Educating Trainers - Hayley Allan

Pendleton's rules

2011-05-29T19:51:00.000+01:00

At the recent ATLS National Day and the Europen meeting of ATLS Educators there were discussions about other courses trying out different approaches to feedback. It seems as though Pendleton's rules for feedback http://www.gp-training.net/training/educational_theory/feedback/pendleton.htm are falling out of favour.

I was asked why this may be the case, and my personal view is that it is not the Pendleton framework which is at fault, but the struggle many people have to either understand the point of Pendleton, or to conduct a developmental conversation that is both specific, based on behavioural evidence and sufficiently constructive.

I have discussed various forms of feedback on here previously (see DEBRIEF), but wanted to make out a case for the use of Pendleton's rules.

For me the benefit of Pendleton is that it reaches all stages of learning, from the competent to the incompetent, and from that which we are aware of to that which we are not aware of.

As I have written before, learning is a matter of developing both competence and conscious awareness. We progress from a state of not knowing that we do not know or cannot do (unconscious incompetence) through the stage of being aware of what we do not know or cannot do (conscious incompetence) to one of knowing what we know and can do (conscious competence) to the final stage of knowing what we know and doing what we do but not being always aware of that (unconscious competence.)

If this is the case, and this learning curve describes the rudimentary stages we progress through when learning a new skill or behaviour, then feedback needs to access each of these stages of learning.

Pendleton's rules map onto these stages of learning beautifully:

1. Asking "What went well with that?" accesses the conscious competence quadrant and focuses the learner's mind on practice that needs to be repeated in future. This question also allows for the teacher to assess the levels of insight the learner displays, in their self evaluation.

2. Providing further discussion of what went well led by the teacher, develops the good practice and may access the areas of strength which the learner has no awareness of (unconsciously competent.)

3. Asking the learner what they were less pleased with and what could be developed further, also checks insight levels, and accesses the consciously incompetent areas of practice.

4. Finally, discussing with the learner what the teacher feels needs to be developed (with an action plan to do so) accesses the unconsciously incompetent quadrant.

Pendleton offers a framework within which we can discuss all aspects of the learning curve, including those areas of competence and incompetence known and unknown to the learner. What we need to do within each of the four questions advocated by Pendleton is to be specific about the strengths and areas for development, not shy away from being honest in our descriptions of the behaviours we have observed. And we must always encourage further actions which develop the weaker areas.

Proof it can be done!

2011-05-16T09:50:00.000+01:00

A great new article from a trainee who was victim to the curriculum changes from BST to ISCP.

This article shows how hard Rafay worked and what he has achieved. He is now deservedly in ST3 training in the specialty of his choice.

http://careers.bmj.com/careers/advice/view-article.html?id=20002902

2011-01-13T21:40:00.001Z

DEBRIEF: A reflective tool for workplace based learning

Hayley Allan

Why do we sometimes act inconsistently? Our heart is pulling us in one direction and our head is insisting on another. What about that gut feeling we have? You know that niggling feeling in the middle of the night? The knowledge, deep down somewhere that what we are doing is not totally right?

Survival has always depended on gut feeling. Humans would long be extinct if they did not have the ability to instinctively know when something is wrong. How many times do we hear someone saying that they “just knew” something was wrong? Paediatricians know that if the mother is worried, they ought to be worried. The girl who was mugged outside the internal front door of her second floor flat, knew there was something not quite right. What is this sixth sense we all have and why are we advised to ignore it at our peril?

Call it intuition, call it experience. (It will depend on where you were schooled. If in the arts or social sciences you may favour intuition as a term for this phenomenon. Medics and those who deal with the allegedly more concrete world would call it experience. )

Experience is a tremendous learning tool because it develops in us over time; it steadily drip feeds our psyche while we work. Experience builds up pattern recognition over time. It swells the coffers of our intellect, adding to the vault of events and feelings that our mind stockpiles over the years. It is a rich resource. Many people, especially those who learned their craft through trial and error, through experimentation and throughput of events, believe there is no other way to learn.

But what if that accumulation of experience could be fast tracked? What if, instead of laying down lots of fifty pence pieces in the bank vault (individually heavy and of low value) we put by the (admittedly less frequent) stash of ten pound notes we came across? Is there a way to take more learning from fewer learning experiences?

Learning from experience and developing metacognition

DEBRIEF is a tool that enables reflection to take place between a number of people or individually. It provides a structure for review of an event in an emotional, a cognitive and a practical way, thus addressing the psychosocial and practical elements of learning. It has been acknowledged that learning is facilitated or hampered by emotions (Boekaerts 1993, Goleman 1995) and that emotions drive learning and memory (Sylvester 1994.) Learning is not a purely cognitive process (Le Doux (1997) Gross (2008) Love & Goodsell (1996). Much has been said about the emotional impact of learning. If we agree that learning is based on experiences then we cannot deny that emotions will play a part in those experiences and how we process them. The DEBRIEF model, in the constructivist tradition, helps learners to “take responsibility for their own learning, to be autonomous thinkers, to develop integrated understandings of concepts and to pose – and seek to answer- important questions.” Brooks & Brooks (1993)

Friere (1970) argued that learning and education is transformed through praxis – that is “reflection and action upon the world in order to transform it.” Vygotsky (1978 ) identified a zone of proximal development – a gap in terms of experience between two people, which could be used to “scaffold” (Wood et al 1976) the learning for the less experienced of the two. Scaffolding works best when functioning in a situated context or a Community of Practice (Lave & Wenger 1991) and remains the most practically useful way for many in training to learn. DEBRIEF offers a simple structure for such scaffolding to follow, but can also develop in time into internal DEBRIEFing, or metacognition.

Where are the trainers? And how do I know what I don’t know?

In current workplaces, trainees rarely have a supervisor with them all the time; the luxury of a more expert person always being at the elbow of the novice to question and support them in their thinking and practice is but a dream. If medical training is to be ‘trainee driven’ ( ISCP 2010, RCPath 2011,RCP 2011 ) then learners have to recognise their own learning needs and seek out an expert with whom to discuss those needs. However many needs, or gaps in knowledge and uncertainty about practice, fall into the zone of ‘unconscious incompetence.’ How can we know what we do not know if we do not know it and do not know that we do not know it? Once we are consciously competent (that is we know what we don’t know) there is not a problem, but often this conscious awareness has to be raised by either experience or a supervisor. If the supervisors aren’t there, we return to the learning by mistakes method, which is no longer tenable in the twenty first century.

This is where gut feeling comes in.

Fig 1. The role of conscious awareness in the development of competence.

There is a halfway house between unconscious incompetence and conscious incompetence where gut feeling resides. It is a small space, barely perceptible to some, but it can be developed given practice and the right conditions. Gut feeling can alert the learner to an inconsistency, or a ‘perturbation’ (Piaget 1954, 1971) and it is then the role of the learner to pursue this. There are several ways to do this, and usually the educational response is to seek out a supervisor or mentor for a conversation such as a Case Based Discussion, or to reflect on the perturbation independently. Both approaches can have limited effect. A CBD may yield a sophisticated level of analysis, resulting in new levels of understanding for trainee and even for the trainer. Often however, the conversation becomes didactic and theoretical and the synthesis between knowledge and application can be lost. Independent reflection is a good habit to develop but if the gut feeling is not explored purposefully and systematically there will be no real development beyond the ever decreasing circles we can be trapped in when trying to work out ‘what went wrong.’

DEBRIEFing

Debriefing is a mixture of reflecting and teaching. Using a framework to discuss the gut feeling with a more experienced colleague can lead to unexpected revelations. Once the framework has been practised several times it may work without another person’s input. If the learner becomes accustomed to following the steps in the model, s/he can uncover information and understanding to which they did not have conscious access previously either with a peer or alone.

DEBRIEF model

Describe events as factually as possible

Evaluate what went well/to change next time

Banish emotions/beliefs/assumptions that cloud judgement and development

Review and analyse in light of previous experience (pattern recognition)

Identify lessons learned

Establish follow up actions

Feedback on actions

©Hayley Allan 2009

Fig 2 DEBRIEF model

How does DEBRIEF work?

DEBRIEF is more than reflection. It is a series of questions asked of the learner which promote recall of the events, evaluation of his or her role in the events, and a psychological review of the impact of the events on the learner’s sense of wellbeing, before addressing the cognitive impact and reviewing the account for previous similarities of behaviour. Often perturbations (Piaget 1954, 1971) occur because we repeat behaviour which is a function of emotional or psychological triggers from past experiences. It is only when trainees can look back in a safe environment, knowing that whilst they may have made mistakes they also had a positive effect on some of the events concerning them, that they are free to own those mistakes. Emotions can block cognitive development and progress and so the examining of the feelings, beliefs, assumptions or motives behind the learner’s actions is often a pivotal point at which the individual unblocks that repetitive behaviour or identifies the gut feeling causing the perturbation. Being able to move onto action planning as a result of the identification of what has been learned is a positive and valuable way for the learner to move on from the event.

How does DEBRIEF differ from regular reflection?

Reflection often follows the Learning cycle of Kolb (1984) but rarely bridges the gap between the action and reflection stages or between reflection and theory stages. Most learners are not able to make those large transitions alone without additional structure.

Fig 3 Kolb’s reflective practice cycle

Fig 4 Kolb’s cycle with DEBRIEF added

DEBRIEF provides a step wise structure to enable the learner to progress through each of Kolb’s learning points, but looking in turn at the behavioural, psychological and cognitive elements of the practice. By following these steps when reviewing an experience the learner is not only processing the experience itself, but is also developing metacognition which will enable further reflection on future experiences.

Building on Pendleton

Many trainers use Pendleton’s rules in discussing performance with trainees. Pendleton’s central tenets are learner comments preceding trainer’s comments, and positive features preceding developmental areas. This is included in the second step of the DEBRIEF model in order to review the actions taken and behaviour used. Without the emotional and cognitive areas of the experience being looked at too, the feedback can remain formulaic and focused on the surface actions rather than the motives or thinking underlying them.

The impact of DEBRIEF on learning

DEBRIEFing makes learners feel in control of their work; by instigating the process and by learning from an honest DEBRIEF, a trainee can relate to the strengths and areas for development within their practice, can understand the psychological impact of events and is able to access theoretical, emotional and practical developmental strategies to change that work for the better. Ownership of learning, especially in the workplace is a fundamental driver for progress. DEBRIEFing using this structure is a versatile process. A case Based Discussion can easily turn into a DEBRIEF session as can using Pendleton’s rules for feedback. A learner can seek out a supervisor, more experienced colleague or a peer and discuss the event using the model outlined here. Alternatively the model can be applied to the event independently, using honest self disclosure to explore the issues and impact.

Conclusion

In a postgraduate medical training world where the pressure upon the trainers to teach has never been greater, but the time for teaching has never been more limited, the DEBRIEF model equips learners to structure and guide their own learning, utilising their supervisors, senior colleagues, peers and their own reflections to make sense of their daily experiences. Learning by pattern recognition is no longer tenable; smaller numbers of experiences carry greater pressure on trainees to learn and develop. DEBRIEF offers a comprehensive model for them to do this.

