The Trainee in DifficultyThe Trainee in Difficulty

Prevalence 6-9%Prevalence 6-9% Lack of knowledge 48%Lack of knowledge 48% Poor judgement 44%Poor judgement 44% Inefficient use of time 44%Inefficient use of time 44%

Attitudinal, interpersonal conflict, Attitudinal, interpersonal conflict, family stress, psychiatric illness, family stress, psychiatric illness, substance abusesubstance abuse

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

Afraid not!Afraid not!

Disjointed selection of thoughts and Disjointed selection of thoughts and observationsobservations

A fine judgement….A fine judgement….

To support a registrar and help them through a difficult time, To support a registrar and help them through a difficult time, or your duty to avoid perpetuating a problem….or your duty to avoid perpetuating a problem….

… …..what ..what reallyreally is in their best interest??? is in their best interest???

Crucial to this is deciding if there Crucial to this is deciding if there reallyreally is a problem or not, is a problem or not, which is not easywhich is not easy

Anticipated progressAnticipated progress

Time

Performance

……having identified that there having identified that there is/may be a problem….is/may be a problem….

1. Inform/involve course organiser, partners, 1. Inform/involve course organiser, partners, registrar etc.registrar etc.

2. Make a diagnosis – characterise the problem2. Make a diagnosis – characterise the problem

3. Structured intervention3. Structured intervention

1. Inform and involve (responsibilities)1. Inform and involve (responsibilities)

Education providerEducation provider (your practice) - employment (your practice) - employment law, educational responsibilities, safety etc.law, educational responsibilities, safety etc.

VTSVTS – as above, counselling, psychology – as above, counselling, psychology involvement, careers advice etc.involvement, careers advice etc.

DeaneryDeanery – governance, financial – governance, financial

NCASNCAS – performance assessment – performance assessment

GMCGMC – fitness to practice – fitness to practice

2. Characterise the problem2. Characterise the problem

Describe and diagnoseDescribe and diagnose

Often intuitive sense of ‘something wrong’, but Often intuitive sense of ‘something wrong’, but characterising the problem is much less easycharacterising the problem is much less easy

How do you characterise How do you characterise the problem?the problem?

What is the problem? (may be really difficult to answer)What is the problem? (may be really difficult to answer)

History of the learner – academic, social and psychological History of the learner – academic, social and psychological History of the problemHistory of the problem Is it a problem that needs to be fixed?Is it a problem that needs to be fixed? Ascertain the learners views and insight into the problemAscertain the learners views and insight into the problem

Where does the problem lie?Where does the problem lie?

What’s the problem?What’s the problem?

Superficial description – what is a Superficial description – what is a symptom and what is a diagnosis?symptom and what is a diagnosis?

Poor performance is a symptom, not a Poor performance is a symptom, not a diagnosisdiagnosis

Deeper diagnosis may be a lot more Deeper diagnosis may be a lot more difficult – may be multi-factorialdifficult – may be multi-factorial

To maximise learning…To maximise learning…

Grounding knowledgeGrounding knowledge

ConcentrationConcentration

MemoryMemory

Problem solving abilityProblem solving ability

ReflectionReflection

ImaginationImagination

InsightInsight

Strategy for learningStrategy for learning

MotivationMotivation

Relate learning to experienceRelate learning to experience

CommitmentCommitment

WillingnessWillingness

InterestInterest

OrganisationOrganisationIntellectIntellect

TimeTime

FacilitiesFacilities

Absence of confounding factorsAbsence of confounding factors

Just get on with it!!Just get on with it!!

GuidanceGuidance

OpportunityOpportunityStimulation/challenge

Incentive

Environment and tools for learning and Environment and tools for learning and development of knowledge.development of knowledge.

