The Registrar in Difficulty

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The Registrar in Difficulty
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Prevalence 6-9

• Lack of knowledge 48
• Poor judgement 44
• Inefficient use of time 44
• Attitudinal, interpersonal conflict, family
  stress, psychiatric illness, substance abuse

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A tidy model and strategy for helping the
registrar in difficulty?

• Afraid not!
• Disjointed selection of thoughts and observations

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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

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Anticipated progress
Performance
Time
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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

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1. Inform and involve (responsibilities)

• Education provider (your practice) - employment
  law, educational responsibilities, safety etc.
• VTS as above, counselling, psychology
  involvement, careers advice etc.
• Deanery governance, financial
• NCAS performance assessment
• GMC fitness to practice

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2. Characterise the problem

• Describe and diagnose

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• Often intuitive sense of something wrong, but
  characterising the problem is much less easy

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How do you characterise the problem?

• What is the problem? (may be really difficult to
  answer)
• 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
• Where does the problem lie?

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Whats the problem?

• 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

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To maximise learning
Time
Guidance

Problem solving ability
Intellect
Organisation
Reflection
Memory
Facilities
Concentration
Relate learning to experience
Strategy for learning
Grounding knowledge
Commitment
Opportunity
Interest
Stimulation/challenge
Imagination
Motivation
Incentive
Absence of confounding factors
Insight
Willingness
Just get on with it!!
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Environment and tools for learning and
development of knowledge.

• 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

• But environment also important
• Opportunity
• Guidance
• Time
• Facilities
• (learning/educational environment)
• Absence of confounding factors
• (psychological, social, physical environment)

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Steinert 2008BMJ 336, 150-153
Where does the problem lie?
Unsupportive Overly critical Unreasonable
expectations Disinterested Non challenging Failure
to meet learners needs
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)
Knowledge Skills Attitudes
Learner
Environment
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• Going to focus on problems with the learner
• (because that is the subject of this workshop)

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Models of learning

• Androgogy
• Experiential Learning Theory
• Blooms Taxonomy

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Androgogy vs. pedagogy
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Experiential learning theory

• Jung
• Kolb
• Honey and Mumford

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How do we learn?
Concrete Experience Feeling

• The Learning Cycle

Diverging (feel and reflect) HM - Reflector
Accommodating (feel and do) HM - Activist
Perception Continuum how we think about
things MB Feeling-thinking scale
Reflective Observation Reflecting
Active Experimentation Doing
Processing Continuum how we
do things MB extroversion-introversi
on scale
Assimilating (think and reflect) HM - Theorist
Converging (think and do) HM - Pragmatist
Abstract Conceptualisation Thinking
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Blooms taxonomy

• 3 domains cognitive, psychomotor, affective
• Hierarchies in each domain, starting with most
  basic, ascending to most developed

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Blooms Taxonomy cognitive domain
High cognitive demand
Evaluation
Fully functional knowledge Learner has to make
deep connections and meaning
Synthesis
Analysis
Application
Low order skills These are a means to achieving
fully functional knowledge
Comprehension
Low cognitive demand
Knowledge
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Levels of cognition
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3. Structured intervention
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Structured intervention
Directed at the source of the problem (learner,
environment, teacher) and to the nature of the
problem

• 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!

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Learning plan/contract

• States
• 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

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What have I been doing differently?

• 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
• Switch emphasis from training in general practice
  to training to learn and study

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Contract of educational and performance objectives

• 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

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Trainers responsibilities

• Raise concerns
• Clarify nature of the problem
• Manage safety
• Maintain confidentiality
• Design and deliver intervention
• Measure outcomes
• Give feedback
• To trainee - to train, not to assess (formative
  not summative)
• To scheme/deanery - to give objective feedback,
  backed up by comprehensive documentation

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Other considerations.

• Your own workload
• Partners workload
• Reimbursement

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Useful starting points

• Recent series in BMJ
• Northern Deanery website
• National Association of Clinical Tutors
• www.gp-training.net

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(The End)