Bibliography

Boekaerts M (1993) Being concerned with well being and with learning Educational Psychologist 32(3) 137 - 151
Brooks JG & Brooks MG (1993) In search of understanding: the case for constructivist classrooms. Alexandria VA, Association for Supervision & Curriculum Development
Friere P (1970). Pedagogy of the oppressed. New York: Continuum
Goleman D (1995) Emotional Intelligence New York Bantam books
Gross M et al (2008) Emotions and feelings in learning process: Understanding emotional learning experiences of Postgraduate students ESREA Life History & Biography Network conference, Canterbury Christ Church university, UK http://tallinn.academia.edu/MarinGross/Papers/253692/Emotions_and_Feelings_In_Learning_Process_Understanding_Emotional_Learning_Experiences_of_Postgraduate_Students
ISCP 2010 https://www.iscp.ac.uk/home/principles_intro.aspx
Lave J, Wenger E (1991). Situated Learning: Legitimate Peripheral Participation. Cambridge: Cambridge University Press.
Le Doux J (1997) The Emotional Brain: the mysterious underpinnings of emotional life New York Simon & Schuster
Love PG & Goodsell A (1996) Enhancing Student Learning: Intellectual, Social and Emotional Integration by Love. ASHE-ERIC Higher Education Report series 95-4, (Volume 24-4), http://www.ntlf.com/html/lib/bib/95-4dig.htm
Kolb D A (1984) Experiential Learning: Experience as the source of learning and development. Prentice-Hall.
RCP 2011 http://www.jrcptb.org.uk/assessment/Pages/Workplace-Based-Assessment.aspx
RCPath 2011 http://www.rcpath.org/resources/pdf/definitions_of_assessment_tools__ar.pdf
Pendleton’s Rules http://www.gp-training.net/training/educational_theory/feedback/pendleton.htm
Piaget, Jean. (1954). The Construction of Reality in the Child. Translated by Margeter Cook. New York: Ballantine.
Piaget, Jean. (1971). Psychology and Epistemology: Towards a Theory of Knowledge. Translated by Arnold Rosen. New York: The Viking Press.
Sylvester, R. (1994). How emotions affect learning. Educational Leadership, 52(2), 60-65.
Vygotsky, L.S. (1978). Mind and society: The development of higher psychological processes. Cambridge, MA: Harvard University Press.
Wood, D. J., Bruner, J. S., & Ross, G. (1976). The role of tutoring in problem solving. Journal of Child Psychiatry and Psychology, 17(2), 89-100.

Supporting medical trainees - a new course

2010-06-12T11:25:00.003+01:00

BEST (Building Excellence in Specialty Training) is a new course I am running on behalf of several Deaneries around the UK, to explore much needed ways for trainees to gain access to opportunities for learning on the job.

With the advent of the latest report on training under the European Working Time Directive,(EWTD) http://www.mee.nhs.uk/PDF/14274%20Bookmark%20Web%20Version.pdf by Professor Sir John Temple, which highlights the need for dedicated training and support for junior doctors, BEST addresses one of the shortfalls in the new WBA (Workplace Based Assessment)and competence based training system.

The Training and Assessment in Practice (TAiP) course that I wrote and have delivered for the last 3 years on behalf of the Royal College of Surgeons of England has seen over a thousand consultants demystified as to what the WBAs are and how they complement existing good training practice. However there has been no such provision for trainees. Many are still using the WBAs incorrectly as retrospective, virtual scoring forms rather than face to face engagement and training tools. They struggle to identify their Educational Supervisor and to gain meaningful Learning Agreements from them. Even when trainees understand the formative and developmental nature of the WBAs, they are often working with trainers who are enculturated into a summative, secretive pass/fail mentality because that is all they have known during their own training.

BEST is available to equip trainees with the skills they need to manage their own training, to access the appropriate opportunities and to engage their trainers within a system they are mandated to use.

Training at Foundation stage and beyond in Core and Specialty training programmes is now built around the use of Portfolios to document evidence of competence and progression. Use of the new Assessment tools (Mini CEX, CBD, DOPs, PBA and a range of 360° feedback) is here to stay and the BEST course will:

• Develop understanding of the assessment tools and how best to use them in everyday practice;
• Show how to manage the Learning Agreement;
• Identify immediate learning needs;
• Consider how to get the best out of trainers;
• Identify ways to ensure trainer observation sessions;
• Use the tools to gain training rather than assessment;
• Manage the reception of feedback from your trainer;
• Agree ways to action plan further learning;
• Identify the appropriate people to ask to conduct your 360° feedback;
• Agree follow up activities to show progress after your 360° feedback;
• Support the development of simple approaches to structure reflective writing;
• Develop and improve a piece of your reflective writing;
• Identify the use and value of a portfolio;
• Discuss ways to add quality to your portfolio;

Sessions are delivered using live demonstrations for candidates to discuss, group work and paired work.

By the end of the course you will have:

• Prepared a PDP
• Drawn up an action plan
• Managed your feedback from a trainer
• Identified follow up activities from an assessment tool
• Improved a piece of reflective writing
• Received advice on your portfolio

Please email me for further details. There are a variety of ways that BEST can be accessed.

Hayleyallan@tiscali.co.uk

Who needs Learning Outcomes?

2010-05-27T13:51:00.002+01:00

I was working this week on a new course with another educationalist. When it came to the Learning Outcomes she, knowing my position on them (that they are great to put in at the end of the programme but no use at all when designing learning events) said, "Let's not start with the LOs...."

Hurrah! said I, and we began to design our session using key messages and activities to achieve those messages. What a joy!

I rummaged through my archives to find a copy of this article that speaks for itself. I wish to reiterate that LOs are great to put in a course programme so that learners see what they are going to get out of the day. But to start off with them when planning learning? Only if you are a businessman.....!

Who needs learning objectives?
Posted by Charles Jennings in Strategy, The training cycle on Tue, 28/07/2009 - 08:42
• This article looks at the case against creating learning objectives
• It explores how learners are often discouraged by box-ticking and how trainers need to implement better systems at helping learners retain information
• Charles Jennings cites examples of how effective learning can be achieved without the use of learning objectives

How many times have you embarked on some formal learning, whether in a classroom or through an elearning or blended course, and the first thing you’re presented with is a list of rather bland learning objectives? This begs the question, are lists for losers? Charles Jennings considers the evidence.

1. At the end of this course you will be able to tie your shoelaces in a double bow
2. At the end of this course you will be able to use a blender to make a tasty fish milkshake
3. At the end of this course you will be able to make gold out of base metal
4. and so on...

Apart from being some of the most de-motivating writing any of us have ever read, lists of learning objectives are the worst possible way to create an environment for learning. In fact, they are often the first barrier to real learning. Why so?

Two basic problems
I see two basic underlying problems with learning objectives. Firstly, many training and development specialists continue to apply a model of learning objectives that was developed more than half a century ago in a context that they don’t really understand. It’s a model that was ‘of its time’ and, although some of the principles still apply, certainly isn’t as relevant in the 21st century as it was in the mid-1900s, even accepting the view that formal learning still has a place in developing people.

Secondly, many training and development specialists are learning obsessed rather than performance obsessed. Their focus is on delivering content and assessing its retention by learners – on ensuring learners ‘learn’ rather than enabling people to ‘do’. Giving fish rather than fishing rods.

"There’s a strong argument that proof of achievement of learning objectives as commonly assessed at the end of the learning event doesn’t even measure learning."
Subsequently their learning objectives tend to be built around a set of post-course assessments. Even then, the way in which the ‘learning’ is assessed is often so poor that it only measures short-term memory retention rather than real learning and behaviour change.

A nod to Bloom
Back in 1956 when Benjamin Bloom and his committee members developed a taxonomy of learning objectives they were working in a very different world than we live in today. Reductionism and codification were the dominant mindsets. The standard approach to teaching at the time (and it was ‘teaching’ rather than ‘learning’) was to design courses and programmes so that students should take the same time to reach a specified level of mastery.
It was a crude approach where the hares won and the tortoises lost. Bloom was kicking against this with his taxonomy. The three learning domains of Bloom’s Taxonomy (cognitive, affective and psychomotor) were, in some way, an attempt to overlay some of the complexity of the learning process on what was seen at the time as a rather deterministic and mechanistic endeavour. Bloom was, underneath it all, a progressive. A former student once described him as "embracing the idea that education as a process was an effort to realize human potential, indeed, even more, it was an effort designed to make potential possible. Education was an exercise in optimism." (Elliot W. Eisner in the UNSECO Quarterly Review of Comparative Education 2000).

Bloom himself saw beyond learning objectives as simply a means to an end. He was convinced that environment and experience were very powerful factors influencing human performance. It’s worth noting that his last book published just six years before he died in 1999 was ‘The Home Environment and Social Learning’. He certainly wasn’t hung up on learning objectives. Bloom’s view of learning was the need to focus on target attainment rather than the ‘race to the finish post’ as was common in the 1950s. It was, in reality, a belief of learning as an enabler. At the time Bloom was addressing an important issue through his learning objectives, today that battle has been won.

Learning objectives and improved performance
So why, 50 years on, do we still have this slavish adherence to presenting learning objectives at the outset of courses in some mechanistic manner, and often skewed to the cognitive domain? It’s often ignorance, and sometimes simply a desire to make the life of the trainer easier, I’m afraid. And sometimes it’s just marketing. Learning objectives are really only useful for the people designing the learning. If used well they can form a helpful framework for instructional designers. However, they should be kept well away from learners or course recipients. If a course is well-designed and targeted to meet a defined performance gap, a list of learning objectives serves absolutely no purpose other than to dull the enthusiasm of those embarking on a course of study.

What any learner, and their manager, wants to know is whether on-the-job performance has been improved through some formal learning intervention. In other words, whether the experiences that the employee had during formal training has resulted in changed behaviour and performance in the workplace. Achievement of learning objectives is not evidence of this. The ability to pass a test or demonstrate a skill in a classroom setting is not the same as being able to do so in workplace conditions. I suppose the notable exception is where the classroom conditions mirror exactly, or almost exactly, the workplace – such as training pilots in a flight simulator. Still, I don’t imagine any one of us would take kindly to flying in a plane with a pilot who has only proved his or her performance in a simulator and hasn’t a modicum of experience in the air, unless there isn’t an alternative.

"Learning objectives are really only useful for the people designing the learning."
In fact there’s a strong argument that proof of achievement of learning objectives as commonly assessed – at the end of the learning event – doesn’t even measure learning. Sometimes the time lag between end-of-course testing and attempting to put the learning into action is such that the ‘learning’ is lost from short-term memory. At other times the work environment is less ‘controlled’ than the learning environment and the added variables mean performance improvement simply doesn’t occur. Most of us have seen situations where people return bright-eyed and bushy-tailed from a training course with plans to do things differently – time management, project management and people management training are good cases-in-point - only to revert to the old ways as soon as the day-to-day pressures of the working environment kick back in.

Measuring performance
If you are going to assess the impact of a course on individual participants’ performance in the workplace you need to forget about learning objectives for doing the job. Remember, learning objectives may be useful to help you create a logical design, but that’s all they’re useful for. When you get to measuring transfer of learning to the workplace you need to engage with the people who are in a position to observe behaviour and performance and those who are in a position to measure outputs. This usually means the manager and the team member who is responsible for maintaining performance metrics for the business or team – the balanced scorecard metrics or similar.

