South Bristol Trainers Workshop 2011Saunton Sands

Lucy Pocock

Introductions

• Introduce yourself with the following information:– Your name– Where you work– A little known fact about yourself

Plan for the day

Gamekeeper turned poacher – my journey from teacher to doctor

Using portfolios to maximise learning:•Planning•Opportunistic learning moments•Assessment•Feedback

Early ideas

• Importance of role models• Widening participation• Admissions process• Being a student again at 30!

A quick poll

Medicine should be graduate-entry only…Yes or No?

Background• US and Canada

– Johns Hopkins Medical School (1898)– Flexner report (1910)

• Australia– 4 graduate-entry only Medical Schools

• UK– Leicester Warwick & St George’s (2000) – Increase proportion of over 20s, from 17% (1996) to 34% (2003)– 15 Medical Schools offering graduate-entry programmes (2007)

• Ireland– Proposed phased introduction of graduate-entry programmes

to account eventually for 40% of total intake (2006)

Assumptions 1• Graduates are more motivated and committed because

they are making a more informed choice of career

• Graduate-entry promotes more equality of access, especially for students from less advantaged schools as it gives them time to equalise with those from advantaged schools

• Students with broader pre-entry training and life experience will have a more understanding approach to patients, better interactional skills, and more diverse skills with which to cope with an increasing range of professional outcomes

Assumptions 2• Graduates are less likely to drop out of the course

• Graduates are more confident, more self-aware, more demanding, more self-directed, more able to take the initiative, and more critical

• Graduates have better study and research skills, better reasoning abilities and a greater breadth of knowledge

Wilkinson et al Are differences between graduates and undergraduates in a medical course due to age or prior degree? Medical Education 2004; 38: 1141–1146

Evidence• Lack of evidence - no differences in:

– Socio-demographic characteristics– Motivation– Academic performance– Research outcomes (Rolfe et al 2004, Elliott & Epstein 2005)

• Career preferences– More likely to choose GP (more significant in men)– More likely to be influenced by domestic circumstances

(Goldacre et al 2007)• Age or prior degree?

– Most benefits associated with prior degree no longer significant when age at entry taken into account

– Co-operativeness is sole outcome where prior degree was the only predictor (Wilkinson et al 2004)

“2 in 1”

• The Bristol Graduate-Entry Programme• Anatomy• Timetabling• Finances• Other students

Life as a medical student

• The waiting game• Commuting to academies• Jumping through hoops• Lack of role• TLHP students• Money

Dr Pocock

• Hoop jumping continues• Impact of EWTD• Specialty training applications• Regrets?

Have you changed your mind?

Medicine should be graduate-entry only…Yes or No?

Love it or hate it?

What is a portfolio?“A professional development portfolio is a collection of material, made by a professional, that records, and reflects on, key events and processes in that professional’s career” (Hall, 1992)

“Above all else the Trainee ePortfolio is where the GPStR records their learning in all its forms and settings. Its prime function is to be an educational tool that will record and facilitate the management of the journey of clinical and personal development through learning. It is the system used to record the evidence collected through the application of the WPBA tools. It might be described as the “glue” which holds the curriculum learning and assessment together. ” (RCGP website)

Hall D (1992) Professional development portfolios for teachers and lecturers, British Journal of In Service Education, 18, pp 81-86.

Using portfolios to maximise learning:

• Planning to meet the learner’s needs• Capitalise on and capture opportunistic

learning moments• Use assessment to drive learning in the right

direction• Provide useful feedback

Using portfolios to maximise learning:

• Planning to meet the learner’s needs• Capitalise on and capture opportunistic

learning moments• Use assessment to drive learning in the right

direction• Provide useful feedback

3 steps to good clinical teaching

A clinical teaching story…Helen is a GPST2 and is a month into her 6 month GP placement. She is asked, by the practice nurse, to carry out a cervical smear on a patient because she is struggling with it.Helen approaches the task with some anxiety, she is not confident to perform the procedure and feels her skills are still fairly weak. Nevertheless, she prepares the equipment and approaches the patient.The patient notices Helen’s concern and asks her if she feels comfortable proceeding. She admits that she does not, and agrees to fetch her trainer, Bridget. About 5 minutes later Bridget arrives ready to perform the procedure. Helen appears embarrassed that she has ‘failed’ to perform the procedure and allows Bridget to begin. Bridget is only too happy to do this: she has a waiting room full of her own patients to see.Before putting on gloves, Bridget prepares the equipment. Helen hangs back at the end of the couch. As Bridget picks up the speculum, Helen begins to walk away, disappearing behind the curtain…

Planning

Task• In your group, read the ‘Planning’ card you

have been given;• How could Bridget and Helen have changed

their experience using what you know about planning?

• How could the portfolio have been used as a tool in this instance?

Using portfolios to maximise learning:

• Planning to meet the learner’s needs• Capitalise on and capture opportunistic

learning moments• Use assessment to drive learning in the right

direction• Provide useful feedback

Missed opportunities

• Talk to another member of the group

• When did they last have the chance to teach, but did not do so?

• What was the scenario?• What stopped them from

teaching?

Some teaching strategies

Some teaching strategies

How would you teach from this case?

The one minute teacher

• Learner interviews and examines a patient, then presents the information to the teacher;

• Takes approximately 10 minutes;• Only 1 minute is spent on valuable discussion:

What does the teacher do differently?

A structured model

1. Listen to the case2. Get a Commitment3. Probe for Supporting Evidence4. Reinforce What Was Done Well5. Give Guidance About Errors and Omissions6. Teach a General Principle7. Conclusion

1. Listen to the case

• What does the learner choose to focus on?• What do they miss out? Why?• What are they concerned about?• What should they be concerned about?

