On clinical teaching and learning theory...

These past few weeks have been all about clinical teaching. I have run a couple of workshops based on the topic of  'on-the-job teaching' for a group of doctors and dentists studying for PgCerts in Medical and Dental Education and  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.

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?

Well, I might start with Stephen Billett’s conception of ‘workplace affordances’ 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. 

I might also turn to Lave and Wenger’s work, looking for examples of ways in which ‘newcomers’ to each setting are provided with opportunities for legitimate peripheral participation.  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.  This extends beyond practical work to cognitive work, in other words, opportunities to rehearse ways of thinking like doctors. 

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).  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. 

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.

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Footnote: for those interested in ways of enhancing workplace based learning, visit the London Deanery website. 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. 

'Reflections' on reflection...

“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?” Schon, 1987, p.3.

I make no apologies for reproducing the first paragraph of Schon’s classic text, Educating the Reflective Practitioner 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. 

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.

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 ‘falls outside the categories of existing theory and technique’ and cannot 'be solved by applying on the rules in her store of professional knowledge’ p. 5.  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 (what if, shall I, it might be, I could, I wonder if, lets go with) with external action.  Evidence-based practice, clinical guidelines and protocols sit rather uncomfortably with Schon’s account of the expert’s ‘professional artistry’.  Reflection-in-action feels a long way away from the rather predictable, ‘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’.

So, how might we reclaim and revive reflection-in-action in medical training, or rather more grandly, create a curriculum to foster professional artistry?

According to Schon, we need to find ways to ‘bring past experience to bear on a unique situation’. 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.  

The case of the 45 year old man presenting with ‘x’ and ‘y’ on findings is extended into other scenarios. 

• ‘What if it had been a 23 year old man, how might that have influenced thinking or action?’
•  ‘imagine that the finding ‘y’ had in fact been finding ‘z’, what might you have done then?’
•  ‘What would you have done if he didn’t respond in the way he had?’ and so on. 

Encouraging explicit links between this and other experiences is vital. 

• ‘To what extent did he present / not present typically?’, 
• ‘think of another case that has presented like this, but turned out to be something different…what was the pivotal piece of information /action that helped move things forward?'

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.

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.

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.