This approach requires training and development managers and instructional designers to engage with business managers and agree on strategies for measuring the impact of the learning before the learning design phase even starts. A good way to do this is to roll it into early engagement with business managers in defining the performance problem to be solved, whose performance needs improving and whether training is likely to help solve the problem (which is usually ‘no’, but sometimes ‘yes’).
In most cases performance change can’t be measured immediately following the training if it is to be meaningful. Take the case of transactional work - data entry or call centre operatives for instance – where the proof that training has led to improved performance requires data taken over a period of time, and not just on the first day or two back in the workplace. All this requires more thought and effort than writing a few overarching learning objectives (even if in well-formed behavioural format) and then developing assessments to ‘test’ whether they’ve been achieved or not. And it requires different skills of the training and development team.

Charles Jennings was chief learning officer at Reuters and Thomson Reuters. He now works as an independent consultant on learning and performance. Details of Charles consultancy work and his blog can be found on his website www.duntroon.com

Reflective Practice - here is how to do it!

2010-05-26T18:36:00.001+01:00

http://www.rcog.org.uk/files/rcog-corp/uploaded-files/ED-Reflective-Prac.pdf

This excellent pdf from the Royal Colleg of Obstetrics and Gynaecology has everything you need to know about writing up your reflections in medical training.

Article in BMJ for medical trainees

2010-05-15T12:48:00.003+01:00

http://careers.bmj.com/careers/advice/view-article.html?id=20001007

This article published in the BMJ this week gives a good overview of the structure of training and the role of the trainee and trainer in negotiating access to training opportunities.

With The Royal College of Surgeons in England, I have worked with over a thousand consultants and senior trainers to establish understanding of the Workplace Based Assessment Tools and their place in Medical and Surgical postgraduate training.

In partnership with some forward thinking Deaneries, we are now offering such courses for Trainees. BEST (Building Excellence in Specialty Training), is a one day course for all Foundation and Core (or ST 1 and 2) trainees who wish to master the approaches needed to get the best out of their training and their trainers.

Cognitive Apprenticeships

2010-05-13T14:18:00.003+01:00

While researching for a course I am writing I found this article on the web which I thought was most interesting. Despite it being about school classrooms - and American ones at that! - it offers a great example of how we can develop active apprenticeships in our more constrained educational environments. I shall certainly be looking at how I can incorporate the key elements of this work into my new course.

http://projects.coe.uga.edu/epltt/index.php?title=Cognitive_Apprenticeship

Early Adopter, Early Cynic, Blind Complier or Blind Rebel? How do you react to training courses?

2010-04-26T15:14:00.006+01:00

Surgeons' reactions to training, assessment and management courses is understandably at a low ebb. With the PMETB trainer requirements deadline earlier this year, many consultants found themselves mandated to attend a range of courses in Educational Supervision; Clinical supervision; Training the Trainers; WBA tools; Assessment and Appraisal; Equality and Diversity; Trainees in Difficulty; or 'Manual Fire Bucket Assessment Handling' as one surgeon referred to the homogenised mass of courses he had to take.

Disparity in content, delivery and quality of these courses has led to a lowest common denominator perception among participant groups. Think of the worst course you have ever attended, multiply it by ten and you have the level of underwhelming expectation with which most groups greet their latest day out of clinical practice.

In little over three years there have been well over a thousand participants (estimates at time of press number over 1200) through the Royal College of Surgeons of England Training & Assessment in Practice (TAiP) course. Such numbers enable perception analysis to be carried out regarding the differing reactions from participants, to the course. Four predominant types emerged:

• Early Adopter
• Early Cynic
• Blind Complier
• Blind Rebel

TAiP was developed by an educator and a group of surgeons to support consultants in the use of the ISCP, a new training and assessment programme developed by the Intercollegiate Surgical body in response to MMC (modernising Medical Careers) and the advent of the EWTD (European Working Time Directive.) Although TAiP contains strategies to support consultants in using the new WBA (Workplace Based Assessment) tools, many participants see the course as an imposition.

The aim of the TAiP course is to give everyone the information they need to use the ISCP system in accordance with good training practices. This requires understanding of the system and a willingness to use it.

In analysing the different responses to the course, it became clear that these two predominant factors are central to a person's response. The first of these concerns capability; that is whether the surgeon comes to the course with either an understanding of ISCP or the capability to develop an understanding within the day. The second factor relates to attitude; does the surgeon have the willingness to work with the system? Some participants have an attitude of open mindedness, or compliance with suggested new approaches. Others have greater resistance to any suggestion of change and are determined not to comply with whatever is suggested. This attitude is very often pre determined by factors outside the area of responsibility of the group facilitators.

Understanding these patterns of behaviour can assist the facilitators to relate appropriately to each participant and to manage the course in slightly different ways, according to the group make up. By examining the four permutations of the aforementioned factors we can see that each response type presents its own challenges to the facilitators.

• Early Adopter - high capability, high compliance
• Early Cynic - high capability, low compliance
• Blind Complier - low capability, high compliance
• Blind Rebel - low capability, low compliance

The Early Adopters in a group have both high levels of compliance and capability. They are often keen to make sense of a new system and to find ways to implement change. They are not afraid to be seen to be different and for this reason often occupy positions of leadership. Early adopters do bring their own challenges to the group facilitators. Whilst their open mindedness means they are willing to look at new perspectives, their high levels of capability require the facilitators to have a sophisticated grasp of the issues and perspectives, the knowledge frameworks and the medical settings within which the participants work. If facilitators demonstrate credibility, considerable levels of knowledge and understanding, and harness the inventiveness of the group to a common goal, even making them think they have developed original ideas, the early adopters will react overwhelmingly positively to the course.

The second group are called Early Cynics because their lack of compliance means that they often announce their cynicism at the start of the course. They can initially appear to be very challenging to the facilitators but by asking about their cynicism it is easy to tell whether it is informed or not. Early Cynics can be the most rewarding of all participants due to their high levels of capability. If their cynicism is ill informed, they are not Early Cynics at all, but fall into the fourth category, Blind Rebels. There are some Early Cynics who have high capability but who are so fearful of change that their high level of non compliance reduces them to the fourth category too. But real Early Cynics have high levels of capability; their ideas are often persuasive and they are quick to grasp new information. It is their intelligence that will triumph over their non compliance and result in a positive response to the course at the end. For course facilitators Early Cynics present two challenges. Their aggression at the start of the course can be disruptive and hold up progress. If they are given a limited space to air their views, this will “park” their scepticism. And then, in a similar way to the early adopters, the Early Cynics require facilitators who are knowledgeable and who also demonstrate persuasive, informed argument. (Cynicism with poor levels of understanding is not cynicism but rebellion. For this reason the only true cynics are those who know what it is they do not believe in.)

The third group of respondents appear to be relatively easy members of the group initially. Called Blind Compliers they are characterized by their apparently high levels of compliance and low levels of understanding. They ask few questions and appear to be absorbing what is being said. However, without careful handling this group can easily leave with little more than they came. Their compliance means they are not likely to question the frameworks being presented, but unless all the details of the course, including acronyms, roles, responsibilities and relationships are spelled out to them, they let much of the new perspectives wash over their heads. Whilst they may present little by way of attitudinal challenge to the facilitators, the faculty must check that Blind Compliers are following, understanding and integrating what they are exposed to on the course into clinical practice. A course can become a one way didactic session never really getting beyond the basics of the course content, if there are lots of Blind Compliers in a group, so facilitators must ensure that these learners are made to think for themselves too. If the overall group has a mixture of Blind Compliers, Early Adopters and Early Cynics, it challenges the facilitators to cover the basics in a simple way but also to extend the complexity of the arguments for those with higher capability and understanding, as already discussed.

The final group is probably the most challenging but they often have the greatest need for the course. With Blind Rebels both their compliance and their capability are low. Most often they have attended the course because they have been forced to do so, either as a result of an appraisal action or because there have been threats associated with non attendance. This group have developed a stance of non compliance as a result of their lack of understanding or willingness to engage in new ideas, and see courses as threats to their professional standing. They will argue fiercely against any proposed change, finding a range of people to blame for the changes they see as having been externally imposed. The difference between this group and the Early Cynics is that the Blind Rebels do not have the capability to argue with any degree of information or logical reasoning. Indeed, the more vociferous they become the more the rest of the group begin to disengage with them. This group of participants can be very disruptive as they can raise a comment or an objection to every point made. The challenge for the faculty is to maintain composure in the face of often rather offensive behavior and to remember that this group need as careful instruction as the Blind Compliers. It would be encouraging to think that information would assist the Blind Rebels to overcome their non compliance but for many in this group it is often not enough. For those who are determined to destroy the course, it may be necessary to respond to their ill informed arguments somewhat aggressively, highlighting where they are misinformed and emphasizing that both information and a change in attitude would indeed help them to overcome their grievances. Often it is only their self instigated isolation from the rest of the group that finally reduces them to silence. Frequently they have to be allowed to hang themselves with their own petards, necessitating a group attack on their disruptive behaviour.

In an unrelated field but one which may be interesting to compare, we can see that similar findings have been discussed with regard to the responses of people to new technology. The Everett Rogers Diffusion of innovations theory - for any given product category, shows five categories of product adopters:

o Innovators – venturesome, educated, multiple info sources;
o Early adopters – social leaders, popular, educated;
o Early majority – deliberate, many informal social contacts;
o Late majority – sceptical, traditional, lower socio-economic status;
o Laggards – neighbours and friends are main info sources, fear of debt.

However this pattern is a linear one, describing types of people within a range of demographic factors, including social background, psychological make up, educational history, personality and popularity, economic situation, social influences and fears. In the paradigm used with surgeon responders to courses I look simply at the responses relating to two factors – those of compliance and capability.

For those of us involved in education and training, this paradigm provides us with an interesting perspective on the challenges facing us in any group of participants in a course group. A surgeon cohort group should not usually be perceived as a mixed ability group in the usual definition of the term. All consultant groups must surely share a similar level of intelligence and motivation to have achieved the position of consultant. But new initiatives coupled with the disenchantment surrounding the many changes we have seen in the last five years, mean that attitude to change as well as engagement with it result in a mixed ability reaction to training courses.

For course facilitators, such groups can be very challenging for a variety of reasons. Understanding the factors behind the behaviours of surgeons attending such courses can help faculty to respond appropriately to each type of participant, ensuring maximum success and minimum disruption for each course group.

Feedback for Learning (FfL)

2010-02-28T12:37:00.013Z

We still haven’t mastered feedback to drive learning. In the medical world, feedback is seen as a commodity rather than a learning process. This needs to change.

A friend and colleague of mine says that feedback is the oxygen to the soul and that we shouldn’t make people gasp for it.

How true it is that many of us out there are wheezing for some guidance as to how we are doing? We work too often in the dark with little idea of how well we are doing or what we are getting away with that could be better.

“Feedback is the corner stone of effective clinical teaching.” (Cantillon & Sargeant 2008)

This kind of statement is rife in medical education and whilst it is not untrue, it gives little away about what feedback is, how we should approach it, who is best placed to engage in it and when that should happen.

A recent article in Medical Education (Archer, Jan 2010) says that, “Only feedback seen along a learning continuum within a culture of feedback is likely to be effective.” Whilst I agree with this statement most emphatically, I am not sure the article goes far enough in its portrayal of feedback for learning. (FfL)

We have moved over the last decade away from assessment being for the stakeholders only (summative assessment) to a position of using formative assessment to diagnose learning need and to instigate actions to develop and train. (WBAs exemplify this.) What we haven’t quite achieved is the recognition that feedback is not an outcome but is, if it is to facilitate reflection and development, a process. We may talk about the feedback process but most often the result of that process is what is seen to be most important. We still refer to a “critique” of a performance, piece of work or discussion, where the feedback becomes a commodity to be recorded by the trainee. Whilst this outcome based view of feedback persists, it will never fully work as a training and learning tool.

