Learning clinical medicine in workplaces

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Learning clinical medicine in workplaces

• Tim Dornan

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PBL

• Anatomy knowledge differs between medical schools
  but not between PBL and non-PBL curricula
• Prince et al 2003
• Manchester graduates are more fit for practice
  since adoption of PBL
• Jones et al 2002 ONeill et al 2003
• Sherbrooke PBL graduates offer better referral
  for mammography, continuity of care, and
  prescribing
• Tamblyn et al 2005

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PBL an RD agenda

• Theorised, bench-tested, and validated
• Translational research
• Sustainability
• New blood tutors
• Behavioural, social, and biomedical scientists
• Clinicians
• Northwest sector
• Health economy
• MMC and trainees

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Problems with applying PBL principles to clinical
setting

• MASTERY and APPRENTICESHIP
• Clinicians wanted to share their mastery with
  apprentices rather than facilitate integrated
  learning as a PBL tutor and learners wanted
  that too
• DISINTEGRATION
• In FCM, paediatricians and gynaecogists found
  common ground in not wanting to include breast
  disease (surgery)

Dornan 2006
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Problems with applying PBL principles to clinical
setting

• DIRECTION
• Community tutors criticised (hospital) PBL tutors
  because students came to community day without
  objectives
• Hospital teachers were bitterly disappointed by
  students lack of self direction

Dornan 2006
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Simulation (Skills training and PBL)

• Simplification to bring learning under control
• An important step towards reality
• Not an end in itself
• Learning must be transferred to reality
  through
• Modelling
• Scaffolding
• Coaching
• Collaborating
• Fading

Dolmans et al 2004
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PBL vs clinical learning

• PBL
• Controlled
• Trigger artefact
• Context safe and simple
• Safety in numbers
• Relationship teacher subordinate to learners
  needs

• Clinical learning
• Uncontrolled
• Trigger reality
• Context dangerous and complex
• Isolation or danger in numbers
• Relationship teacher in charge

Dornan 2006
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Workplace learning
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Virtuous triangle of mastery
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Practice vs teaching

• Outpatients is wonderful for cardiology but
  youve got to see so many patients. They might
  have murmurs but you might not be getting them on
  and off the bed particularly if theyve had their
  echocardiogram the week before. Therefore, if you
  are going to use them as teaching cases, you are
  doing extra things

Dornan et al 2005a
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Clinicians narratives of teaching and learning

• DISENFRANCHISEMENT
• Unaware of curriculum ILOs
• Confused about whats expected of them
• Narratives of teaching and practice completely
  divorced from one another
• Dominance of
• Clerking
• Exotic physical signs
• Hospital inpatient setting

• ve ATTITUDES towards
• Learning
• Learners as eager and able people
• Forming relationships with learners
• Workplace learning

Dornan et al 2005a
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The self directed learner

• We need a framework to know where we are going
  because we are adjusting to clinical medicine and
  it is so vast that we do not really know what we
  have got to learn or what we have to get out of
  this semester
• I just thought "well I don't know what I need to
  do", so I put more hours in, but they weren't
  productive, effective hours, because I was
  casting around trying to kind of get hold of
  something that I needed to know

Dornan et al 2005b
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(No Transcript)
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Direction or motivation?

• I think you really need to make a
  differentiation between self-direction and
  self-motivation. The objectives for this
  particular module (are) our direction, but it
  is up to us to pursue that
• It is like being provided with a map. Suddenly
  you are able to take some control, which is a big
  change

Dornan et al 2005b
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Key lessons

• DIRECTION
• Students learned better when supported
• Direction was an important source of support
• ACTIVITIES
• Optimum condition for clinical workplace learning
  was supported participation beside a master

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ExBL Experience based learning Social theory
of clinical workplace learningComplements PBL
and skills training
Doctor
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I predict that medical students will learn best
in workplaces if we
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• Offer guidance on appropriate objectives ..
• Prepare students and titre them in to ..
• Supportive learning environments ..
• In as near a 111 relationship as possible ..
• Where they can participate in practice to the
  benefit of patients ..
• And grow into the identity and role of a doctor
  ..
• By being stretched and reflecting on their
  experiences

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Evidence that we need to do better

• 53 of trainees in the NW found the transition to
  foundation training stressful
• 24 felt they had insufficient knowledge
• 20 felt they had inadequate skills
• 45 did not feel confident to start training
• 29 did not feel they were truly a doctor 4
  months after entering FP

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Evidence that we need to do better

• I felt I was well prepared by being given so much
  responsibility in final year, particularly on my
  elective, and on European Option placement in
  Switzerland, where doctors have much higher
  expectations of students than in Manchester