type activity, so individual doctors had
a chance to review existing educational practices and adapt them in light of
new requirements. The third ‘transforming’ response involved a radical
re-thinking of training practices. Here colleagues came together to explore
what was working on the ground but also where the difficulties lay. They
adopted and generated new forms of faculty development practices including team
observations, faculty groups and joint development activity between trainers and
trainees to find solutions to the problems being encountered post reform.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">So, how does this relate to the initial
query i.e. how the issue of agency is dealt with in activity theory? In
activity theory the world is understood as partially conceptualized, the world acts
on us but we also act upon the world. In finding themselves positioned to act
in a particular way (to professionalise medical education through faculty
development), the doctors and educators I spoke to chose to respond in a range
of ways. They showed agency. This agency was influenced by the biographical and
theoretical tools they had to draw upon, and the extent to which they were
willing to go with, or against, the grain of reform.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
</div>
Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com20tag:blogger.com,1999:blog-8548648637110176926.post-46829908611878976622012-08-16T09:18:00.000-07:002012-08-16T10:10:04.155-07:00Simulation, orthodoxy and doctrine...<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Over the past year or so, I have been involved
in a range of faculty development activity for medical and healthcare educators
using simulation in Higher Education and NHS contexts. The emphasis of my work
has been on enhancing the educational value of simulation, shifting the gaze
from technical and clinical aspects. In doing this, I have found myself grappling
with what I can only call simulation ‘orthodoxy’… my observations on the 'simulation doctrine' follow.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">
</span></div>
<div class="MsoNormal">
<span lang="EN-US"><b><i>Simulation improves patient safety.</i></b><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">It seems to me that many of the claims
about simulation are based on assumptions of transfer, from one context to
another. For example, we note that simulation has improved safety in the
aviation industry and assume it will do the same in medicine. We see that
performance is enhanced in simulation and assume that this enhanced performance
will readily transfer to the workplace. Yet we know that transfer is a
problematic concept in education generally, and medical education specifically.
<a href="http://www.esrc.ac.uk/my-esrc/grants/RES-153-25-0084/read" target="_blank">Studies of transition to greater levels of medical responsibility,</a> for example,
show dips in performance in new jobs, because transfer from one context, setting or team to
another is not a straightforward process. <span style="mso-spacerun: yes;"> </span>How sure are we really that simulation
achieves all that is claimed in its name?<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">
</span></div>
<div class="MsoNormal">
<span lang="EN-US"><b><i>Fidelity matters.</i></b><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Beware the seductive appeal of new technologies...<a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2012.04243.x/abstract" target="_blank">fidelity does not appear to be a significant determiner of the learning experienced.</a> Can I suggest we start a dialogue about authenticity, which I suspect is more important? By authenticity, I mean the extent to which participants are able to
engage in a simulation experience that feels meaningful, congruent and close to
their lived experiences of working in clinical teams, in clinical contexts.