For effective feedback to work in terms of developing knowledge and understanding, attitudes and perspectives and behaviours and actions, it needs to be seen as a process, not an outcome.

This is not a new idea. In 1983 Schon said: “To achieve effective feedback, the health professions must nurture recipient reflection-in-action.” More than 25 years later this is still not happening.

Archer begins to address this but fails to go beyond the outcomes model. He draws a distinction between feedback as directive or facilitative in nature, explaining that “directive feedback informs the learner of what requires correction. Facilitative feedback involves the provision of comments and suggestions to facilitate recipients in their own revision.” In most cases of facilitative feedback the recipient will still focus on the facilitator’s suggestions and comments as the outcomes that must be achieved.

In directive feedback the educator generally tells the trainee how they have done. The trainee then has to understand what has been said, deal with the emotional response that may invoke in him or her and then accept or reject the comment. Acceptance and rejection often have more to do with the emotional response than with the accuracy and relevance of the comments made. In this way what is intended by the educator can often be greatly misinterpreted by the trainee.

Similarly in facilitative feedback, the comments and suggestions, albeit perhaps more acceptably and sympathetically offered, are still dealt with in the same way by the recipient, and may also be interpreted very differently.

Archer claimed that we need to “build on self monitoring informed by external feedback.” I would go further and say that as trainees progress, we need to build on self monitoring within a process of reflective conversations using open questions to guide and develop. Archer says that “the ability to shape capability through self monitoring with self directed assessment seeking requires an individual to accept the feedback provided. “ But if the feedback process is a process where the recipient has to do all the thinking, and the facilitator merely asks appropriate relevant open questions, then there is no feedback to be accepted, except the recipient’s own.

Feedback for Learning (FfL)

What is required is a third form of feedback during which the educator or facilitator does no “telling” whatsoever. Instead the focus is entirely on the trainee, and the trainee does all of the work. Feedback is facilitated with a series of open questions. As a result the learners have to think evaluatively about their experiences. They provide information regarding what they have done or not done, to which they may still have an emotional reaction, but which cannot be immediately rejected as it is they who have stimulated it. To any emotional or difficult reaction the facilitator responds supportively and with questions concerning further actions. In this way the facilitator of the feedback is seen as a helper and supporter of learning, not a critic. The role of the educator is then to move the learner forward to consider ways to address, amend or develop practice for the future.

Archer recommends that feedback is done by trained facilitators and discusses a useful model for scaffolding feedback:

1. Motivate the learner
2. Deconstruct the task
3. Provide direction
4. Identify gaps between actual and ideal performance
5. Reduce risk
6. Define goals

This framework is helpful but still focuses on the facilitator of the feedback as the one who drives the process.

If we return to the model of feedback using open questions only (FfL), we can add to Archer’s scaffolding model with some suggested open questions to elicit learning reflection and thus learning driven feedback.

1. Motivate the learner
• What would you like to get from this review session?
• How do you see this review contributing to your practice?

2. Deconstruct the task
Tell me:
• What happened/what you did
• How you felt/what you assumed/what you believed would happen
• What you think about this experience/have you had this happen before?

3. Identify gaps between actual and ideal performance
• Describe the differences between what you did here and what you would like to do in -x- time?

4. Provide direction & reduce risk
What next steps can you set yourself for this?
How will you do that? Who may you need to help you?

5. Define goals

• Jot down the goals you have set yourself here, along with the time scales, who is involved, where and when you will achieve them and how you propose to review and monitor them.

Previously trainers have been reluctant to use only open questions as they say that the feedback then relies on the honesty and perception and insight of the trainee to identify where they went wrong. It is indeed true that if the trainee is unconsciously incompetent they will not be able to identify errors and ways to develop. However, the skill in using open questions means that the facilitator can enable the trainee to identify that unknown area through questioning and elicitation. This is a skill which is not endemic to all trainers. Therefore the skill must be developed in trainers as well as in trainees.

FfL as professional reflection in action

Feedback is the pre cursor to professional reflection in action. As children we are disciplined so that as adults we develop self discipline. Junior doctors – or anyone starting off in a profession, need to develop professional reflection on and in action in order to function as independent practitioners after some time. If feedback continues to be a commodity that is bestowed from on high, the dependence of trainee upon trainers will never diminish. As educators our role is not just to train, pass on wisdom, transmit knowledge and skills, but to develop the trainee to become critical thinker, reflective practitioner and measured decision maker.

As a consultant surgeon I worked with this week said to me, “I want to teach them to think for themselves.” We can only do this if the feedback we engage in makes them think for themselves. Feedback for Learning offers a process to enable that to happen

Archer J, State of the Science in Health Professional Education. Effective Feedback: Medical Education 2010:101 – 108
Cantillon P, Sargeant J, Giving feedback in Clinical Settings BMJ 2008: 337a 1961
Schon D, From technical rationality to reflection in Action in Schon D, The Reflective Practitioner: how professionals think in action. London basic books 1983 21 - 75

How to reflect - a guide for trainees and students

2009-09-06T09:28:00.002+01:00

Developing reflective writing
A guide for doctors in training
©Hayley Allan 2009

Reflective practice is an essential component of the Portfolio for all trainees today. The ISCP ( Intercollegiate Surgical Curriculum Programme) requires it as do other forms of training and education both at undergraduate and postgraduate level. However, very few syllabuses or training programmes define exactly what it is; fewer still give any advice on how to do it. This paper will give trainees a greater understanding of how to approach their reflective practice, and some simple frameworks for structuring their writing.
What is it?
“Reflection is vital for learning from clinical experiences” (Driessen et al, BMJ 2008 336)
To many people "experience" means "making the same mistakes with increasing confidence over an impressive number of years" (O’Donnell, 1997). The “impressive number of years” that surgeons spent in training previously has now gone and in the era of EWTD and ISCP, trainees cannot afford to make the same mistake twice. One way of addressing this is to encourage and develop the use of reflection in all trainee doctors.
Defining reflection
When we say that trainees need to be more reflective, what we mean is that they need to let future behaviour be guided by systematic and critical analysis of past actions and beliefs and the assumptions that underlie them. (Dewey, 1933)
Why use it?
All doctors in the UK are now required to make reflection a critical foundation of their lifelong learning (GMC 2000). Research evidence from nursing, (Jarvis in Nurse Educ 1992) and teaching (Korthagen et al, 2001) suggests that reflection can help students learn from their experiences.
How do we do it?
Most trainees do know how to reflect effectively on their practice, but they may not be aware that they are doing this. They may be aware that something has not gone particularly well; for Dewey, reflection was stimulated by an event that aroused a state of doubt, perplexity and uncertainty that often leads to the individual searching for the possible explanations or solutions. (Dewey, 1933) We are less given to reflect on practice that has gone well, although it is useful for us to do this from time to time to ensure that we understand why it went well in order to replicate the good practice. However, most of us want to improve the poor practice and this is where much of reflection is centred.
The benefits of regular reflective writing
Reflective writing provides an opportunity for us to think critically about what we do and why. It provides
· a record of events and results and our reactions to them,
· data on which to base reflective discussion,
· opportunity for us to challenge ourselves and what we do and to look at doing it differently and better,
· impetus to take action that is informed and planned,
· an opportunity to view our clinical practice objectively and not see all problems as personal inadequacy,
· increased confidence through increased insight
· Basic documentation to support future entries in our portfolio and for job applications etc.
(http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm)
Where do we use it?
We need to be able to assess and analyse our actions and devise alternative actions. That is the essence of reflective practice in the workplace. To begin with it is helpful to have guidance and some structure given by more experienced colleagues. In the bust context of the clinical setting it is difficult to gain time to do this, but requesting that a trainer provide you with five minutes to run through an event, can be all that is needed to trigger the reflection you need.
1. Asking for feedback after conducting an assessment (mini CEX, CbD, DOP, PBA)
Ask the trainer what they felt your strengths were in that activity. Add your own view of the strengths and ask for comments
Ask the trainer where they think you could develop. Add your own view of areas for development
Ask them to focus on one or two key areas for follow up action and to give some suggestions for follow up activity to enhance learning
This approach to feedback is based on Pendleton’s rules. It is imperative that you draw up actions for development, and not merely talk about how to improve. Adding quality to your learning, practice and portfolio requires you to show progress as a result of learning on the job.
Example:
After a Mini CEX in clinic, you and your trainer identify together the strengths of professionalism and appearance, rapport with a patient and organisation of encounter. In need of development was the history taking. You discuss the areas of weakness here and agree that you will shadow him/her in clinic next week, recording his/her history taking approach. You will then teach this to the F1s the following week and do a follow up mini CEX the week following that.
This is the most helpful way you can begin to develop reflection early in your training career. Make sure you document your development, with evidence in this case of the records you make of your trainer’s history taking, and the evaluations you receive from the F1 teaching the following week. When you next complete your Mini CEX form you can put all of these pieces of evidence together to show that you have learned from this period of time.
Try this model for structuring your reflections:
ALAC: (Driessen 2008)

Action - choose experiences that support and develop your learning (ie those from which you can learn)

Looking back - Separate performance from person (a mistake does not mean the person is a failure); be trustworthy and honest; acknowledge and make success explicit; seek feedback; obtain information and evidence from various sources and put it into your portfolio

Analysis - Focus on your own role in the success or failure; take the perspective of others; ask ‘why’ questions; ‘confronting’ questions; ‘generalising’ questions; look for inconsistencies in your analysis; generalise between experiences

Creating alternative actions - suggest options for change; formulate plans and check these are in line with analysis; focus on SMART objectives for learning

SMART: Make sure your actions are:
Specific
Measurable
Achievable
Relevant
Timely

Peer reflection
Engaging in open and collaborative discussion about work with a peer is a process that can enable us to become more reflective doctors. You can use any of the models advocated above if you and your peer are reasonably confident and experienced in challenging one another in reviewing an event. If you are new to this you may wish to reflect with a supervisor first until you become more confident.

Assumptions
A helpful way of understanding the process of reflection described by Stephen Brookfield (1995) describes the process of hunting out our assumptions and critically examining them. Ask yourself what are the assumptions behind your practice and then try to develop a contrary argument. You now have two sides of an argument to evaluate. This is engaging in personal critical reflection.

Keeping a journal
The journal is parallel to the field book or laboratory notes of the scientist. We not only record what happened or what was observed but in addition we can record a tentative hypothesis or the development of new understanding, we can use our writing to make a new sense of phenomena. Reflective writing has the potential to provide us with a systematic approach to our development as a reflective, critical and constructive learner. Our journal can provide an opportunity to make explicit our position on a range of issues of personal significance.
Your journal could be structured:-
· as a personal learning journey, tracking and documenting an evolving understanding of your clinical practice and learning
· a critical reflection on a clinical encounter you have witnessed between a colleague or your registrar or consultant supervisor

Ideas for getting started on reflective writing:
1. Use a checklist
· What is the current problem or issue? Describe the context
· What additional information would be useful?
· How is it related to other issues?
· Who or what could help?
· What are my assumptions? How can I test them?
· What can I do to create a change? Be as adventurous as you can
· What are the possible outcomes of these?
· What action will I take? Why?
· List the outcomes you hope to achieve.
· Reflection on the actual outcome What worked well?
· What could I do differently next time?

