What's the point of faculty development?

In recent weeks, the GMC have laid out their implementation plan for the recognition and approval of medical educators and trainers working in academic and clinical contexts. In future medical trainers should

• be ‘appropriately trained’ for their educational roles,
• evidence their competence against the seven standards originally put forward by the Academy of Medical Educators and
• engage in appraisal processes specific to educational roles.

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?  

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 (faculty development leads to better training leads to better learning leads to better clinical practice leads to better patient care) has not, to my knowledge at least, been the subject of any large-scale research study.

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.

What is the point of faculty development?

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.

A conforming 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.   Teaching here was perhaps seen as a technical enterprise or craft.

A reforming 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. 

A transforming 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.

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.

Apprenticeship: a rose-tinted view?

Commenting on my last blog, Kirsty asked whether ‘we hold a rose tinted view of apprenticeship’? 

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 implied rationale for the move towards structured, competency-based training systems in postgraduate medical education, under the heading of Modernising Medical Careers. This leads me to explore a series of propositions about medical apprenticeship. 

Apprenticeship was too risky.

A dominant discourse in both undergraduate and postgraduate medical education, is that of patient safety. The most recent (2009) edition of Tomorrow’s Doctors (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 first. 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 ‘being thrown in at the deep-end’ 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^st 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. 

Was apprenticeship really inherently more risky?

 Apprenticeship is open to abuse of power.

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. The ‘lost tribes’ of Senior House Officers 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 exemplar of rather than an expert in their own condition) is another reason to rethink training practices of old. Prof Alan Bleakley talks, with passion, about the need to democratize medical education.

I wonder the extent to which new medical education and training practices move the profession towards this goal?

Apprenticeship is financially unsustainable.

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. 

"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." Modernising Medical Careers: the Next Steps (2004) 

Should new managerialist principles replace sound educational thinking when designing medical curriculum?

Apprenticeship fails on learning grounds?

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. 

Rose-tinted? Perhaps!

Lost in translation? Postgraduate Medical Training Curricula

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

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

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

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

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

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

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

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