Which brings me on to the next point…<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><b><i>Role-play is accepted as a proxy for actual
performance</i></b><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Too often in simulation we bring together a
group of learners, all at the same stage in training, typically all within the
same professional grouping, and give them parts to play. We ask a group of FY1s
to ‘play’ the registrar, the nurse, the consultant and so on. In so doing, we
ask them to play out their understandings of ways of being, thinking and
acting…fine, if the goal is to work with their stereotypes! If simulation is to
be meaningful, I think we need to stop thinking about role play, and move into
role-rehearsal. We need to give opportunities to rehearse the types of work
activity that are at the level of expectation (or just beyond) the learners
point in development. We need to construct scenarios that seek authenticity in
terms of roles, responsibilities and contexts. </span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">We are missing a real
opportunity to bring ‘real’ teams into the simulated space, to run through
scenarios they have already experienced, to consider different ways of being
and acting in order to improve practice. Simulation is used in ways that are
anticipatory of future action, why not use them to re-think the past? Which
leads us to consider the types of learning experience we offer in simulation.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><i>All simulated scenarios involve ‘surprises’
and ‘challenges’</i></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">From observation and discussion, it appears
to me that the typical simulated scenario involves a moment (or several) of
surprise, placing the learner in a position of uncertainty and challenge. Typically I witness a short briefing, a scenario
that plays out to the agreed conclusion, with faculty observing and intervening
only to lead the debrief. This is, of course, a perfectly legitimate use of
simulation, if the intended learning outcome is to develop approaches to
dealing with uncertainty /acute clinical situations. I fear this downplays much
of the learning value of simulation. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
</div>
<ul style="text-align: left;">
<li>How would it be if we used simulation to
explore a range of responses to more typical situations? </li>
<li>How would it be if we
involved learners in choosing or shaping the scenario, so they could rehearse
situations they are daunted by? </li>
<li>How would it be if in the briefing, we gave an
account of what was going to be encountered, and talk through possible ways of
responding before the scenario? </li>
<li>How would it be if faculty came alongside the
learner, with an option on both sides to ‘freeze’ the scenario, to discuss
possible options for action before moving on? </li>
</ul>
<br />
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Such variations would allow us to
maximize the learning value of simulation.<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><b>Debrief and feedback are inter-changeable</b><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">In the past 6 months I have asked faculty
to provide me with a simple definition of each of these terms and an account of
the pedagogic strategies they use for each. The answers suggest that
distinctions are unclear and that strategies merge into each other. The
simulation literatures aren’t that helpful in this regards either! I do think they
serve different purposes and require different actions as result. My working
distinctions are as follows…<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Feedback, is for me at least, a
developmental conversation. This conversation (dialogue, not monologue) builds
upon what is known (or shared) about performance, as a basis for moving
forward. Whilst group feedback is possible (if the performance of the whole
group is the focus), feedback is typically about the development of an individual. So, after a simulation session, this would mean
finding time to talk to the individual about their performance and what they
might do to develop their practice in light of that. With their consent, this
might be ‘in the round’, so that peers might offer suggestions and benefit from
listening in to tutor guidance. It is not ‘a given’ that an individual’s
performance in the simulated scenario is open for discussion in the group (no
more than it would be on a ward round, for example).<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">The term debrief has military origins –
according to one on-line dictionary, to debrief means to question someone
(typically a soldier or spy) about a completed mission or undertaking. The
soldier provides a vivid account of what s/he has experienced (sight, sound,
smell, sense). The purpose of the debrief, in this case, is for the unit to
gain inside information, and, together, to consider next steps for action. </span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Translating this into medical simulation, the debrief is a pedagogic strategy where the lived experience of one team member is offered up to the whole group as a
shared resources for learning. By inviting the learner to provide a narrative account, which includes affective responses to their experience of simulation, they are offering a gift to the group. Together they analyse ways of responding. Together they seek to make connections between the simulated experience and those experienced in vivo. Together they identify the learning arising from the scenario that they each can benefit from. This kind of debrief would be particularly powerful when bringing teams in to analyse existing practices and try out new ways of working to enhance patient care.<o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Simulation has the potential to be a powerful educational tool, if seen as that, a tool that supports learning of individuals (hence feedback) and development of teams and practice (hence debrief). It is time to take a critical stance to simulation and consider how it might make a meaningful, authentic contribution to developing patient care.</span></div>
<br />
<br /></div>
Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com4tag:blogger.com,1999:blog-8548648637110176926.post-13453473410449871872012-08-10T15:19:00.001-07:002012-08-11T01:27:34.981-07:00'Reflections' on reflection...<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="color: #0b5394;">“<i>In the varied topography of professional
practice, there is a high, hard ground, overlooking a swamp. On the high
ground, manageable problems lend themselves to solution through the application
of research-based theory and technique. In the swampy lowland, messy, confusing
problems defy technical solution. The irony of this situation, is that the
problems of the high ground tend to be relatively unimportant to individuals or
society at large, however great their technical interest may be, while in the
swamp lie the problems of greatest human concern. The practitioner must chose.