2. Focus on a critical incident that took place in your clinical practice.
· Describe the incident as objectively as possible.
· What were the assumptions that you were operating with?
· Is there another way to see this event?
· How would your patients explain this event?
· How do the two explanations compare?
· What could you do differently?

3.And from time to time...
· What has using this journal confirmed that I already know about my learning and how I affect that?
· What do I need to do to improve the quality of what I do?
· What might I do instead of what I do now?
· What innovation could I introduce?
· What professional development activities should I be seeking?

For recording your reflective writing, keep it simple.

HEADLINE: What you have learned from this event
EVENT: 1-3 sentences about the event itself with some idea of the area you targeted from reflection
LEARNED: now you can spend longer on this area, discussing what it was you learned from the event and expressing this in developmental but positive terms
ACTION: This is where you identify the actions resulting from the reflection. They may be short, medium or long term and you can revisit them after you have implemented them to comment on their efficacy once used in practice.
Remember to always follow up with a review of your amended practice after you have implemented your actions. This completes the cycle of learning initiated from the original piece of reflection.

For more information on reflective practice see:
Ballantyne, R & Packer, J; (1995)Making Connections: Using Student Journals as a Teaching/Learning Aid, HERDSA ACT.
Boud, D; Keogh, R; & Walker, D, (1995) Reflection: Turning Experience into Learning, Kogan Page, London.
Brookfield S. (1995) On Becoming a Critically Reflective Teacher, Jossey Bass, San Francisco.
http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm
Dewey J. How we think: a restatement of the relation between reflective thinking to the education process. Boston: Heath, 1933Driessen E, van Tartwijk J, Dornan T The self critical doctor: helping students become more reflective. BMJ 2008 336:0
General medical Council. Revalidating doctors: ensuring standards, securing the future. London: GMC, 2000
Jarvis P. Reflective Practice and nursing. Nurse Educ 1992; 12; 174 – 81
Korthagen FAJ, Kessels J, Koster B, Lagerwerf B, Wubbels T. linking theory and Practice: the pedagogy of realistic teacher education. Mahwah, NY: Lawrence Erlbaum Associates, 2001
O’Donnell M. A sceptic’s medical dictionary. Oxford: Blackwell BMJ books, 1997
Schon, D; (1987) Educating the Reflective Practitioner; Jossey Bass, San Francisco.

Compentecy based education and Quantity assurance - why nobody can think for themselves any more

2009-06-29T12:30:00.005+01:00

Thanks to the excellent groups I worked with last week (almost 40 consultant doctors in two South London trusts), as well as some of the great literature around in Generic and Medical Education, I think I am somewhat further forward in identifying what is so wrong about our current education philosophy and practice in the UK.

It is the political control over our hospitals and schools that has led to the implementation of competence based education. This political climate has as its closet epigraph: “Let’s only value that which we can easily measure; forget trying to measure what is of value.” Added to that is the obsession of measuring for the benefit of the organisation (Government, Trust, University, Royal College etc…) and not just forgetting but turning a blind eye to the end user – the patient, the trainee doctor, course participants and students.

This realisation that organisations no longer care about the end user of their services, but only about their financial accounting and those involved in the decision making, prompted me to research the meaning of Quality Assurance.

It is a set of activities intended to ensure that products (goods and/or services) satisfy customer requirements in a systematic, reliable fashion…. It is important to realise also that quality is determined by the intended users, clients or customers, not by society in general (http://en.wikipedia.org/wiki/Quality_assurance)
This also incorporates measuring all process elements, the analysis of performance and the continual improvement of the products, services and processes that deliver them to the customer. (http://www.thecqi.org/Knowledge-Hub/What-is-quality-new/)

What I took from this is that the end user is of paramount importance – we do QA for them and for the products and services that they require. Therefore they ought to be involved in it and given a voice to shape and improve those products and services where possible.

So far so good.

A medical school lecturer shared their approach to QA with me:

Level 1- Course satisfaction: feedback forms completed at the end of event. This gauges the immediate reactions of participants and will highlight immediate issues.
Level 2- Transfer to work place: (completed 2-3 weeks after event) electronically. This allows time to reflect on the learning and relate usefulness to own learning needs and role.
Level 3- Impact on processes/performance: This involves a qualitative approach with a structured discussion with a sample of participants.

But some institutions are cutting back on the levels of QA they use. Rather than using level 1 evaluation at the end of the course, they are moving to an on line version of level 2 several weeks after the event. Whilst this may gather data on the transfer of learning to the workplace, I suspect that since course participants will not be able to receive their certificate until they do complete the e feedback form, less qualitative data will result. My guess is that the tick box exercise will remain.

When I looked elsewhere, I found that some of the barriers to doing what is best for the end user were frighteningly similar in hospital trusts. A radiologist told me about the two week targets they face; A+ E clinicians regularly face a choice of quantity over quality of care and are penalised when they choose the latter. Waiting lists have gone down in hospitals, but at what cost to patient care? Or to the very people who provide that care?

In much the same way trainee doctors are asked to gather evidence of their clinical practice, on single sheets of paper with tick boxes printed on them. The more pieces of paper, the better. Once again the quantitative triumphs over the qualitative.

And I ask the question, should we not be calling our evaluation processes “Quantity Assurance?”

To escape from the harsh realities of the overworked and undervalued doctors I work with, I turned to the literature, in the hope that I would find a new idea I could use with my trainers, to mitigate against this inexorable decline into robotic delivery of “care” or “education” as a commodity like sandwiches or exhaust pipes.

One hot sleepless night, I unearthed a new book from beside my bed on Reflective Practice, in the hope that it would have a soporific effect! It did quite the opposite. (Reflective Practice by Gillie Bolton, 2005, SAGE, London. ISBN 978-1-4129-0811-5)

As I flicked through it my attention was caught by the phrase, “Teachers are assessed on the value they offer the consumer….” Bolton was attacking competency based education. Hurrah! As someone who finds “Learning Outcomes” just a bit too management oriented, I read on.
Bolton’s critique claims that knowledge and skills are seen like commodities and ignore educational processes such as the teacher learner relationship and the learning environment, to name but two. She says that, “Giving students set pro formas, lists of prompts, questions or areas which must be covered in reflective practice will stultify, make for passivity and lack of respect. Professionals need to ask and attempt to answer their own questions. Otherwise their practice is being moulded towards the system’s wants and needs.”

Furthermore, says Bolton, testing and checking up on students to see if they have acquired the competencies further endorses this subordinate sense. Trainers talk about ‘getting the trainees to do’ …..which means that all our next generation are doing is joining the dots and filling in the blanks. Providing evidence of a competency does not guarantee that the trainee has learned anything or understood the case or the patient. Bolton says: “It matters not that it is solely a paper exercise as there is no continuity between course and practice, no one to see practice has been changed or developed; what matters is the product: the neatly ticked boxes look right.” And she references Prosser and Trigwell 1999 and Rust 2002 in calling this “Surface Learning.”

Most of the trainers I work with complain bitterly about the spoon feeding culture and about the trainees they have who cannot think for themselves. What we don’t realise is that the system requires that trainees cannot think for themselves – the system specifies what it wants and orders its learning outcomes and behaviourists statements of performance accordingly. Unless we intervene and do something about this, the next generation will be fit for nothing except robotically following those in power.

1984 or what?

This morning I turned to Medical Teacher, (http://www.medicalteacher.org/) hoping for some respite from this depressing situation. And I found it. Well, a chink of light.

I came across a table in the current edition of Medical Teacher Vol 31 number 4, April 2009 in an article on assessing medical professionalism (Assessment of medical professionalism: who,what,when,where, how and ….why? Hawkins et al 2009;31:348 – 361.) The table contrasts two frameworks for defining the elements of professionalism. One framework is the horribly familiar “Behaviours oriented framework” which specifies the specific behaviours that trainee doctors should be able to “evidence” and tick off in their portfolios:

“Responds promptly when paged or called
Takes on extra work to help the team
Listens and responds to others respectfully
Discusses colleagues and co-workers in a respectful manner…..”

However, the other framework cheered me up somewhat. This is a “Principles oriented framework” in which the key headings relate to less observable competencies:

Excellence – dedication to improving quality of care; commitment to competence
Humanism – respect, compassion, empathy, honour/integrity
Altruism – putting patient interest above own
Accountability – embraces self regulation, public service/advocacy

I was immediately struck by the stark difference in these two lists. Not only is there the obvious difference of the first one being easy to “tick off”, but what struck me about the first list is that some of these behaviours are of such a low level. Are these really professional behaviours or just common or garden courtesies all workers ought to show as a matter of course? Are these things really necessary to document? Surely they should be taken as read and anyone not consistently behaving like this ought to be referred to HR for the relevant disciplinary action? Is this what we get when HR encroach on educational and training? A list of things you have to do to avoid being disciplined?

What about true professionalism? What about aspiring to be the best? The Principles list gives us the beginning of an outline of what a real professional ought to want to be. Surely professionalism is not something we put on (like a white coat) when we get to work? For me it pervades my life and is who I am and not just what I do.
Feeling bolstered, I read further in this article……and fell back to earth with a bang. It said:

“While such principle driven frameworks are quite useful in thinking broadly about construction of an assessment programme, they are not easily applied to the assessment of measureable behaviours.” The authors bemoan the lack of consistency in assessing these principles, but do admit to the behaviours oriented framework being a “bottom up approach.”

They do go on to make some interesting and useful suggestions for assessing professionalism, but still within a context of assessing behaviours and documenting evidence.

What I have come to realise over the last few weeks, from both my reading and my practice and accounts of other people’s practice, is that we inhabit an evidence based, competency focused education, training and medical system. The results of this, whether in terms of patient care or trainee development, is for the lowest common denominator to be the benchmark of satisfaction. Quality and quantity seem to be linked as are the two bowls in an old fashioned measuring scale; when one improves, the other suffers. As waiting times are reduced and patients receive test results in less than two weeks, so quality of care is compromised. The more evidence that trainees gather about their competence, related to observable and documented behaviours, so the simpler the competencies become.

Those concerned with quality assurance need to stop looking at easy ways to gather the lowest levels of data, (or else call it quantity assurance) and start looking at indicators of quality – that is descriptive feedback from their end users. In fact, they just need to consult the end user, without whom there would be no NHS, no University or Royal College. We need to stop satisfying the masters, and look at the servants – for it is they who employ us.

A book recommendation

2009-06-21T12:23:00.003+01:00

I have just read an outstanding book - unputdownable!

Direct Red by Gabriel Weston, an ENT surgeon in London, is about her reflection on her surgical training experiences over the last 13 years. As a piece of writing it is up there with my favourite writers, and is poetic and moving. As a piece of reflective practice it is awe inspiring.

I have always had great respect for the surgeons I meet, most of whom manage to combine what I see as a pretty mutually exclusive set of skills - patient empathy and removed dispassion; decisive action and reflective consideration. Gabriel is also aware of these conflicting requirements of the surgeon's skill set, and even, I think, subconsciously questions what is essentially a nature/nurture question regarding the approaches to surgical action and the evolution of the 'surgical personality.'

Part of my job is to encourage and develop the reflective, trainee centred element which lurks in most surgeons, and whilst I doubt many trainees could produce as eloquent a piece of reflective writing as this is, the book provides a great starting point for the encouragement of that additional skill.

