Aspiring to Excellent Medical Practice

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Aspiring to Excellent Medical Practice

• - The role of the doctor the implications for
  postgraduate medical education and doctors in
  training

Professor David Sowden SRO MMC
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When a man reasoneth, hee does nothing else but
conceive a summe totall, from addition of
parceles or conceive a remainder, from
subtraction of one summe from another.for
reason.is nothing but reckoning.
Thomas Hobbes 1588-1679 Leviathan
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Why are we here there is currently no
strong consensus on the role of the
doctor at various career stages the
policy objective of postgraduate medical
training is unclear.
Sir John Tooke Aspiring to excellence
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And!

• consensus on the role of the doctor needs
  to be reached by the end of 2008 (and the
  service contribution of trainees better
  acknowledged)

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The expert medical clinician

• distilling and dealing with complexity
• ability to make decisions in the face of
  (considerable)
• uncertainty and/or difficult circumstances
• effective and efficient problem solving
• taking legitimate risk via a process of
  professional judgement
• capability to lead in clinical settings,
  especially in emergency
• situations
• capability to demonstrate an intuitive grasp of
  clinical situations
• based on a deep, tacit, understanding of the
  specialist or
• generalist areas of practice
• capacity for intellectual leadership

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• a commitment to evidence based innovation in
  clinical
• care, and to establishing an evidence base
  where none
• or insufficient evidence exists
• commitment to the health of the population as
  well as
• the individual patient
• capability to support patients through the
  clinical
• pathway for example as care navigator and as
  an expert
• translator
• commitment to patient safety
• technical expert (relevant to some specialties
  only)
• experience

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Current problems with postgraduate medical
education (not exclusive !)

• language and meanings poorly understood
  (competence, competences, competency)
• trainer preparation and time to train, supervise
  and assess
• doctors are either trained or not trained
• time (Calman, MMC, EWTD, New Deal etc)

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Current problems continued

• Competence paradigm risks creating an inflexible,
  reductionist approach to professional learning.
• Does it aspire to produce expert practitioners,
  partners and leaders?

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Consequences

• Since assessment drives learning competence
  acquisition may become a tick box exercise
• Focus moves to ensuring competency but not
  proficiency or expertise
• Language needs clarifying
• Competences may be acquired but at expense of
  confidence and experience

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The medical professional is ..someone with a
wide range of interventions available and who can
move cleanly and elegantly amongst them. Cleanly
and elegantly I like that we dont see the
joins or hear the machinery creaking. The least
we owe trainees is to keep the possibility of
this delight and elegance alive and to defend
time and space to discover them.
ROGER NEIGHBOUR The Inner Consultation
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Millers Pyramid

Does
Performing
Shows how
Competent
Knows how
Knowledge/understanding
Knows
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Summary of the Dreyfus Model of Skills Acquisition

• Level 1 Novice
• Rigid adherence to taught rules or plans
• Little situational perception
• No discretionary judgement
• Level 2 Advanced Beginner
• Guidelines for action based on attributes or
  aspects (aspects are global characteristics of
  situations recognisable only after some prior
  experience)
• Situational perception still limited
• All attributes and aspects are treated separately
  and given some equal importance

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• Level 3 Competent
• Coping with crowdedness
• Now sees actions at least partially in terms of
  longer-term goals
• Conscious deliberate planning
• Standardised and routinised procedures
• Level 4 Proficient
• See situations holistically rather than in terms
  of aspects
• See what is most important in a situation
• Perceives deviations from the normal pattern
• Decision-making less laboured
• Uses maxims for guidance, whose meaning varies
  according to the situation
• Level 5 Expert
• No longer relies on rules, guidelines or maxims
• Intuitive grasp of situations based on deep tacit
  understanding
• Analytic approaches used only in novel situation
  or when problems occur
• Vision of what is possible

Eraut, M (1994) Developing Professional Knowledge
and Competence
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