What and how do general practice trainees learn in practice ? Tim Dornan

What and how do general practice trainees learn in practice ? Tim Dornan

Faculty of Health Medicine & Life Sciences – Department of Educational Development and Research

Outline of this talk

• “The fate of our times”• What do trainees learn?• How do they learn it?• What is your role?





‘The fate of our times’ Frank 2013

That, which is particular to a given historical period … and determines the fate of people who live then


‘The fate of our times’

NOUNS•Training•Competencies•Skills•Simulation•Feedback•Supervision•Assessment




DISCOURSE•Simplicity

•Outcomes

•Standardisation

•Accountability





•Outcomes

•Standardisation

•Accountability






Ski

ll ba

sed

Slip

s

Pat

ient

62,

44

Workload82,80,76, 64,61,44, 27,14,3

Rushing 82,80,76,64,

61,44,27,14,3,1

Doing >1 job at a time 64,62,44

A&E policy 44

Wanting to go home 82

Understaffed 80,64,27,3

Pressure from nurses 64

Feeling flustered 89,61

Not checking82,44,14

Poor communication with other Drs

poor 80,46

Others error/violation 46,80,14

Unknown patients 82,

62

Tired 80,64

Covering lots of wards 64

Only paid for 48 hrs 27

Ignored E rxingwarning 76

Design of E rxingsystem 76

Alert fatigue 76

Nurse 82,19,61,14

Pharmacist 3,1

On call 76

Slips (12)

Self 80,76,64,27,46

Start

Start


Ski

ll ba

sed

Slip

s

Pat

ient

62,

44

Workload82,80,76, 64,61,44, 27,14,3

Rushing 82,80,76,64,

61,44,27,14,3,1

Doing >1 job at a time 64,62,44

A&E policy 44

Wanting to go home 82

Understaffed 80,64,27,3

Pressure from nurses 64

Feeling flustered 89,61

Not checking82,44,14

Poor communication with other Drs

poor 80,46

Others error/violation 46,80,14

Unknown patients 82,

62

Tired 80,64

Covering lots of wards 64

Only paid for 48 hrs 27

Ignored E rxingwarning 76

Design of E rxingsystem 76

Alert fatigue 76

Nurse 82,19,61,14

Pharmacist 3,1

On call 76

Slips (12)

Self 80,76,64,27,46

Start

Start

Context


• Technical rationality: Using the fruits to science to solve problems

• Practice:– Problems do not present themselves to the

practitioner as givens– “Problem-setting” involves naming the

things to which we will attend, framing the context in which we will attend to them

– Practitioners “design” solutions

Approaches to problems Schön 1983


The swampy lowlands of practiceSchön 1983

• We have no satisfactory way of …accounting for the artful competence which practitioners reveal in what they do

• Complexity, uncertainty, instability, uniqueness, and value-conflict do not fit the model of Technical Rationality





Complexity•Outcomes

Process•Standardisation

Individualisation•Accountability

Emancipation





Complexity•Outcomes

Process•Standardisation

Individualisation•Accountability

Emancipation

Complexity





How do peoplelearn to do a job?


How do peoplelearn to do a job?


Study of occupational learning in early Imperial China, Hellenic Greece etcBillett 2014

• Novices engaged in work activities incrementally and progressively

• They learned by their own effort, indirectly guided by more experienced workers


Study of occupational learning in early Imperial China, Hellenic Greece etcBillett 2014

• Novices engaged in work activities incrementally and progressively

• They learned by their own effort, indirectly guided by more experienced workers

• Does that sound familiar?


How do peoplelearn to do a job?Billett 2014

Mimesis






“Mutual interdependence” Billett 2006

Learning environment

offers




offers




offers




offers

(Authentic) patient care


GP supervision – the evidence

Expert clinician

Ensures patient safety Wearne

2012



Expert clinician

Ensures patient safety

Organising•Setting the scene•Negotiating and agreeing an agenda



Expert clinician


2012



Expert clinician


Assessing•Identifying gaps•Asking stimulating questions•Making it safe to admit mistakes



Expert clinician


2012



Expert clinician


Promoting•Acting as a mirror•Providing resources (and being one)•Giving feedback including praise•Role modelling

Wearne2012



Expert clinician


2012



Expert clinician

Ensures patient safety Wearne S

2012; inpreparation

Monitoring the person•Observing practice – particularly with junior learners



Expert clinician


2012; inpreparation



Expert clinician


2012; inpreparation

Monitoring learning•Encouraging supervisee to speak•Listening intently



Expert clinician


2012; inpreparation



Expert clinician


2012; inpreparation

Summarising•Putting learning into words•Planning future sessions


Summary

• “The fate of our times” – (Over)simplification in order to regulate

• What do trainees learn?– The complexity of practice

• How do they learn it?– Work; mimesis; inviting environment

• What is your role?– Form an educational alliance


Documents

What and how do general practice trainees learn in practice ? Tim Dornan