It ought to be on the syllabus for all medical schools around the country.

A focus on learning - great article to read!

2009-06-14T11:52:00.004+01:00

Most of the materials I write or courses I facilitate encourage people to think about the learner before the teacher. Most of my key messages are about being learner focused, at the planning stage, the participation stage and when recording and assessing progress.

A recent Training the Trainers course with a surgeon colleague led us to consider the three different types of curriculum: the specified, enacted and experienced curriculum. I was as usual emphasising the point that as educators and trainers we tend to focus more on the first two - ie what is laid down to be taught, and what we need to 'deliver' at the expense of what our learners are experiencing and where that takes them.

The surgeon involved has taken this concept and mapped it onto a whole training programme for a set of operative skills in a most inspiring way, using other learning and assessment ideas to ensure that skills in this area can be learned in a structured, supported and cascaded environment. His ideas were the most exciting ones I have seen in years. I shall share them in greater detail once they have been written up.

What this conversation led me to do was to revisit the Open University materials with which I worked for 9 years on curriculum and learning. The chair of that OU course has been re developing that course and I came across part of her revised work in a very useful article which summarises the key ideas of the course.

I post the link here and encourage anyone involved in training and education to read it. It encapsulates most of my philosophy on learning and teaching and gives us all food for further thought.

http://www.sagepub.com/upm-data/24800_01_Murphy(OU_Reader)_Ch_01.pdf

Happy reading and do let me know what you think.

Some of us are born teachers.....others have teaching thrust upon them

2009-05-16T15:51:00.002+01:00

How many people in work place based training and education have a teaching qualification? How many have fallen into training colleagues and juniors because it was part of the remit when they were promoted, or it "goes with the territory"? Is teaching something we can all do? Does it have to be especially taught? Does anybody really care?

I am not sure that we value teaching and training in this country to the extent that we should. In many of the professions the 'apprenticeship' model is alive and kicking purely because it requires little to no funding. Passing on one's professional knowledge, skills and judgement is an innate responsibility for any professional....isn't it?

These are rather deep questions, for which there is no hard and fast answer. However, in compulsory education, the healthcare services, public sector such as police and paramedic work, as well as in many other areas of professional life, the funding for and formal acknowledgement of dedicated training, teaching and mentoring, is almost non existent.

Pre service training is seen as all that is necessary for a teacher, a police officer and to an extent a doctor, to achieve the necessary "competencies" (Oh I hate that word!) to do their job. And this is where I suspect the problem lies. Competency based careers are just that - jobs. I would argue that professional careers require much more time and thought and dialogue than the mere ticking of lists and provision of "evidence" to show that one is competent (which now means 'just good enough!') A professional surgeon, lawyer, teacher, police officer, paramedic, nurse (I could go on) require more than just a degree in their subject or even a subsequent qualification in their vocational area. Professional expertise in all these areas takes time, requires guidance and mentoring, on the job coaching and reflection, and a dedicated commitment to development. Without the input of a more experienced other (a coach, teacher, mentor, trainer) this will not happen.

So back to my original question: How many people who find themsleves in this role, have the necessary skills, underpinning knowledge and natural aptitude to fulfil it? If everyone can be a teacher because they have been taught, can everyone be a doctor because they have been ill?

Increasingly I hear the lament from everyone around me that things are no longer working. Apart from the fact that policemen are getting younger (!) is there some truth in the complaints regarding a lowering of standards and attitude? If we are to do anything to counter this in professional life, we need to invest in those who are responsible for guiding the next generation, by educating them to think for themselves, and forget about ticking boxes.

If you have had teaching thrust upon you, I urge you to demand some support in this role. Most workplace based trainers are successful in what they do and many manage to communicate their skills, to a degree, to their trainees. But in a workplace that demands investment in health and safety, equality and diversity, and other such "rights", where are the rights of those who maintain the quality of the next generation?

2009-05-04T17:27:00.002+01:00

http://www.med-ed-online.org/pdf/Res00279.pdf

This may be of interest - a study reported on Medical Education Online, about reflective practice in medical students in the Netherlands. Bedtime reading for me tonight!

Reflective Practice -- guidance for trainees and students

2009-05-03T21:20:00.003+01:00

Reflective Practice - How to write a reflective piece - guidance for trainees and students

As part of any learning experience, you may be asked to or to choose to keep a reflective practice log . This can be done in electronic form or on paper, as you see fit.

Many learners are often advised to include pieces of reflective writing in their portfolio or record of learning during a course. These will maximise your potential for learning from practice, record your thoughts, beliefs and actions and build upon the learning activities you undertake both in class, in a peer group setting, on line and with your mentor as well as at organised study events and in your everyday practice. Reflective practice acts as the cement which holds together the building bricks of formal learning activities and everyday practical work.

You can complete a reflective piece whenever you like but a useful way to engage in reflection on practice is to be incident led. As a time consuming exercise, reflective writing is not something you can formally do every day. It is however, something that can be carried out following an event of note. This may be:

Ÿ a particularly difficult event or procedure,
Ÿ an emotional patient or client encounter,
Ÿ a successful personal intervention,
Ÿ a challenging case or situation
Ÿ A difficult part of the course you are following
Ÿ A particularly useful encounter with a colleague or mentor

Reflection on practice does not have to focus only on practical or clinical events; remember that many learning programmes are made up of Knowledge, Skills, and Reflection. All aspects of learning should be reflected upon.

So what is reflective practice?

Reflective practice is not new; as a concept it has been used to underpin adult and professional learning for over two decades. The cultivation of the capacity to reflect on, and in action has become an important feature of courses and professional training programmes in many disciplines.

You need to ensure that you understand what you are learning and in understanding, that you develop the skills to retain and develop your understanding, to transfer it to different contexts, pass it on to others and take control of your own professional development in order to gain the most you can from all of your practical and learning experiences.

Reflective practice is related to Experiential Learning. That is to say that having an experience is an important part of learning but that having an experience is not the same as understanding its meaning. We know that repeated practice is the best way to improve technical and vocational proficiency but if we do not understand the theory behind the practice we will take much longer to reach the level of competence required, if at all. We may need to go beyond that to achieve excellence. We also need to remember that practice may not make perfect - it may make permanent but if it is not correct practice it will become dangerous in its permanence.

There are two different uses of Reflective Practice:

Ÿ Reflection on Practice
Ÿ Reflection in Practice

Reflection on practice is a retrospective activity, free from the urgency and the pressures of the immediate situation. It can be maximised by feedback and ideas from others and is usually the first stage of our development of reflection as a habit. Engaging in formal reflection from time to time not only deepens understanding and learning but also develops an internal ability to reflect in practice.

Reflection in practice is a hands on approach to thinking on your feet. It can take place during the action with a “where do we go from here?” question. This can be very useful in the full range of professional practices encountered in a career in dentistry. Reflection in practice develops over time after considerable experience of reflecting on practice.

Reflective practice is not then, a bolt on extra to a learning programme. It is an integral and vital part of the learning process. Reflective practice is a way for us all to make sense of the different elements of learning and how they fit into training and good practice.

How do we write a reflective piece?

There are many ways to structure reflection on practice and learners will find preferred ways of doing this. However, to help you, here is our recommended approach for any situation.

Event - what happened? Go through the basics of the incident on which you wish to refelct, pulling out the facts as you saw them
Debrief - try to list the good elements of the event and the bad. Work out what you would do again and what you would wish to change. Isolate any emotions that may stand in the way of you revisiting the event again, and deal with them at this point.
Actions - set actions to intervene and amened the elements you were not so happy with and plan for those interventions
Review - look at the interventions and follow up actions and see how they made a difference to your practice.

This is similar to the original Reflective Practice cycle developed by Kolb (1984) in that it takes as its starting point an action or an event. This approach is unique in that it encourages us to examine our practice from three different perspectives - factual, emotional and theoretical before making changes for future use.

HOW DO I INCLUDE MY REFLECTIVE PIECES WITHOUT MAKING ME SOUND LIKE A TOTAL IDIOT?

Some of you have expressed concern about the “bearing my soul” aspect of reflective practice and it is true that there is a fine line between sharing experiences honestly and laying oneself open to criticism for doing so.

What we would suggest is that you do the whole reflective process for your own benefit, because it is only by being totally honest and open about it that you can learn properly from it. But when it comes to including that reflective piece in your portfolio, it may be an idea to edit it thus:

HEADLINE: What you have learned from this event
EVENT: 1-3 sentences about the event itself with some idea of the area you targeted from reflection
LEARNED: now you can spend longer on this area, discussing what it was you learned from the event and expressing this in developmental but positive terms
ACTION: This is where you identify the actions resulting from the reflection. They may be short, medium or long term and you can revisit them after you have implemented them to comment on their efficacy once used in practice.
Remember to always follow up with a review of your amended practice after you have implemented your actions. This completes the cycle of learning initiated from the original piece of reflection.

Good luck!

2009-05-03T19:43:00.003+01:00

Surgical Training – a Spiral of Learning – Are you ready?
S Vig, H Allan, L Hadfield-Law, A Hollowood , M Deakin

William Halsted was an innovator of surgical training in the early 20th century. Traditionally training was offered to the senior professors and Halsted wished to improve this, not change it and bring it round full circle but to take training and education to a higher level.
Halsted changed the focus of training to the house officer. House officers were given graduated responsibilities including supervised surgery within an apprenticeship model. Dependent on time served and large numbers of patients treated, the programme ensured that the resident surgeon would be skilled and experienced at the end of it.This concept of surgical training has continued to be used successfully but has recently had to evolve again with the implementation of MMC and EWTD.
Trainees no longer have access to a wealth of experience or time. Trainees need to understand the knowledge, skills, judgment and professionalism needed to become the Consultant Surgeon. They also now need to use every opportunity and patient encounter to learn.
Trainees have adapted and have embraced the Foundation Programme. Assessments and reflective practice have been key to developing education and training and are mandatory for the trainees. These trainees have now become the CT1s and 2s registered with Intercollegiate Surgical Curriculum Programme (ISCP). They are keen and enthusiastic and determined to succeed to become the next generation to influence surgery. Trainees are expected to lead their learning and ask for assessments to direct their learning needs. They are ready.
Are the trainers ready? Although some surgeons took part in the ‘Tools of the Trade’ training sessions which introduced the new workplace based assessments used in the Foundation Programme, many didn’t. Some surgeons took part in briefings associated with the implementation of the Intercollegiate Surgical Curriculum Programme (ISCP) which involved an introduction to the assessment methods, as well as the curriculum and the web site but many did not.

ISCP not only specifies a syllabus within a curriculum but also designated educational and mentoring responsibilities of the Assigned Educational Supervisor (AES), Clinical Supervisor, Trainer and Assessor. The College Training the Trainer course was updated to reflect the new curriculum and in particular the needs of the Clinical Supervisors as teacher and trainer, but what of the AES and Assessor?

Training and Assessment in Practice (TAIP) was developed, by surgeons and educators for the Raven Department of Education, to coincide with the implementation of the curriculum. TAIP developed a framework to clarify the usage of the new assessment tools.

From the first pilot, before implementation, participants were feeding back how helpful the course was in developing their understanding of workplace based assessment and where it fits into the process of supporting a trainee’s learning, including using assessments formatively to provide developmental feedback.