Shall he remain on the high ground where he can solve relatively unimportant
problems according to prevailing standards of rigor, or shall he descend to the
swamp of important problems and non-rigorous inquiry</i>?” Schon, 1987, p.3. </span></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">I make no apologies for reproducing the
first paragraph of Schon’s classic text, <a href="http://www.amazon.co.uk/Educating-Reflective-Practitioner-Professions-Jossey-Bass/dp/1555422209/ref=sr_1_1?ie=UTF8&qid=1344636849&sr=8-1" target="_blank">Educating the Reflective Practitioner</a>
in full – it is a paragraph that turned my world upside down! At the time I was
undertaking an MA in Higher and Professional Education and working as a Senior
Lecturer (in Speech Pathology and Therapeutics). I was trained (and was
training) within the technocratic, scientific tradition captured in the pre-clinical/clinical
divide of professional education. Schon’s glorious imagery of the high-ground
(the ivory tower of academia for me at that point) and the messy swampy
lowlands (of clinical practice) immediately resonated with my lived experience
of both being a clinician and of preparing future-clinicians. The invitation to
adopt a critical stance to the ‘apply theory to practice’ mantra of
professional education was thrilling. Donald Schon became my ‘first love’ in
the world of educational theory, and although he has subsequently been
supplanted by my ‘grand affair’ with socio-cultural and activity-theorists, I
will always have a soft spot for him. </span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Which is perhaps why I feel the need to
speak out about the injustices being committed in his name, through the
wholescale adoption of (compulsory), written ‘reflections’ as part of the
assessment practices of medical, dental and healthcare professionals. These
instrumental practices seem so very far removed from Schon’s accounts of
professional artistry and the ways in which expert practitioners negotiate the
swampy lowlands, generating and testing out novel solutions to complex problems
that do not respond to a by-the-book approach. </span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Schon’s accounts of reflection-in-action
relate to the types of in-the-moment analysis and problem framing that happens
when we encounter a unique case or situation, that, in his words ‘<i>falls outside
the categories of existing theory and technique</i>’ and cannot '<i>be solved by
applying on the rules in her store of professional knowledge</i>’ p. 5.<span style="mso-spacerun: yes;"> </span>The practitioner adjusts her problem
framing, and formulates a response, which may involve aspects of improvisation,
hypothesis formulation and testing and experimentation, which in my experience
at least, may involve simultaneous internal narrative (<i style="mso-bidi-font-style: normal;">what if, shall I, it might be, I could, I wonder if, lets go with</i>)
with external action. <span style="mso-spacerun: yes;"> </span>Evidence-based practice, clinical guidelines and protocols
sit rather uncomfortably with Schon’s account of the expert’s ‘professional
artistry’.<span style="mso-spacerun: yes;"> </span>Reflection-in-action
feels a long way away from the rather predictable, ‘<i style="mso-bidi-font-style: normal;">chose something that did not go so well this week, reflect on why that
was the case and rationalize what you will do differently (and therefore
better) next time’</i>. </span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">So, how might we reclaim and revive reflection-in-action
in medical training, or rather more grandly, create a curriculum to foster
professional artistry? </span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">According to Schon, we need to find ways to
‘<i style="mso-bidi-font-style: normal;">bring past experience to bear on a
unique situation’</i>. One way to do this, might be in the use of Case Based
Discussion (or chart stimulated recall). Rather than fall into the trap of
using CbD to check out whether practice was by the book (ie done the way you
would have done it), the case becomes a trigger for a richer discussion, that
allows exploration of other ways of thinking and responding to the situation in
hand and situations in the future.<span style="mso-spacerun: yes;"> </span></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">The case of the 45 year old man presenting with ‘x’ and ‘y’ on findings
is extended into other scenarios. </span></div>
<div class="MsoNormal">
</div>
<ul style="text-align: left;">
<li>‘<i>What if it had been a 23 year old man, how might
that have influenced thinking or action?</i>’</li>
<li> ‘i<i>magine that the finding ‘y’ had in
fact been finding ‘z’, what might you have done then?</i>’</li>
<li> ‘<i>What would you have
done if he didn’t respond in the way he had?</i>’ and so on. </li>
</ul>
<br />
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Encouraging explicit
links between this and other experiences is vital. </span></div>
<div class="MsoNormal">
</div>
<ul style="text-align: left;">
<li>‘<i>To what extent did he
present / not present typically?’, </i></li>
<li><i><span lang="EN-US">‘think of another case that has presented like this, but
turned out to be something different…</span>what was the pivotal piece of information
/action that helped move things forward?'</i></li>
</ul>
<br />
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Schon also encourages on-the-spot
experimentation, clearly something that raises alarm bells in the clinical
world. But how would it be if we used simulation rather more creatively here?