Grounding knowledgeGrounding knowledge(knowledge)(knowledge)

ConcentrationConcentration MemoryMemory IntellectIntellect Problem solving abilityProblem solving ability Organisation Organisation ReflectionReflection ImaginationImagination Insight into own ability Insight into own ability Strategy for learningStrategy for learning Relate learning to experienceRelate learning to experience

(skills)(skills)

Motivation/incentiveMotivation/incentive Commitment Commitment WillingnessWillingness InterestInterest

(attitudes)(attitudes)

But environment also important…But environment also important…

OpportunityOpportunity GuidanceGuidance TimeTime FacilitiesFacilities

(learning/educational environment)(learning/educational environment)

Absence of confounding factorsAbsence of confounding factors(psychological, social, physical environment)(psychological, social, physical environment)

Teacher

Learner Environment

Unsupportive Overly critical

Unreasonable expectationsDisinterested

Non challengingFailure to meet learner’s needs

KnowledgeSkills

Attitudes

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)

Where does theWhere does theproblem lie?problem lie?

Steinert 2008:BMJ 336, 150-153

Going to focus on problems with the learnerGoing to focus on problems with the learner

(because that is the subject of this workshop)(because that is the subject of this workshop)

Models of learningModels of learning

AndrogogyAndrogogy Experiential Learning Theory Experiential Learning Theory Bloom’s TaxonomyBloom’s Taxonomy

Androgogy vs. pedagogyAndrogogy vs. pedagogyPedagogyPedagogy AndrogogyAndrogogy

Need to knowNeed to know Know that they must Know that they must know what the know what the teacher teachesteacher teaches

Need to understand Need to understand relevance before relevance before learninglearning

Learner’s self-conceptLearner’s self-concept That of a dependent That of a dependent personalitypersonality

Responsible for own Responsible for own decisions and actionsdecisions and actions

Role of experienceRole of experience Experience of limited Experience of limited value to learning value to learning processprocess

Value and use own Value and use own experiences in experiences in learninglearning

Readiness to learnReadiness to learn Ready to learn what Ready to learn what the teacher tells themthe teacher tells them

Ready to learn what Ready to learn what they need to knowthey need to know

Orientation to Orientation to learninglearning

Topic oriented Topic oriented learninglearning

Life centred, problem Life centred, problem centred learningcentred learning

MotivationMotivation External motivation External motivation (exams etc.)(exams etc.)

Internally motivated Internally motivated (self improvement (self improvement etc)etc)

Experiential learning theoryExperiential learning theory JungJung KolbKolb Honey and MumfordHoney and Mumford

How do we learn?How do we learn?

The Learning CycleThe Learning Cycle

Reflective Observation Reflecting

Concrete Experience

Feeling

Active Experimentation

Doing

Abstract Conceptualisation

Thinking

Processing Continuum

how we do thingsMB – extroversion-introversion

scalePerception Continuum

how w

e think about thingsM

B – Feeling-thinking scale Assimilating(think and reflect)

HM - Theorist

Diverging(feel and reflect)HM - Reflector

Converging(think and do)

HM - Pragmatist

Accommodating

(feel and do)HM - Activist

Blooms taxonomyBlooms taxonomy 3 domains – cognitive, psychomotor, 3 domains – cognitive, psychomotor,

affectiveaffective Hierarchies in each domain, starting Hierarchies in each domain, starting

with most basic, ascending to most with most basic, ascending to most developeddeveloped

Bloom’s Taxonomy – cognitive domainBloom’s Taxonomy – cognitive domain

Evaluation

Synthesis

Analysis

Application

Comprehension

KnowledgeKnowledge

High cognitivedemand

Low cognitivedemand

Low order skills

These are a means toachieving fully functionalknowledge

Fully functional knowledge

Learner has to make deepconnections and meaning

Levels of cognitionLevels of cognition

Cognitive levelCognitive level Sample activitiesSample activities

Evaluation Appraise, critique, evaluate, justify

Synthesis Compose, create, design, devise

Analysis Compare, contrast, differentiate, relate

Application Demonstrate, construct, prepare, predict

Comprehension Summarise, interpret, explain, translate

Knowledge Recall, reproduce. identify, match

3. Structured intervention3. Structured intervention

Structured interventionStructured intervention

Change the environment (training practice etc.)Change the environment (training practice etc.) Change the trainerChange the trainer Draw up a learning contractDraw up a learning contract Define objectives, communicate expectationsDefine objectives, communicate expectations Additional teaching/support, mentoringAdditional teaching/support, mentoring Counselling, sick leaveCounselling, sick leave Further information gathering (psychology report, previous Further information gathering (psychology report, previous

teachers, etc.)teachers, etc.) Reduce workloadReduce workload Protected timeProtected time Regular feedback on progress against agreed objectivesRegular feedback on progress against agreed objectives

Dismissal…..in association with careers advice, support, Dismissal…..in association with careers advice, support, constructive feedback etc., etc!constructive feedback etc., etc!