‘I particularly valued the video analyses and the scoring and the discussions that followed. Equally, I valued the trainer/trainee case scenario demonstrations – very very powerful.’ (Leeds Participant 2008)

“Assessment tools demystified…” said a participant on a recent Training and Assessment in Practice (TAIP) course held in the West Midlands.

‘the sessions looking at how to incorporate assessment tools into everyday practice and what exactly we are assessing will make the greatest difference to my practice.’ (Reading participant 2008)

The course does not just cover the new assessments but also covers the learning agreement, portfolio assessment and development and how to encourage the trainees learning experience drawing on the ISCP and utilising on-line forms. TAIP also encourages a quality assurance of the assessment process.

The interactive course, with faculty including a surgeon, an educator and trainee has had additional benefits to the consultants attending:
They are able to apply the same systematic approach to learning, recording evidence and building a portfolio for their own practice which is helpful in preparation for revalidation;
The programme provides evidence of the consultant’s continuing professional development (CPD). This is further enhanced if the surgeon becomes faculty on the programme.

From a deanery/Schools of Surgery perspective, the course provides evidence that their surgeons are meeting the ISCP requirements that AESs and Assessors are trained (No5 vol89 ISSN:1473-6357) and the PMETB standard 4 for trainers (http://www.pmetb.org.uk/fileadmin/user/QA/Assessment/PMETB_STANDARDS_FOR_TRAINERS_JAN_2008.pdf).

Recent developments in the programme include:
· greater cooperation between the Education Department and Schools of Surgery to deliver the programme locally. The benefits to surgeons are decreased costs both in terms of fees and travel and accommodation as well as time away from home (and the workplace)
· In response to feedback from participants and Schools of Surgery the programme has been modified so that the College is now able to offer a one day course tailored to the day to day needs of Trainers and Assessors.

For further information on TAIP please contact the Professional Development team: 020 7869 6350 or pdcourses@rcseng.ac.uk

Experience Based Learning

2009-05-03T19:19:00.004+01:00

EXPERIENCE BASED LEARNING: Making the most of Surgical Training
Hayley Allan, Stella Vig

Introduction & Rationale
It is widely believed that it is impossible to train surgical trainees to CCT level in a mere 48 hour week; that trainees cannot gain sufficient exposure to surgical disease or carry out an acceptable number of procedures to gain the confidence and competence for CCT within the time now available. (Ann R Coll Surg Engl (Suppl) 2009;91:78-79)

EWTD is a reality and hospitals are already implementing strict controls to ensure its trainees do not exceed the hours they are allowed to work, resulting in a consultant led service which furthermore restricts training time and opportunity. (Ann R Coll Surg Engl (Suppl) 2009;91:70-71)

Traditional training in surgery followed the immersion method. Trainees were on site for most of the week and quickly saw a wide variety of cases. The apprenticeship model (Wenger 1999, Lave & Wenger 1991) is one of which the profession is proud; trainees learned their craft from the ‘master’, acting as assistant and developing through a sustained and protracted mentorship. Surgical ‘firms’ ensured that learning and training were cascaded down from the consultant to Consultant to Registrar to SHO and so on. One learned everything from very few teachers. The fear today is that one learns much less from a greater number of trainers. An alternative approach is sought.

Given that EWTD is something we cannot overturn in the immediate future, it is our responsibility as educators of tomorrow’s surgeons to find a way around this hurdle. We cannot change EWTD; ISCP and the newer training methods are here to stay for the short term at least, and the current trainees cannot afford to miss out. As their future patients, neither can we.

Experience Based Learning
The way forward is an Experience Based Learning curriculum. This takes as its central tenet the merits of apprenticeship learning and blends with that trainee responsibility for ‘training on the job; learning off the job.’ Trainees may only be allowed in the hospital for 48 hours a week but they – with our help – can ensure that they receive the best dedicated training by managing their practical and clinical skills on the job with supplementary learning off site. On the job learning needs to be in the clinical context – in theatre, on the wards and in out patients. This is what the ISCP takes as its classroom setting and this is where the EWT hours should be focused. The other areas of learning a trainee surgeon engages in, audit, presentations, research, journal clubs etc ought to be kept for their off the job time.

DOING (on the job) leads to

LOOKING BACK (debrief/reflection)leads to

THINKING/LEARNING (off the job)leads to

LOOKING FORWARD (planning/preparation)leads to DOING....

Experience Based Learning Model (Allan & Vig 2009)

This model shows how training on the job and learning off the job are integrated to make meaningful connections between clinical practice and medical education. If trainees are encouraged to take away their experiences and learn from them, out of hospital working hours, following discussions of these experiences with a trainer, with relevant action planning to target future learning activities, then each clinical experience will take the trainee further than it would have done without such additional processing. In this way, the learning experiences on the job, although fewer in number, have greater impact qualitatively, upon trainee development.

Training on the Job
The assessment ‘tools of the trade’ facilitate this focus. Using feedback maximises learning and training opportunities on the job. Trainees ought to be getting feedback on their DOPs and PBAs at every possible opportunity in theatre. Scheduling one trainee observation into an Out Patient clinic every week, with ten minutes to teach through feedback, is not an impossible task. Ward rounds ought to be prepared for, used as (group) training opportunity and again subject to training feedback focused on the trainee(s) stage and needs. Admittedly it is difficult to organise given the time pressures, the Clinic appointment templates and the dearth of training lists in theatre, but there are still opportunities available.

The Apprenticeship system worked because surgeons integrated clinical and training commitments. However, for modern clinicians this may be something of a revelation; a recent consultant participant on a TAIP (Training and Assessment in Practice) course said that she had realised during the course that clinical and training commitments were not separate; that if she tried to meet them individually she failed. She said that she intended to integrate her clinical and training work in the future. Training on the job, using the ISCP tools as recommended by the TAIP course, ensures that trainees and trainers focus on the workplace based opportunities for learning that most of us worry will be eroded by EWTD.

Learning off the job
Learning off the job has always been a fact of life for the trainee surgeon, as it is for trainee nurses, teachers, lawyers, police officers and many more professional groups. When we embark on a career the training period and early years of that career will occupy more hours than those we are paid for. All surgeons want to succeed and most are prepared for the extra work that requires. Learning off the job is a reality for surgeons and there are many opportunities for them to continue to do so, leaving clinical and surgical development to be the focus of the time they are officially at work. Indeed learning does not stop at CCT. Lifelong learning has always been a part of a surgeon’s job and will continue to be.

As trainers, we need to consider how trainees can fit learning off the job into their already busy programme of surgical training. Naturally trainers see their main responsibility as on the job training, but an additional feature of a great surgical trainer, whether in 1909, 1959 or 2009 is that of mentorship. The ISCP has defined the responsibilities of those designated Programme Directors, Educational Supervisors and Clinical Supervisors, but it is those trainers who are able to structure the learning of their juniors to allow for observation, discussion, teaching and learning followed with brief feedback and action planning, who are distinguishing themselves with the trainees today. Ensuring that trainees receive support and development whilst engaging in clinical care, with immediate feedback and discussion and follow up activities to reinforce the learning, may well reduce the number of times a trainee has to do something before they are proficient at it. It could be that more overt and directed training proves to be more time efficient than some of the more covert ‘immersion’ methods previously used.

EBL – maximising the time available
Quantity is not a guarantee of competence. If it took ‘Bill’ 7 procedures to perfect his technique in 1983, because he was largely unsupervised, it may only take ‘Ben’ 2 or 3, because he has been well prepared with video footage, staged training, detailed feedback and follow up teaching using the DOPs and PBA forms. He may have had access to a wet lab to practise the particularly tricky part of the operation, and observed another surgeon doing the same procedure. He may well reach the same level of competence as ‘Bill’, only 4 or 5 procedures earlier.

EBL does not promote having the same experience 7 times; it focuses on what we can learn from each experience before the next one comes along so that we can change it for the better.

Professional learning and development in many spheres has been influenced over the last 15 years by the ideas of Wood, Bruner & Ross ( 1976 ) who rejected the traditional mode of see one, do one, or the “copy me” approach to training. Rather a trainer teaches through dialogue, providing “scaffolding” support structures to assist the trainee in their practical learning. As the trainee grows more proficient the support structures are reduced and trainees gain in confidence and autonomy. Many good trainers do this already; some do not.

Dialogue and Debrief
Dialogue on the job is not always possible. In theatre, scaffolding has been used by effective trainers for centuries, but on the wards and in clinic, due to patient presence, it is not possible for trainer and trainee to articulate their thoughts and actions whilst seeing a patient. For this reason the dialogue has to take place as soon after the episode as possible. The ISCP calls this dialogue assessment; TAIP refers to it as feedback. Traditionally such dialogue would happen informally in the mess or the pub. That trainers and trainees need to talk about what they do together to learn and train, is undeniable. How they do this and when they do it, is less clear.

Five minutes is all that is required to feedback to or to debrief a trainee if the learning episode has been structured and observed. Since Training the Trainers and the ATLS Instructor courses were developed 15 – 20 years ago, Pendleton’s rules (1984)have been used for debriefing trainees. There may be no better tool for evaluating simple, practical procedures but some of a surgeon’s work requires slightly more than the questions, “What went well?” and “what can be improved?”

To be of any educational value, debriefs need to be:
• Two way
• Open
• Specific
• Evidence based
• Behaviour focused
• Honest
• Developmental
• Supportive

A simple mnemonic can be used to debrief trainees meaningfully. Once they have accepted and understood the method they can use it reflexively to self evaluate too.

Describe events
Evaluate what went well/to change next time
Banish emotions that cloud judgement and development
Review and analyse in light of previous experience
Identify lessons learned
Evidence learning in portfolio
Follow up with action plan

 All debriefs should start with a simple summary of what has happened. Trainees may view an event differently from their trainer and discrepancies need to be identified early.

 Pendleton’s rules can be used initially to evaluate areas of good practice and areas requiring development. Deeper analysis is often necessary especially if a trainee does not understand why certain aspects were or were not effective.

 If the event has produced any strong feelings in the trainee these should be elicited as they may have a bearing upon judgement and the ability to move forward.

 Next the trainee should be encouraged to review the event in light of previous experiences of a similar nature. Is there a pattern emerging? (BMJ 2008;336;827-30)

 Trainee is then asked to review the debrief and to summarise lessons learned from the incident and the conversation.

 Follow up area 1: evidence of learning from the event to be documented in the Portfolio

 Follow up area 2: future actions to be implemented and reviewed.

Future Actions
On most of the ISCP assessment tools, there is a box for “Agreed actions.” Often documented actions include ‘reading’ and ‘practice’. Whilst both are excellent sources of future learning and development, without trainer involvement in these actions, there is a risk of bad practice being reinforced rather than a change in practice as the outcome. Agreed actions have to complete a learning loop.

Event - Debrief - Actions - Review

Learning Loop (Allan & Vig 2009)

Without a review of the agreed actions, the trainee does not know if he or she has benefitted from the debrief and action plan, and the trainer is not aware of whether the trainee has in fact learned from the original event and the following debrief. Assessment is not a linear process; it needs to revisit and review the original training interventions to see whether those interventions have had the desired impact on learning. Suggested actions include:
 Read x and teach the medical students. Put in your portfolio the teaching notes and student evaluations.
 Practise x in the skills lab with (a registrar). Next time we are in theatre you will show me how to do this and we will fill in a relevant assessment form.