Rather than create ‘surprise’ scenarios for ‘simulated teams’, why not provide
opportunities for actual teams to come together, to re-run known situations,
trying out and discussing a range of possible options for action? They might
also rehearse new practices, anticipating those situations which don’t always
go according to plan, using think aloud and debrief techniques so that ‘reflection’
becomes a shared endeavour, rather than a solitary pursuit in front of computer
screen. Through rehearsing different approaches to a known situation, it is
possible to find ways of thinking and working together that allow
experimentation. This fits well with Schon’s encouragement to use virtual
worlds, where ‘the pace of action can be varied at will’, allowing slow motion
replays of both action and thinking. </span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US">Ultimately, reflection-in-action has to
involve action – opportunities to engage in a rich and varied ‘practicum’ of
the workplace. Recent calls to consider whether trainees have sufficient time
to reflect are admirable, but only relevant if they have meaningful experiences
to reflection in and upon.</span></div>
</div>Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com8tag:blogger.com,1999:blog-8548648637110176926.post-36187693450503901582012-08-03T03:16:00.000-07:002012-08-03T03:16:02.325-07:00Apprenticeship: a socio-cultural view<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span lang="EN-US">My starting point, when thinking about
apprenticeship, is to turn to <a href="http://books.google.fr/books/about/Situated_Learning.html?hl=fr&id=CAVIOrW3vYAC" target="_blank">Lave and Wenger, who set out to ‘rescue the idea of apprenticeship’</a>. Their social-anthropological study of diverse forms of
apprenticeship opened up thinking about the nature of learning, challenging
dominant (cognitive-behavioural conceptions of learning). It is their work that
informs Sfard’s (1998) learning-as-participation metaphor, <a href="http://www.medicaleducationmatters.blogspot.fr/2012/07/lost-in-translation-postgraduate.html" target="_blank">explored in an earlier blog.</a><span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Lave and Wenger looked at learning as a
social practice, analyzing apprenticeships out-with formal teaching and
learning structures. As a result, they put forward an analytic viewpoint on
learning, with two inter-related concepts, legitimate peripheral participation (LPP)
in communities of practice.<span style="mso-spacerun: yes;"> </span>The term CoP
is widely (and loosely) evoked, but, for Lave and Wenger, it did not simply
mean a team, rather a grouping of people, who shared a common purpose, working
together (not in parallel) to sustain and develop practice, over time. Rather
than use hierarchical distinctions (such as expert-novice, master-apprentice)
they talked of <i>newcomers</i> (to a community) and <i>old-timers</i>, who preserve the work
of the community. Newcomers are invited into the work of the established
community through processes of legitimate peripheral participation, which
socialize them into ways of thinking and practicing. The interesting point
made, is that the engagement of a newcomer will always change established
practice, and so the development of practice is a shared endeavor. Within a
true community of practice, expertise is a distributed phenomenon; no single
practitioner can undertake the work of the community alone. To over-simplify, </span>apprenticeship might be seen as the
learning arises from engagement in social practices, such as work, within a
community of practice. <a href="http://books.google.fr/books/about/Communities_of_Practice.html?id=heBZpgYUKdAC&redir_esc=y" target="_blank">Wenger later went on to explore the dimensions of any social theory of learning,</a> arguing it encompasses elements of learning as
meaning (sense-making), learning as practice (participation in a social
practice (such as work), learning as belonging (to a community of practice) and
learning as becoming (identity formation).</div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Lave and Wenger looked at informal
apprenticeships, so their work is not directly applicable to medicine; their
analytic standpoint is. The question for me therefore, is to what extent do
(historical) forms of medical apprenticeship involve legitimate peripheral
participation in a community of practice? (As an aside, I have written up
research of medical student attachments as times spent in CoP in a f<a href="http://www.radcliffehealth.com/shop/work-based-learning-clinical-settings-insights-socio-cultural-perspectives" target="_blank">orthcoming publication</a>, which presents a range of interesting research on learning in
clinical workplaces.) I would argue, from an analytic standpoint, that training
