15 March 2009

The war on experiential learning and professionalism

Dr Grumble is responsible for a large number of doctors in training. Not as many as 100 but close to 100. There has been a great deal of focus on the training of junior doctors in recent years. Who advised on this Dr Grumble has no idea but he does wonder. Whether any practising doctors were involved Dr Grumble has no idea. He wonders about that too. Because, as we all know, what our junior doctors have ended up with is lots of boxes to get ticked. It seems that the process is more to do with covering the backs of managers than training doctors to a high standard. After all if a doctor has lots of competency boxes ticked there can't be a problem, can there? But, in reality, we all know that these boxes only score adequacy at a very basic level. They are not about excellence. The competencies are not the same as understanding. They do not measure the higher level functioning of a professional. Come to think of it, they do not seem to measure anything useful at all. So it does not surprise Dr Grumble to learn that there is actually no evidence to support their use. So, if there is no evidence, why was this rolled out the way it was across the nation in every specialty? That's something else Dr Grumble does not know the answer to.

Wind back now to when Dr Grumble was a junior doctor. The NHS then was thronging with junior doctors. There were few consultants. The junior doctors spent long hours in a learning environment called a hospital where they worked at being doctors. They learned a lot. They became enormously experienced. Many worked more hours as junior doctors than some people work in a whole lifetime. It was a training that worked and worked well. Doctors came from around the globe to train in the UK. Not just from deprived parts of the world, Australians and the like used to come too. But now it's the other way around, our doctors are leaving to train in the Antipodes. Now why do you think that is?

So where did the competency model that we had no need for come from? It was actually from industry. The idea is that you have a task in, say, a factory and you break it down into its component parts. You then assess the trainee on each of the stages involved. Perhaps it is appropriate to the production line. Dr Grumble has no idea. But is it appropriate to the practice of medicine? Meeting competency criteria are certainly not the same as being professionally competent but our masters seem to make out that it is. Being able to give an anaesthetic might seem to an outsider to be a straightforward competence that you can tick a box on but even an ordinary doctor like Grumble knows that anaesthesia is much more than that. And so, of course, is the rest of medicine. It is about professionalism. It is about high level complex decision making based on experiential learning. True professionals don't just follow rules. That's not what they are there for. They are there to think on their feet at a high level. They are there to deal with uncertainty. They work in areas of greyness. The practice of medicine is not about simple competencies. It is about multifaceted high-level professional competence. These are not things that can be simply measured. They are too complex for that though they can be recognised when you see them. Sadly, appraisal, grading and league tables seem to be the order of the day for our political masters. There is no getting away from them. And now it is reaching really absurd levels.

Can we do better in our assessment of junior doctors? Dr Grumble does not think we easily can. We do not yet even understand the heuristic processes by which a doctor makes a diagnosis. If we don't even understand how good doctors do these basic things how can we easily appraise learners?

And, to make matters potentially worse, we are now going to have to reduce the hours our doctors work whether we or they like it or not. There are 168 hours of the week when care needs to be given. If hours are too short consultants and juniors will only meet like ships in the night.

Whatever happened to Tooke? Sometimes there seems to be no progress at all and that our masters keep blundering on.


Betty M said...

I am a professional of a different sort to you working in a different part of the public sector. We have just been told our appraisal system is changing for the 3rd time in 4 years. We now have 7 competencies to perform against. These are worded differently from the 5 "skills" that we are supposed to be working to as part of the wider part of the sector we are in. We are also supposed to report on people meeting these competencies (with evidence) in 500 words or less - so 71 words per competence. Absurd doesn't even begin to describe it.

sam said...

I think those responsible for training surgeons are now considering extending the years of training to ensure training is up to the required standards Dr G. I do not know 'anything' about training surgeons but when MMC reduced the years of training, I wonered why? Of course there is also the use of simulation as well as virtual environments to 'assist' training.

What do you think? Your expert opinion will be greatly appreciated here :-)

Dr Grumble said...

Unfortunately, Betty M, these nonsenses are getting everywhere. How it has been possible to foist them on intelligent professionals who have no faith whatever in the processes? Who is responsible for it all?

Sam, the Grumble hospital is now full of expensive simulators of one sort or another. The powers-that-be seem to think that a few afternoons with the simulator will make up for the loss of a few years in the operating theatre. Since Dr Grumble's surgical experience is limited to a score or two of appendicectomies and a few other minor operations he will make no comment. But he can tell you that performing a rectal examination on a porcelain bum is not much like the real thing.

It may be that laparoscopic surgery can now be simulated quite well and I believe there is evidence that experience with video games gives you a head start. Your friend Lord Darzi is said to be keen on this approach. Doubtless simulators do have a role. My students, critical of much of their teaching, seem to find them quite useful.

Mrs Grumble teaches her trainees to do core biopsies using an olive embedded in a piece of chicken. You get extra marks for getting the pimento in the middle. Cheap and effective apparently.

sam said...

