Mould or nurture?

Abraham Kuijper (known often as Kuyper) (1837-1920) was a Dutch politician, journalist, statesman and theologian. He was prime minister of the Netherlands between 1901 and 1905. Kuijper was particularly interested in education during his political life. Kuijper explored the difference between forming (as in moulding) and nurturing in education.
Let's take a tree sapling as an example: it might be possible to trim the roots and the branches and produce a beautifully formed bonsai. Alternatively we could give the sapling some fertiliser and just let it grow under its influence.
What sort of GP are we trying to train? I wonder if the current trend towards moulding in GP training (eportfolio rules, quality assurance, rigidity and a top-down management style) has lost its way just a little to the nurturing that trainers naturally do - providing the fertiliser. Perhaps the GMC and the RCGP – and all of us educators - might reflect on Kuijper's thoughts.

Some thoughts from a colleague

Well, of course on-line learning is going to take over.
Not just because the RCGP has got some enormous DoH contract to write the silly stuff.
But as you will know, university lecturers and schoolteachers have been made redundant in their droves, so effective is online learning.
It’s especially good for teaching teamwork skills, moral reasoning, and communication skills.
We’ll all be out of a job by next Christmas.
Bah.
Humbug, even.

More seriously, as someone increasingly able to look back on decades of educational development, it is wonderful to see how every 5 to 10 years, a new technology appears which is absolutely going to solve all educational problems, whatever they may be.
1960: setting behavioural objectives  programmed texts
1965: teaching machines (tape slide)
1970: audio tape cassettes
1975: video tape cassettes
1980: video discs
1985: CDs
1990: computers
2000: the internet
2005: integrated CBI

All of these have attracted hordes of enthusiasts and lodsa govt money. And the result?
But it gives boys something to do.

The CSA and "revision"

I hear of GPRs "revising" for the CSA. I wonder what they are doing in that learning space. The CSA is testing what the GPR does on a day-today basis in the consultation. It strikes me that the best way to pass this exam is to see patients, reflect on the process, define the learning needs, address those needs, then try them out - the learning cycle. Becoming competent requires this upward learning spiral, and the eportfolio makes the process explicit. I'm not sure that "cramming" is going to help.

Hospital clinical supervisors and the eportfolio

The hosp clinical supervisors have a hard task. It may not be feasible....

They may focus on GPRs being “good eggs” generally and mark them as competent or excellent, which they are not, in eportfolio terms, as they are not being ranked in competency terms as an independent GP as the WBPA requires, but as an ST1 or ST2 trainee. There is no solution to this as far as I can see, because if, say, a GPR is doing an ENT post, at the end of it he is being assessed by the ENT clinical supervisor as competent in ENT for general practice, not as a competent GP in every respect.

This makes this are of the WBPA unfit for purpose as it currently stands. I think we need to have different approaches to hospital clinical supervision feedback of competencies, therefore. The hospital clinical supervisors feedback comments are “naturally occurring evidence” and should be viewed by the educational supervisor in this light, and his advice to the ARCP panel moderated accordingly.

Flash points and Balint

Champagne moments
Or…
Even champagne has unwanted effects

Flash points

Balint described the flash technique where doctors become aware of their feelings in the consultation and sometimes interpret the feelings back in a way that can give the patient some insight into the problems that are presented.

This applies to teaching GPRs too
Teacher gets emotional feedback > encourages him to continue


Danger – GPR is very vulnerable > the apostolic function (P216 of "Doctor, patient illness")

It is almost as if every (doctor) trainer had revealed knowledge of what was right and what was wrong for (patients) registrars to expect and endure, and further, as if he had a sacred duty to convert to his faith all the ignorant and unbelieving amongst his (patients) registrars.

….if asked, he will readily quote impressive reasons for his choice, but these on closer examination reveal themselves to be secondary rationalsations.