to be a doctor has, historically, involved LPP in a CoP. The firms of old, with
stable work teams were close to CoP, determining the nature, type and amount of
work activity newcomers engaged in, as part of the shared care of
patients.<span style="mso-spacerun: yes;"> </span>Through processes of LPP (at
different speeds, based on perceptions of readiness) newcomers therefore became
integral to the work of the community. <span style="mso-spacerun: yes;"> </span>Work
is therefore the curriculum for training, with work activity being
safety-netted by the CoP and other learning processes (sense-making,
professional identity formation) being mediated by old-timers (firm leaders). <o:p></o:p></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
</div>
<div class="MsoNormal">
<span lang="EN-US">CoP in the literature come across as being rather
benign groupings, with issues of power differentials seldom explored. The
critique of apprenticeship I tried to offer up in the earlier blog, suggested
that these power differentials led to inequitable training practices. (<a href="http://www.avetra.org.au/abstracts_and_papers_2001/Billett_full.pdf" target="_blank">Stephen Billet talks of workplace affordances, how these support learning and how they fail to be benignly distributed</a>). <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">For a whole host of reasons, not explored
here, I think this type of apprenticeship is unsustainable within current NHS/
medical working structures and practices. I think there has been a move away
from a socio-cultural account of apprenticeship to something that is framed in
cognitive-behavioural terms. Here, work-based learning is understood as having
a work experience, that you subsequently reflect upon and, as a result, adapt
your work practices to be more effective. Whilst I think socio-cultural
accounts downplay the importance of cognition, ie how doctors put knowledge to
work, they do provide a much richer, situated, collective account of learning
arising through, from and for work reasons than the rather over-simplified metric of do-reflect-adapt which is put forward as being how medical learning happens. (I find<a href="http://www.tlrp.org/pub/documents/apprenticeshipcommentaryFINAL.pdf" target="_blank"> Unwin and Fuller’s work on restrictive-expansive apprenticeships </a>useful here, along with <a href="http://www.wlecentre.ac.uk/cms/files/pktw/putting_knowledge_to_work-a_new_approach.pdf" target="_blank">Evans, Guile and Harris’ work on ‘putting knowledge to work’</a> through processes of
recontextualisation).<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">The current framing of medical training seems
to isolate individuals and individual practice, disconnecting them from the
work of the communities they are part of. This for me, is part of the diminishing of the cultural-heritage of apprenticeship.<o:p></o:p></span></div>
<br />
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
</div>Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com6tag:blogger.com,1999:blog-8548648637110176926.post-31033252682508942962012-08-02T12:15:00.002-07:002012-08-02T14:25:24.867-07:00Apprenticeship: a rose-tinted view?<div dir="ltr" style="text-align: left;" trbidi="on">
<br />
<div class="MsoNormal">
<span lang="EN-US">Commenting on my last <a href="http://www.medicaleducationmatters.blogspot.fr/2012/07/lost-in-translation-postgraduate.html" target="_blank">blog</a>, Kirsty asked
whether ‘<i style="mso-bidi-font-style: normal;">we hold a rose tinted view of
apprenticeship</i>’?<span style="mso-spacerun: yes;"> </span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">It is a question that struck a chord,
having been asked something very similar in my doctoral viva; on both occasions
I have tried to adopt a critical stance to the idea of apprenticeship. Part of
that stance involves engagement with the <i style="mso-bidi-font-style: normal;">implied</i>
rationale for the move towards structured, competency-based training systems in
postgraduate medical education, under the heading of <a href="http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4079532.pdf" target="_blank">Modernising Medical Careers</a>. This leads me to explore a series of
propositions about medical apprenticeship.<span style="mso-spacerun: yes;">
</span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><span class="Apple-style-span" style="color: #0b5394;"><b>Apprenticeship was too risky</b>.</span><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">A dominant discourse in both undergraduate
and postgraduate medical education, is that of patient safety. The most recent (2009) edition of <a href="http://www.gmc-uk.org/TomorrowsDoctors_2009.pdf_39260971.pdf" target="_blank">Tomorrow’s Doctors</a> (TD), for example, highlights the responsibility
of medical schools in ensuring that patients are not put at risk by being
