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

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.

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/