Transcript The registrar in difficulty - gp

The Registrar in
Difficulty
Prevalence 6-9%
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Lack of knowledge 48%
Poor judgement 44%
Inefficient use of time 44%
Attitudinal, interpersonal conflict,
family stress, psychiatric illness,
substance abuse
A tidy model and strategy for
helping the registrar in difficulty?
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Afraid not!
Disjointed selection of thoughts and
observations
A fine judgement….
To support a registrar and help them through a difficult time,
or your duty to avoid perpetuating a problem….
…..what really is in their best interest???
Crucial to this is deciding if there really is a problem or not,
which is not easy
Anticipated progress
Performance
Time
…having identified that there
is/may be a problem….
1. Inform/involve course organiser, partners,
registrar etc.
2. Make a diagnosis – characterise the problem
3. Structured intervention
1. Inform and involve (responsibilities)
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Education provider (your practice) employment law, educational responsibilities,
safety etc.
VTS – as above, counselling, psychology
involvement, careers advice etc.
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Deanery – governance, financial
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NCAS – performance assessment
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GMC – fitness to practice
2. Characterise the problem
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Describe and diagnose
Often intuitive sense of ‘something wrong’, but
characterising the problem is much less easy
How do you characterise
the problem?
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What is the problem? (may be really difficult to answer)
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History of the learner – academic, social and psychological
History of the problem
Is it a problem that needs to be fixed?
Ascertain the learners views and insight into the problem
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Where does the problem lie?
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What’s the problem?
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Superficial description – what is a
symptom and what is a diagnosis?
Poor performance is a symptom, not
a diagnosis
Deeper diagnosis may be a lot more
difficult – may be multi-factorial
To maximise learning…
Guidance
Time
Problem solving ability
Intellect
Organisation
Memory
Facilities
Reflection
Concentration
Relate learning to experience
Strategy for learning
Grounding knowledge
Commitment
Opportunity
Interest
Stimulation/challenge
Motivation
Willingness
Imagination
Incentive
Absence of confounding factors
Insight
Just get on with it!!
Environment and tools for learning and
development of knowledge.
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Grounding knowledge
(knowledge)
Concentration
Memory
Intellect
Problem solving ability
Organisation
Reflection
Imagination
Insight into own ability
Strategy for learning
Relate learning to experience
(skills)
Motivation/incentive
Commitment
Willingness
Interest
(attitudes)
But environment also important…
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Opportunity
Guidance
Time
Facilities
(learning/educational environment)
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Absence of confounding factors
(psychological, social, physical environment)
Steinert 2008:BMJ 336, 150-153
Where does the
problem lie?
Unsupportive
Overly critical
Unreasonable expectations
Disinterested
Non challenging
Failure to meet learner’s needs
Knowledge
Skills
Attitudes
Learner
Teacher
Work
(e.g. workload, unsupportive staff)
Social
(e.g. marital, financial)
Personal
(e.g. substance abuse, illness)
Training
(e.g. unsupportive VTS, lack of guidance)
Environment
Going to focus on problems with the learner
(because that is the subject of this workshop)
Models of learning
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Androgogy
Experiential Learning Theory
Bloom’s Taxonomy
Androgogy vs. pedagogy
Pedagogy
Need to know
Know that they must
know what the
teacher teaches
Androgogy
Need to understand
relevance before
learning
Learner’s self-concept That of a dependent
personality
Responsible for own
decisions and actions
Role of experience
Experience of limited
value to learning
process
Value and use own
experiences in
learning
Readiness to learn
Ready to learn what
Ready to learn what
the teacher tells them they need to know
Orientation to
learning
Topic oriented
learning
Life centred, problem
centred learning
Motivation
External motivation
(exams etc.)
Internally motivated
(self improvement
etc)
Experiential learning theory
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Jung
Kolb
Honey and Mumford
Concrete Experience
How do we learn?
Feeling
The Learning Cycle
Accommodating
Processing
Perception Continuum
Active
Experimentation
Doing
how we think about things
MB – Feeling-thinking scale
(feel and do)
HM - Activist
Diverging
(feel and reflect)
HM - Reflector
Continuum
how we
do things
MB – extroversion-introversion scale
Converging
(think and do)
HM - Pragmatist
Assimilating
(think and reflect)
HM - Theorist
Abstract
Conceptualisation
Thinking
Reflective
Observation
Reflecting
Blooms taxonomy
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3 domains – cognitive, psychomotor,
affective
Hierarchies in each domain, starting
with most basic, ascending to most
developed
Bloom’s Taxonomy – cognitive domain
High cognitive
demand
Evaluation
Fully functional knowledge
Synthesis
Learner has to make deep
connections and meaning
Analysis
Application
Low order skills
Comprehension
Low cognitive
demand
Knowledge
These are a means to
achieving fully functional
knowledge
Levels of cognition
Cognitive level
Sample activities
Evaluation
Appraise, critique, evaluate, justify
Synthesis
Compose, create, design, devise
Analysis
Compare, contrast, differentiate, relate
Application
Demonstrate, construct, prepare, predict
Comprehension
Summarise, interpret, explain, translate
Knowledge
Recall, reproduce. identify, match
3. Structured intervention
Structured intervention
Directed at the source of the problem (learner,
environment, teacher) and to the nature of the problem
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Change the environment (training practice etc.)
Change the trainer
Draw up a learning contract
Define objectives, communicate expectations
Additional teaching/support, mentoring
Counselling, sick leave
Further information gathering (psychology report, previous
teachers, etc.)
Reduce workload
Protected time
Regular feedback on progress against agreed objectives
Dismissal…..in association with careers advice, support,
constructive feedback etc., etc!
Learning plan/contract
States…
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What will be learned
How it will be learned
What resources are needed
How learning will be measured
How long it will take
Joint responsibility, between trainer and registrar
What have I been doing differently?
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Informed partners and PM but no other staff
Contract of educational objectives
Monthly review of performance compared to agreed objectives
Doing greater proportion of seminars myself
Fewer topic based seminars and more seminars focused on eP and PDP
More proactive in teaching, rather than reactive
Very specific learning tasks, in small chunks, working up the cognitive ladder of
Blooms taxonomy, but tending to stick at lower end of cognitive hierarchy
Tendency to challenge more and take less for granted
Review all consultation records
Screen all referrals before sending
Markedly reduced registrar workload
Few home visits
All Cuedoc shifts supervised
More joint surgeries
More proactive in seeking feedback from colleagues
Exhaustive record of discussions from structured teaching sessions
Documentation in form of daily diary
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Switch emphasis from training in general practice to training to learn and study
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Contract of educational and
performance objectives
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Undergo assessment by educational psychologist
CBD every month
COT every month
All referrals to be recorded on eP
Weekly joint consulting session
All learning points to go onto learning log
All learning objectives onto PDP
All PDP entries to be SMART
Self appraise at least one video every week and
record on eP
(Takes a lot of time though)
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Evidence and objectivity at all stages
Documentation and record-keeping
Regular appraisal and feedback
Fairness
Confidentiality
90% of problem learners succeed after
structured intervention
Trainers responsibilities
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Raise concerns
Clarify nature of the problem
Manage safety
Maintain confidentiality
Design and deliver intervention
Measure outcomes
Give feedback
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To trainee - to train, not to assess (formative not summative)
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To scheme/deanery - to give objective feedback, backed up
by comprehensive documentation
Other considerations….
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Your own workload
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Partners workload
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Reimbursement
Useful starting points
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Recent series in BMJ
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Northern Deanery website
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National Association of Clinical Tutors
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www.gp-training.net
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