involved in medical education. Patient safety is the first domain of this new
version of TD; it was barely mentioned in the <a href="http://www.gmc-uk.org/Tomorrows_Doctors_1993.pdf_25397206.pdf" target="_blank">first</a>. I observe increasingly
risk-averse training practices being adopted (such as simulation), and listen
to doctors who are increasingly anxious about delegating medical work to
medical students or others. Medical colleagues (of a certain age) talk about ‘<i style="mso-bidi-font-style: normal;">being thrown in at the deep-end</i>’ and
share vivid stories of early near-misses. All this might lead you to think that
apprenticeship systems of the past were inherently more risky than those we
adopt now. Yet, I watched with interest the 1<sup>st</sup> of August twitter
feed yesterday, as comments from new and transitioning doctors echoed anxieties of the past. The inherent contradiction here is, of course, that risk-averse practices restrict learning opportunities, thereby increasing risks to patients. </span><br />
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US"><i>Was apprenticeship really inherently more
risky? </i><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span class="Apple-style-span" style="color: #0b5394;"><b><span lang="EN-US"><o:p> </o:p></span>Apprenticeship is open to abuse of power</b>.</span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Apprenticeship is often, unfairly in my
view, coupled to accounts of teaching-by-humiliation, as if the two were
integrally related. Strongly hierarchical systems amplify power differentials;
senior doctors had considerable leverage over important decisions about
progression to greater levels of medical responsibility in the past. These
decisions are perhaps more transparent now; certainly the evidencing of
decisions is more visible. <a href="http://217.154.121.42/doh/Docs/Unfinished-Business.pdf" target="_blank">The ‘lost tribes’ of Senior House Officers </a>were put
forward as part of the rationale for modernizing medical careers. Inequitable
gender distributions across particular specialties, limited access to part-time
training, under-representation of particular socio-economic groupings in
medicine each suggest there have been inequitable training practices
historically. An apparent silencing of the patient’s voice in medical
education, (with patients seen as an <i style="mso-bidi-font-style: normal;">exemplar</i>
<i style="mso-bidi-font-style: normal;">of </i>rather than an <i style="mso-bidi-font-style: normal;">expert in</i> their own condition) is
another reason to rethink training practices of old. <a href="http://www.pcmd.ac.uk/profiles.php?id=ableakley" target="_blank">Prof Alan Bleakley</a> talks,
with passion, about the need to democratize medical education. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><i>I wonder the extent to which new medical
education and training practices move the profession towards this goal?</i><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<b><span class="Apple-style-span" style="color: #0b5394;">Apprenticeship is financially unsustainable.</span></b></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Over the past three decades we have witness
significant form throughout the public sector, based on financial imperatives.
The three e’s of new managerialism, ‘economy, efficiency and effectiveness’ have
driven much of this reform, shaping the ways in which healthcare is organized
and delivered. Apprenticeship into the medical profession is a lengthy,
resource demanding process, involving significant investment of time and
energies. </span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
</div>
<span style="color: rgb(16.100000%, 14.500000%, 14.900000%); font-family: 'AGaramond'; font-size: 11.000000pt;">"<i>The apprenticeship model, long the bedrock of our training in the past remains important but now
needs to be set within efficiently managed, quality assured training Programmes compatible with the
Working Time Directive</i>." <a href="http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4079532.pdf" target="_blank">Modernising Medical Careers: the Next Steps (2004) </a></span><br />
<br />
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US"><i>Should new
managerialist principles replace sound educational thinking when designing
medical curriculum? </i><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US"><b><span class="Apple-style-span" style="color: #0b5394;">Apprenticeship fails on learning grounds?</span></b><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">In adopting a critical stance, it is clear,
to me at least, that apprenticeship is costly in terms of human and financial
resource. I recognize that apprenticeship practices were distorted by the
playing-out of power differentials, leading to inequitable training practices.