Directed at the source of the problem (learner, environment, teacher) and to the nature of the problem

Learning plan/contractLearning plan/contract

States…States…

What will be learnedWhat will be learned How it will be learnedHow it will be learned What resources are neededWhat resources are needed How learning will be measuredHow learning will be measured How long it will takeHow long it will take

Joint responsibility, between trainer and registrarJoint responsibility, between trainer and registrar

What have I been doing differently?What have I been doing differently? Informed partners and PM but no other staffInformed partners and PM but no other staff Contract of educational objectivesContract of educational objectives Monthly review of performance compared to agreed objectivesMonthly review of performance compared to agreed objectives Doing greater proportion of seminars myselfDoing greater proportion of seminars myself Fewer topic based seminars and more seminars focused on eP and PDPFewer topic based seminars and more seminars focused on eP and PDP More proactive in teaching, rather than reactiveMore proactive in teaching, rather than reactive Very specific learning tasks, in small chunks, working up the cognitive ladder of Very specific learning tasks, in small chunks, working up the cognitive ladder of

Blooms taxonomy, but tending to stick at lower end of cognitive hierarchyBlooms taxonomy, but tending to stick at lower end of cognitive hierarchy Tendency to challenge more and take less for grantedTendency to challenge more and take less for granted Review all consultation recordsReview all consultation records Screen all referrals before sendingScreen all referrals before sending Markedly reduced registrar workloadMarkedly reduced registrar workload Few home visitsFew home visits All Cuedoc shifts supervisedAll Cuedoc shifts supervised More joint surgeriesMore joint surgeries More proactive in seeking feedback from colleaguesMore proactive in seeking feedback from colleagues Exhaustive record of discussions from structured teaching sessionsExhaustive record of discussions from structured teaching sessions Documentation in form of daily diaryDocumentation in form of daily diary

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

Contract of educational and Contract of educational and performance objectivesperformance objectives

Undergo assessment by educational psychologistUndergo assessment by educational psychologist CBD every monthCBD every month COT every monthCOT every month All referrals to be recorded on ePAll referrals to be recorded on eP Weekly joint consulting sessionWeekly joint consulting session All learning points to go onto learning logAll learning points to go onto learning log All learning objectives onto PDPAll learning objectives onto PDP All PDP entries to be SMARTAll PDP entries to be SMART Self appraise at least one video every week and Self appraise at least one video every week and

record on ePrecord on eP

(Takes a lot of time though)

Evidence and objectivity at all stagesEvidence and objectivity at all stages Documentation and record-keepingDocumentation and record-keeping Regular appraisal and feedbackRegular appraisal and feedback FairnessFairness ConfidentialityConfidentiality

90% of problem learners succeed after 90% of problem learners succeed after structured interventionstructured intervention

Trainers responsibilitiesTrainers responsibilities

Raise concernsRaise concerns Clarify nature of the problemClarify nature of the problem Manage safetyManage safety Maintain confidentialityMaintain confidentiality Design and deliver interventionDesign and deliver intervention Measure outcomesMeasure outcomes Give feedbackGive feedback

To trainee - to train, not to assess (formative not summative)To trainee - to train, not to assess (formative not summative)

To scheme/deanery - to give To scheme/deanery - to give objectiveobjective feedback, backed up feedback, backed up by comprehensive documentationby comprehensive documentation

Other considerations….Other considerations….

Your own workloadYour own workload

Partners workloadPartners workload

ReimbursementReimbursement

Useful starting pointsUseful starting points Recent series in BMJRecent series in BMJ

Northern Deanery websiteNorthern Deanery website

National Association of Clinical TutorsNational Association of Clinical Tutors

www.gp-training.netwww.gp-training.net

(The End)(The End)