Transcript South Bristol Trainers Workshop 2011 Saunton Sands

South Bristol Trainers Workshop 2011
Saunton 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
Prepare: when and how will
you teach?
Teaching methods: how will
you actively involve learners?
Review: how will you evaluate
and reflect on your 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
Clarifies
expectations
Clarifies roles
and
responsibilities
Sets aside time
for teaching and
feedback
Focuses learners’
priorities and
tasks
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
Using questions
to diagnose: the
OMP model
Sharing ‘illness
scripts’ and
‘teaching scripts’
Using other
learners as
teachers
Asking for
feedback
The informal
‘clinical
conference’
Role modelling
Some teaching strategies
Using questions
to diagnose: the
OMP model
Sharing ‘illness
scripts’ and
‘teaching scripts’
Using other
learners as
teachers
Asking for
feedback
The informal
‘clinical
conference’
Role modelling
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.
2.
3.
4.
5.
6.
7.
Listen to the case
Get a Commitment
Probe for Supporting Evidence
Reinforce What Was Done Well
Give Guidance About Errors and Omissions
Teach a General Principle
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.
2.
3.
4.
5.
Listen to the case - presenter
Get a Commitment - challenger
Probe for Supporting Evidence - inquisitor
Reinforce What Was Done Well - good cop
Give Guidance About Errors and Omissions –
bad cop
6. Teach a General Principle - guru
7. Conclusion
Some teaching strategies
Using questions
to diagnose: the
OMP model
Sharing ‘illness
scripts’ and
‘teaching scripts’
Using other
learners as
teachers
Asking for
feedback
The informal
‘clinical
conference’
Role modelling
Some teaching strategies
Using questions
to diagnose: the
OMP model
Sharing ‘illness
scripts’ and
‘teaching scripts’
Using other
learners as
teachers
Asking for
feedback
The informal
‘clinical
conference’
Role modelling
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 assumptions
Independent
variable
Dependent
variable
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 questioning
Click 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