I fail to be convinced, that apprenticeship systems were inherently more risky
than those we adopt now. Indeed, I grow increasingly concerned about the amount
of hands-on experience gained and the increasingly narrow range of work
activity undertaken by medical students and doctors in training. But did
apprenticeship fail on learning grounds? I am not sure it did and I have found
few accounts critiquing apprenticeship in the learning literatures. Medicine
has a rich cultural inheritance in apprenticeship. A reformed NHS may make it
increasingly difficult to sustain, but there is merit, in my mind at least, in
taking time to re-think and develop a new form of medical apprenticeship. </span></div>
<div class="MsoNormal">
<span lang="EN-US"><br /></span></div>
<div class="MsoNormal">
<span lang="EN-US"><i>Rose-tinted?
Perhaps!</i><o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<br /></div>
</div>Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com5tag:blogger.com,1999:blog-8548648637110176926.post-6730468402818628702012-07-29T14:17:00.002-07:002012-08-02T04:09:56.873-07:00Lost in translation? Postgraduate Medical Training Curricula<div dir="ltr" style="text-align: left;" trbidi="on">
<div style="text-align: left;">
</div>
<div class="MsoNormal">
<span lang="EN-US">In a previous <a href="http://medicaleducationmatters.blogspot.fr/2012/07/why-wpba-arent-working.html" target="_blank">blog on WPBA</a>, I observed there
has been a culture shift in postgraduate medical education, from that of a <i style="mso-bidi-font-style: normal;">time-served apprenticeship</i>, to one of <i style="mso-bidi-font-style: normal;">time-measured training</i>. 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…<o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">Historically, in a <i style="mso-bidi-font-style: normal;">time-served apprenticeship</i>, 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 <a href="http://www.infed.org/biblio/communities_of_practice.htm" target="_blank">communities of practice</a>,
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. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">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 <a href="http://www.it.uu.se/edu/course/homepage/cosulearning/st12/reading/Sfard_ER1998.pdf" target="_blank">Sfard’s (1998) account of two metaphors for learning</a> might see time-served apprenticeship in
terms of ‘learning-as-participation’ and time-measured training as
‘learning-as-acquisition’. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">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. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">So where next for postgraduate medical
education? I take some comfort in the revised <a href="http://www.foundationprogramme.nhs.uk/pages/home/curriculum-and-assessment/curriculum2012" target="_blank">foundation curriculum</a>, although I
believe it has some way to go. <o:p></o:p></span></div>
<div class="MsoNormal">
<br /></div>
<div class="MsoNormal">
<span lang="EN-US">The <b>move away from competences</b> 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
(<a href="http://anes-som.ucsd.edu/images/Documents/VP08/Swide/Kate%20and%20Scheele,Acad%20Med%202008%20EPAs.pdf" target="_blank">entrustable professional activities)</a> 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. <o:p></o:p></span></div>
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<span lang="EN-US">The <b>move away from workplace based
assessments</b> 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. <o:p></o:p></span></div>
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<span lang="EN-US">Finally, the new curriculum <b>revives 'the
firm'</b>, 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.<o:p></o:p></span></div>
</div>Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com23tag:blogger.com,1999:blog-8548648637110176926.post-35831137379299442142012-07-28T03:48:00.001-07:002012-08-09T15:30:54.330-07:00Why WPBA aren't working.<div dir="ltr" style="text-align: left;" trbidi="on">