“Practice” = “habitual action”
Vs
Showing humanity – we all make mistakes


“Trainer as drug”
Vs
Modelling


In spite of our almost pathetic lack of knowledge about the dynamisms and possible consequences or “reassurance” and “advice”, these two are perhaps the most often used forms of medical treatment (p116)

“Simple supportive treatment”, “advice”, “reassurance” in dealing with GPRs with problems > our need to make it right
Vs
Appropriate challenge, devolvement of responsibility fro problems and actions
(but what about mental health issues?)

gp-training.net blog: Preparing the ground for the educational supervisors report

gp-training.net blog: Preparing the ground for the educational supervisors report

Preparing the ground for the educational supervisors report

The first deanery panel is coming up for Februay PR finishers, yet there is little published about the content or process of the educational supervisors interview. My thoughts are here.

Plus ca change

The Tooke report disturbed me more than a little. After having gone through a huge chunk of change in GP vocational training, this report all but suggests that we start again. I have just about got to the stage of stability with the VTS that I lead. What we need now is a period of consolidation, quality assurance and considered development. Certainly the Association of Course Organisers (ACO) was not consulted prior to the report's publication, yet it focuses heavily on GP training. Maybe it is about time change was educationally rather than politically (ie reactively) led.

COT to Calgary Cambridge

The nMRCGP COT criteria are derived from the summative old MRCGP video criteria, so may not necessarily be the appropriate springboard for the behavioural change needed when developing communication skills.

The big question for trainers, then: when using a COT to assess a video, how do we triangulate the simple COT criteria with the Calgary Cambridge criteria.

This table points to the Calgary Cambridge criteria for each COT criterion (although in practice most Calgary-Cambridge criteria will apply in some way to each COT criterion, it is not a straightforward linear relationship!). Each learning need may therefore cascade into other Cal-Cam areas, and the skill of the educator is in developing this.

The two sets of criteria in question here are trying to do different things, and are looking at the consultation from a different perspective. By moving the focus from Cot to Cal-Cam, we can explore the behavioural skills needed to allow improvemnt in the COT "score".

Report from the ACO Conference, May 2007

A successful conference at Cumberland Lodge, Windsor, focusing on the use of humanities in teaching. Some resources will become available over the next few weeks at www.aco.org.uk.
Those of you who know Paddy McEvoy (who wrote “Educating the Future GP”) will be sorry to hear of his imminent retirement from GP education. The ACO, with Paddy’s blessing, are planning a significant bursary to fund educator time to produce a new edition of this book. Please contact admin@aco.org.uk for further details.
Trainers could join the ACO and therefore receive the Green Journal at a much lower price. The ACO membership numbers are reduced, though this is in part related to a 10% drop in the number of course organisers employed in the UK in the last 2 years. This has been particularly focussed on one or two Deaneries who have made redundancies.
The Da Vinci programme provides grants to allow vocational exchanges to the EU. More details at http://www.ets-lichfield.com/english/index.html

The curriculum and the nMRCGP
Many COs had not seen the e-portfolio and were not clear how this fitted into the WBPA and the training throughout the 3 years. Some schemes have moved to a final 12 months in GP and some Deaneries are not yet able to provide 18 months in GP. A few schemes were planning to use COs as educational supervisors, but trainers were to be targeted as educational supervisors in most areas. There was unanimity in the need to reimburse trainers appropriately for this extra work. Benchmarking and QA of the WBPA and the CSA is needed throughout the country, and although the RCGP are planning this, the consensus was that we needed to act on this issue locally and soon.

Increasing the ACO’s impact on national change
The ACO will explore closer links with NAPCE, the UKCEA and the putative national trainer group body (which is being proposed by the BMA), perhaps developing a joint representative body which may carry more political weight than the constituent organisations.

The ACO questionniare
The questionnaire, which were endorsed by the feelings of the ACO delegates at the conference, can be viewed at http://www.aco.org.uk/news/questionnaire_2007.htm

Future ACO conferences
The ACO Conference 2008 has been booked for Wednesday 4 – Friday 6 June at Madingley Hall, Cambridge. The 2009 conference is being run by the Northern Deanery.

I have always enlisted the help of the GPR in writing their reference. We talk about their strengths and the areas that they could develop. We discuss what they can offer a practice. Together, we formulate the reference. This results in a truly open and honest document. Read the detail at http://www.gp-training.net/training/gptrainer/writing_reference.htm

Welcome to the gp-training.net blog. I am not yet quite sure what I am going to do with this, but thought a weblog might be worth a bit of exploration.