• What do you know about what the learner’s needs are?

2. Get a commitment

• Push the learner beyond their level of comfort;

• Gain insight into the learner’s reasoning.

• What might be an appropriate question?

You could ask:

• “What do you think is going on with this patient?”

• “What other diagnoses would you consider in this setting?”

• “What tests do you think we should get?”• “How do you think we should treat this patient?”• “Do you think this patient needs to be

admitted?”• “Based on the history you obtained, what parts

of the examination should we focus on?”

3: Probe for supporting evidence

• Resist the urge to pass immediate judgement on their response;

• Explore what the basis for their opinion was;• Try to understand the learner’s clinical

reasoning.

• What might be an appropriate question?

You could ask:

• “What factors in the history and examination support your diagnosis?”

• “Why would you choose that particular medication?”

• “Why do you feel this patient should be admitted?”

• “Why do you feel it is important to do that part of the examination in this situation?”

4: Reinforce what was done well

• The learner needs to know what they do well!• Try to avoid general statements of praise, eg.

“You did well with this patient”.• Try to include specific examples of actions

that demonstrated knowledge skills or attitudes which you think the learner did well.

• Praise the learner for something, and they’ll probably repeat the behaviour.

5: What could be improved?

• There is a difference between telling the learner what was “bad”, and telling them what areas they could improve upon;

• Try to be specific about areas for improvement;

• Try to suggest alternative actions;• If nothing occurs to you, ask the learner what

they think!

6: Teach a general principle

• What could the learner take from this case to apply to their next?

• As an experienced clinician, what general principles does this case suggest to you?

• Try to move learning from specific isolation towards general synthesis;

• What other learning does this case draw upon?

7: Conclusion

• What should the learner do next?• What areas should they focus on next?• What would you like them to look for next

time?• How should the management of the patient

progress, and what is the learner’s role in this?

Practise

1. Listen to the case - presenter2. Get a Commitment - challenger3. Probe for Supporting Evidence - inquisitor4. Reinforce What Was Done Well - good cop5. Give Guidance About Errors and Omissions –

bad cop6. Teach a General Principle - guru7. Conclusion

Some teaching strategies

Some teaching strategies

Illness and teaching scripts

• Illness scripts– The typical symptoms and

physical findings,– The predisposing factors that

place the patient at risk of the illness under consideration, and

– The pathophysiological problem that results in the symptoms the patient describes and the examination reveals.

• Teaching scripts– Three–five key points with

illustrations,– An appreciation of common

errors learners encounter, and

– Effective ways of creating frameworks for beginners to build their own 'illness scripts' in memory

Clinical teaching: an example

• What does Mr Whitman do well?• How would you alter his practice?• How might a ‘teaching script’ help him?

Task

• Work in pairs• Decide on 3 skills or areas you teach on most

often• Choose one of these: write a ‘teaching script’

for the event

Using portfolios to maximise learning:

• Planning to meet the learner’s needs• Capitalise on and capture opportunistic

learning moments• Use assessment to drive learning in the right

direction• Provide useful feedback

Challenging assumptionsIndependent Dependent

variablevariable

Traditional: Learning Examination

Sneider: Examination Learning

(The Hidden Curriculum)

Case-based discussion

“A structured interview designed to explore professional judgement exercised in clinical

cases which have been selected by the GPStR and presented for evaluation”

Use of questioningClick to Watch on line

Task

Draw Bloom’s taxonomy (cognitive domain) onto a flip chart and write in examples of questions appropriate for each level

Applying Bloom to ‘Goldilocks & the Three Bears’

• Knowledge: List the items used by Goldilocks in the bears’ house

• Comprehension: Explain why Goldilocks liked Baby Bear’s chair the best

• Application: Demonstrate what Goldilocks would use if she came to your house

• Analysis: Think about the unreal parts - which emotions might they represent?

• Synthesis: How would the story be different if it were Goldilocks and the 3 Fish?

• Evaluation: Was Goldilocks good or bad? Defend your opinion

Consultation observation tool

“The starting point for this assessment is either a video recorded consultation or a consultation directly observed by the trainer. In either case

the observation should generate discussion and feedback for the GPStR and yield evidence

which will be recorded in the Trainee ePortfolio.”

COT

“Feedback is the single aspect that makes work-based assessments educationally meaningful. It is effective

feedback, and not the evaluation, that promotes growth in the trainee's clinical skills.”

Forrest, K., Cooper, N. and Belfield, P. (2006), Introducing Foundation Programmes.

The Clinical Teacher, 3: 238–241

How not to give feedback...

Improve the feedback

• Look at the poor feedback speech bubbles and discuss what’s wrong with each – try briefly to improve it.

• Match each example with the more helpful version.

• Now look at the sheet ‘More poor feedback’. Discuss why it is unhelpful feedback and how you might improve each one.

Feedback to less than perfect students: ‘openers’

• “Are you finding … a bit difficult?”• “There is something you really need to

address”• “It’s not easy to … when I was a registrar I …”• “I noticed that you didn’t manage to …”• “What did you think about how you did …?”

Any more?

Scenarios

• In 3s with an observer• Take it in turns to be tutor/student/observer• Think briefly about your attitude/approach

before starting the role play• De-brief after each one.• Observer – note positive points/ideas for

improvement.

Summary

• Fail to prepare, prepare to fail• Make the most of learning opportunities• Assessment is of little use without timely

feedback• The portfolio can be used as a tool to help all

these processes (with a little imagination!)

What will you do differently after today?

THANK YOU