<span class="Apple-style-span" style="color: #333333; font-family: Helvetica, sans-serif; font-size: 12px; line-height: 15px;">'Clare, you need a blog' - well Anne-Marie, here is my first attempt!<br /><br />Curiously, as a medical educator who champions the use of blogs as a pedagogic strategy, I have seldom used one myself. However, recent twitter-conversations about workplace based assessment in medicine, lead me to extend and share my thinking about the ongoing debate about the value, or otherwise, of these tools.<br /><br />I have spent the past six years, post MMC, engaging in rich, often challenging, conversations with educational and clinical supervisors, many of whom decry the learning value of WPBA and resort to meaningless, tick box practices to meet regulatory requirements. Others, wishing to use them as intended, raise anxieties about using the 'full range' of performance judgments, on the basis that the mean is '<i>above expectation'</i> unless the trainee is experiencing difficulties. It is hardly surprising then, that <a href="http://www.mee.nhs.uk/pdf/401339_MEE_FoundationExcellence_acc.pdf" style="color: #2262f5; text-decoration: none;" target="_blank">Collin's (2010) evaluation of foundation training</a> describes assessment of trainees as '<i>excessive, onerous and not valued</i>'. The move away from WPBA to <i>'supervised learning events</i>' is poignant, given that the original intent of WPBA was to capture learning arising from everyday working practices. WPBA were meant to 'script' in time for trainers and trainees to come together, to discuss observed practice and to ensure that feedback was an integral part of working life. I wonder then, what went wrong?<br /><br />It seems to me that WPBA embodied a fundamental shift in the culture of medical training, a shift from time-served apprenticeship to time-measured training. Assessments, historically, were significant, loaded affairs, based around high-stake summative judgements allowing entry into the profession, or otherwise. WPBA in their fledgling foundation form, were designed to be something very different; a 'diagnostic' tool, illuminating profiles of performance, that could form the basis of a shared 'developmental' conversation. They were designed as formative tools, capturing everyday working practices, tracing development over a trainee's working year. For this reason, the foundation WPBA were individually formative (for learning) and collectively summative (of learning). They used both criterion (pre-determined descriptors of performance) and normative referencing, with the norm being what it was reasonable to expect of a trainee at the END of that stage in training. They were valid because they were designed to sample authentic practice (not assessed performance) and reliable in that they were based on multiple assessments, on multiple occasions, by multiple assessors.<br /><br />In my experience, the lack of faculty development activity to support the introduction of these tools, meant that trainers defaulted to known assessment practices. i.e. WPBA were viewed as summative hurdles to overcome, and trainees baulked at any judgement below 'at the level of expect ion'. Boxes were ticked; feedback sections left empty. All too soon, WPBA started to shape working practices ('<i>we better do all your assessments today, as your time here is nearly up</i>') rather than respond to working practices. All too often, trainers unaware of the normative benchmark, used the tools to judge performance relative to the stage of training, rather than end point. All too soon, these skewed assessment practices diluted any potential learning value embedded in the tools.<br /><br />So where next with WPBA? Given that WPBA are being held onto during specialty training, at least for now, are their ways to retrieve their learning value.<br /><br />1. Assessors to be very clear about the intended purposes and parameters of the tools they are using. Formative or summative? Norm or criterion referenced? Understanding their purpose will lead to more purposeful use.<br />2. Royal Colleges should be explicit about the design and development of the tools they are advocating. How has their validity and reliability been assessed? What constitutes 'best practice' in their use. All assessments involve some kind of 'trade off';being clear about limitations of tools is just as important as knowing their strengths.<br />3. Trainers and trainees should have opportunities to familiarise themselves with tools before they are used; where merited this may include some shared faculty development activity so the learning value of tools can be enhanced.<br />4. Rather than seeing WPBA as a driver for learning, see them as a way of capturing and fostering learning. If you are going to use them, use them authentically and in so doing, add meaning to their use.<br />5. Feedback is key; not the rather instrumental 'good bad good' routine, rather a rich, developmental conversation which explores the ways in which performance might be developed, with 'what happens next' being a far more important topic than 'what just happened'.<br /><br />Clare.</span></div>Anonymoushttp://www.blogger.com/profile/13539591178759056897noreply@blogger.com14