Good on Mrs G Dr G! Hers is 'proper innovation; make do with what you have .. but .. what does she herself eat for lunch then?!


Dr Grumble said...

I think they eat chicken and olives. It's a sterile procedure after all.

I remember practicising liver biopsies on an orange. An orange is not at all like a liver but Tru-Cut biopsy needles become mysterious the moment you cannot see the tip. I found this out to my cost when trying to teaching a not very practically minded doctor to do liver biopsies.

None of my registrars can do liver biopsies. It is not on their repertoire. But that's not at all bad. They are now done by people who do them all the time with proper support and imaging. We used to do them on the ordinary ward using a water divining method to find the right spot. Things have fortunately moved on.

Garth Marenghi said...

The reason is this:

less hours, less experience, and the powers that be know this,

they want a way of pretending they can train people just as well even if they are not,

hence if they create huge verbose syllabi with numerous tick box competency based assessments to prove how trainees are competent at everything they used to be, then they can continue to ignore the lack of emphasis on training and leave it to rot at the expense of the short term service

it is time consuming and overly bureaucratic, it also means that training is less effective as so much time is wasted doing stupid tick box exercises

this has all come from the DH in the form of PMETB,

Tooke has been ignored,

Deaneries are DH stooges, trainees have no way of pointing out how poor their training is when it is poor without fear of reprisal, the BMA is in denial over EWTD, there is no emphasis on good training financially so Trusts just ignore it and prioritise targets like 18 weeks

it's an attempt to pretend all is well when it clearly is not,

thank God, John Black is making a stand on this issue, hopefully it's not too late

Garth Marenghi said...

ps add in the fact that Run Through Training has led to a massive dumbing down of standards including Royal College Exams, hence tick box assessments are there to prove just how today's trainees are just as good as yesterday's when some of them clearly are not

Trainer 1 said...

I am afraid, after a very long time of trying to make sense of this, we must start to confront a very uncomfortable truth. This dovetails with your recent posts regarding an apparent agenda to undermine the NHS.

This whole agenda, and its language, is baffling because it is supposed to be. Jargon is the language of the junta. This is part of a more generalised assault on individuality, intellectual life and professionalism. Medical education is being subjected to a deliberate "dumbing down" process designed to stifle individual thought and enquiry. This process has afflicted the general educational establishment for years. The "skills agenda" is part of this. You could call that "skills for serfs".

I would recommend visiting www.deliberatedumbingdown.com and downloading the pdf book by Charlotte Iserbyt - an educational whistleblower. This gives a very clear account of educational upheavals in America.

She describes the processes by which changes are achieved by "change agents": reaching "consensus" (2 steps forward 1 step back), "gradualism" and "semantic deception" (ie Orwellian doublespeak). Does this sound familiar?

So why suppress free thought and intellectual rigour?

Well you just need to follow the paper trails of where these ideas come from.

Dr Grumble said...

Thank you, Trainer 1. This all sounds very familiar. Dr G has read chapter 1 of the book you recommend which is clearly essential reading.

Trainer 1 said...

Dr grumble is obviously an intelligent man and, like most intelligent people, has sensed that something has been wrong for a long time. The key to understanding all this is finding the source. The driving force. The funding. As they put it one memorable film from the 1970s "follow the money".

If one looks at, for example, the sources that have funded North American educational reform (as per previous post on "dumbing down") they are, amazingly, rather similar to those which are funding the UK educational and "skills" agenda as well as reforms of medical recruitment and education.

Think 'think tanks'. Think the 'charitable sector'.

Since when was medical education 'training'. When did we start 'training the trainers'. When will we start to 'train the trainers to train the trainers'. I remember we used to 'train' pets, not professionals.

I am afraid this is not accidental, it is stategy. It may even relate to certain 'leadership' agendas Dr Grumble has recently touched on. Again look for the funding.

Bear in mind the source of many of these educational reforms originally had an interest in psychological warfare. This is a very long game.
It goes beyond educational reform. The following is taken directly from the website of a 'charitable institute' which is influencing these reforms...

"Strengthening the voluntary sector infrastructure and and increasing parenting provision, specifically by filling gaps in the availability of parenting support and improving access for and take-up by groups not currently well served"

When exactly did third parties start providing "parenting provision"?

Doctors, like Grumble and trainer 1, need to start looking at parallels for what we are seeing in medical education in society at large. They are not coincidental. And they will accelerate.

Dr Grumble said...

You are a bit cryptic, Trainer 1, but Dr Grumble, as you will know, is already onto the powerful but not very visible organisations behind all of this. But what can we do? If the stubborn medical profession, which is actually rather good at thinking for itself, cannot stand up to all of this nonsense it is doubtful whether any other group can. So does that mean there is no hope and we might as well play along with it?