Conclusion
Experience Based Learning proposes a ‘training on the job, learning off the job’ model for surgical training, whereby trainees use as their curriculum setting the workplace contexts of theatre, ward and out-patients clinic. Supplementary activities such as audit, research, teaching and presentations are conducted outside of the EWT week. Trainers continue to train as they have always done, on the job, ensuring that debrief and follow up review of agreed actions is carried out. In this way, the requirement for trainees to learn from their mistakes without the guidance of an experienced expert, is reduced and so too are the numbers of procedures they have to do. Experience Based Learning provides trainees with experiences from which to learn, whilst under the apprenticeship guidance of their trainer consultants. Workload can be shared, once the trainee has mastered the relevant skills and knowledge to undertake the work required. Every experience has a training purpose, and each experience is utilised to this end. The appeal of the old apprenticeship model was the relationship built between trainer and trainee; effective debrief and review will provide this too.

Birchley D, Ann R Coll Surg Engl (Suppl) 2009;91:70-71

Black D, Ann R Coll Surg Engl (Suppl) 2009;91:78-79

Driessen E, van Tartwijk J, Dornan T (2008) TEACHING ROUNDS The Self Critical Doctor; helping students become more reflective. BMJ 2008;336:827 – 30

Lave J, Wenger E, 1991 Situated Learning: Legitimate Peripheral Participation. Cambridge University Press
D Pendleton et al, The Consultation: an Approach to Learning and Teaching, 1984
Wenger E, 1999 Communities of Practice: Learning, Meaning, Identity. Cambridge University Press

Wood D, Bruner JS, Ross G, 1976 The Role of Tutoring in Problem Solving in The Journal of Psychology & Psychiatry 17.
TAIP – Training and Assessment In Practice http://www.rcseng.ac.uk/education/courses/TAIP_.html/

Developing reflective writing among trainees

2009-05-03T13:58:00.001+01:00

This is something I wrote to encourage trainers to use reflection with their trainees, and to guide them to encourage trainees to use a structured approach to reflection in completing their portfolios

Reflective practice is an essential component of the Portfolio for all trainees today. The ISCP requires it as do other forms of training and education both at undergraduate and postgraduate level. However, very few syllabuses or training programmes define exactly what it is; fewer still give any advice on how to do it – or for supervisors and trainers, how to teach it. This paper will give trainees a greater understanding of how to approach their reflective practice, and trainers a framework for encouraging and developing the practice among their juniors.

What is it?
“Reflection is vital for learning from clinical experiences” (Driessen et al, BMJ 2008 336)
To many people "experience" means "making the same mistakes with increasing confidence over an impressive number of years" (O’Donnell, 1997). The “impressive number of years” that surgeons spent in training previously has now gone and in the era of EWTD and ISCP, trainees cannot afford to make the same mistake twice. One way of addressing this is to encourage and develop the use of reflection in all trainee doctors.

Defining reflection
When we say that trainees need to be more reflective, what we mean is that they need to let future behaviour be guided by systematic and critical analysis of past actions and beliefs and the assumptions that underlie them. (Dewey, 1933)

Why use it?
All doctors in the UK are now required to make reflection a critical foundation of their lifelong learning (GMC 2000). Research evidence from nursing, (Jarvis in Nurse Educ 1992) and teaching (Korthagen et al, 2001) suggests that reflection can help students learn from their experiences.

How do we do it?
“Students do not generally adopt reflective learning habits spontaneously, so teachers must help them” (Driessen et al, BMJ 2008 336)
Most trainees do not really know how to reflect effectively on their practice. They may be aware that something has not gone particularly well; for Dewey, reflection was stimulated by an event that aroused a state of doubt, perplexity and uncertainty that often leads to the individual searching for the possible explanations or solutions. (Dewey, 1933) Trainees are less keen to reflect on practice that has gone well, although it is useful for them to do this from time to time to ensure they understand why it went well in order to replicate the good practice. Most of us want to improve the poor practice and this is where much of reflection is centred.
Supervisors and trainers need to stimulate students to assess and analyse their actions and devise alternative actions. To do this they need to provide a safe learning environment, give honest feedback and ask the right questions. The skill of the trainer is to listen well and ask open questions

Approaches to stimulating reflection in trainees
1. After conducting an assessment tool (mini CEX, CbD, DOP, PBA)
- Ask the trainee what they felt their strengths were in that activity.
- Add your own view of the strengths
- Ask the trainee where they think they could develop
- Ensure you shape the area(s) for development to make them meaningful and not too many
- Finally ensure that there are agreed actions for the trainee to follow up in order to learn from and then demonstrate development in this area.

Example:
After a Mini CEX in clinic, you and your trainee identify together the strengths of professionalism and appearance, rapport with a patient and organisation of encounter. In need of development was the history taking. You discuss the areas of weakness here and agree that he will shadow you in clinic next week, recording your history taking approach. He will then teach this to the F1s the following week and do a follow up mini CEX the week following that.
This is the most helpful way you can encourage reflection in a trainee especially early in their specialty training career. Encourage them to document their development too, with evidence in this case of the records he makes of your history taking, and the evaluations he receives from the F1 teaching the following week. When he has received his next mini CEX form he can put all of these pieces of evidence together to show that he has learned from this period of time.

2. LISA model for reflecting
- List - basic elements of practice, situation, problem
- Identify - assumptions, beliefs, feelings, rules, motives etc underlying practice and your approach to it
- See - with other practice? Possible alternatives? Comparative merits
similarities and drawbacks?
- Act - plan and then implement a new approach.
LISA is the framework used in the TAIP manual and provides a basic approach to Reflecting on practice from which to begin a reflective conversation with a trainee. In a simpler, but similar manner to Dewey’s 5 stage approach (Dewey 1933) LISA looks at the facts of the event or problem, the assumptions or beliefs or feelings that resulted from it and may stop the learner from accessing further learning or activity, the cognitive progress made from the reflection – looking at thought processes and other comparable practice and the patterns between them, before finally deciding upon an alternative action plan to implement. Like most reflective practice this is influenced by Schon (1987).

3. ALAC: (Driessen 2008)
Element of reflection - How to support reflective learning
- Action
Help trainees choose experiences that support and develop their learning
- Looking back
Separate performance from person (a mistake does not mean the person is a failure); be trustworthy and honest; acknowledge and make success explicit; provide feedback; encourage trainees to obtain information and evidence from various sources and put it into their portfolio
- Analysis
Focus on the trainee’s own role in the success or failure; encourage trainee to take the perspective of others; ask ‘why’ questions; ‘confronting’ questions; ‘generalising’ questions; point out inconsistencies in trainee’s analysis; help them generalise between experiences
- Creating alternative actions
Ask trainees to suggest options for change; encourage them to formulate plans and check these are in line with analysis; help them to focus on SMART objectives for learning

SMART: Make sure your actions are:
- Specific
- Measurable
- Achievable
- Relevant
- Timely

Advice for trainees in reflecting on their practice
The benefits of regular reflective writing
Reflective writing provides an opportunity for us to think critically about what we do and why. It provides
· a record of events and results and our reactions to them,
· data on which to base reflective discussion,
· opportunity for us to challenge ourselves and what we do and to look at doing it differently and better,
· impetus to take action that is informed and planned,
· an opportunity to view our clinical practice objectively and not see all problems as personal inadequacy,
· increased confidence through increased insight
· Basic documentation to support future entries in our portfolio and for job applications etc.
(http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm)

Peer reflection
Engaging in open and collaborative discussion about work with a peer is a process that can enable us to become more reflective doctors. You can use any of the models advocated above if you and your peer are reasonably confident and experienced in challenging one another in reviewing an event. If you are new to this you may wish to reflect with a supervisor first until you become more confident.

Using the LISA framework
A helpful way of understanding the process of reflection described by Stephen Brookfield (1995) describes the process of hunting out our assumptions and critically examining them. Ask yourself what are the assumptions behind your practice and then try to develop a contrary argument. You now have two sides of an argument to evaluate. This is engaging in personal critical reflection.

Keeping a journal
The journal is parallel to the field book or laboratory notes of the scientist. We not only record what happened or what was observed but in addition we can record a tentative hypothesis or the development of new understanding, we can use our writing to make a new sense of phenomena. Reflective writing has the potential to provide us with a systematic approach to our development as a reflective, critical and constructive learner. Our journal can provide an opportunity to make explicit our position on a range of issues of personal significance.

Your journal could be structured:-
· as a personal learning journey, tracking and documenting an evolving understanding of your clinical practice and learning
· a critical reflection on a clinical encounter you have witnessed between a colleague or your registrar or consultant supervisor

Ideas for getting started on reflective writing:
1. Use a checklist
· What is the current problem or issue? Describe the context
· What additional information would be useful?
· How is it related to other issues?
· Who or what could help?
· What are my assumptions? How can I test them?
· What can I do to create a change? Be as adventurous as you can
· What are the possible outcomes of these?
· What action will I take? Why?
· List the outcomes you hope to achieve.
· Reflection on the actual outcome What worked well?
· What could I do differently next time?

2. Focus on a critical incident that took place in your clinical practice.
· Describe the incident as objectively as possible.
· What were the assumptions that you were operating with?
· Is there another way to see this event?
· How would your patients explain this event?
· How do the two explanations compare?
· What could you do differently?

3.And from time to time...
· What has using this journal confirmed that I already know about my learning and how I affect that?
· What do I need to do to improve the quality of what I do?
· What might I do instead of what I do now?
· What innovation could I introduce?
· What professional development activities should I be seeking?

For more information on reflective practice see:
Ballantyne, R & Packer, J; (1995)Making Connections: Using Student Journals as a Teaching/Learning Aid, HERDSA ACT.
Boud, D; Keogh, R; & Walker, D, (1995) Reflection: Turning Experience into Learning, Kogan Page, London.
Brookfield S. (1995) On Becoming a Critically Reflective Teacher, Jossey Bass, San Francisco.
http://www.clt.uts.edu.au/Scholarship/Reflective.journal.htm
Dewey J. How we think: a restatement of the relation between reflective thinking to the education process. Boston: Heath, 1933Driessen E, van Tartwijk J, Dornan T The self critical doctor: helping students become more reflective. BMJ 2008 336:0
General medical Council. Revalidating doctors: ensuring standards, securing the future. London: GMC, 2000
Jarvis P. Reflective Practice and nursing. Nurse Educ 1992; 12; 174 – 81
Korthagen FAJ, Kessels J, Koster B, Lagerwerf B, Wubbels T. linking theory and Practice: the pedagogy of realistic teacher education. Mahwah, NY: Lawrence Erlbaum Associates, 2001
O’Donnell M. A sceptic’s medical dictionary. Oxford: Blackwell BMJ books, 1997
Schon, D; (1987) Educating the Reflective Practitioner; Jossey Bass, San Francisco.

2009-05-03T13:52:00.001+01:00

Hello

This is a site for anyone who is involved in or interested in educating trainers. I do not use these terms lightly. In a 'training' focused world, my mission is to educate through training. In medicine and surgery, my main place of work, there is much talk of training and little consideration of education. I see this as a dangerous distinction; to train someone we show them how to be like us - a useful first step in their development - but we must go further than that and educate them to think for themselves. This is time consuming and onerous and it is not surprising that the quick fix of training is more attractive in today's NHS and elsewhere.

I intend to post up here some of the materials I have written for my work, to share with anyone who is interested. And please, share your views on here, add your own thoughts. I look forward to "talking" to you.

Best Wishes
Hayley