Experience Based Learning

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/