Training paediatricians for the future

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Training paediatricians for the future
h.davies_at_shef.ac.uk
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Paradigm shift in PG medical education
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The challenge

• And how do you you know they are a good doctor?

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The challenge
And how do you you know they are a good doctor?
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Whats a good doctor?
Doctors as managers of their environment Peer
communication Resource utilisation Systems
management Clinical governance Respect for
colleagues Health of populations Teaching
students Quality assurance
Doctors as managers of patient care Clinical
expertise Patient management Patient
communication Patient education Quality assurance
Doctors as managers of themselves Insight into
own limits Self care Lifelong learning Continuing
education Quality assurance
Hays, R.B., et al., Selecting performance
assessment methods for experienced physicians.
Med Educ, 2002. 36(10) p. 910-7.
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Whats a good doctor?
Doctors as managers of their environment Peer
communication Resource utilisation Systems
management Clinical governance Respect for
colleagues Health of populations Teaching
students Quality assurance
Doctors as managers of patient care Clinical
expertise Patient management Patient
communication Patient education Quality assurance
Doctors as managers of themselves Insight into
own limits Self care Lifelong learning Continuing
education Quality assurance
Hays, R.B., et al., Selecting performance
assessment methods for experienced physicians.
Med Educ, 2002. 36(10) p. 910-7.
7
Medical knowledge
Communication
Doctors as managers of their environment Peer
communication Resource utilisation Systems
management Clinical governance Respect for
colleagues Health of populations Teaching
students Quality assurance
Doctors as managers of patient care Clinical
expertise Patient management Patient
communication Patient education Quality assurance
Systems based practice
Patient care
Doctors as managers of themselves Insight into
own limits Self care Lifelong learning Continuing
education Quality assurance
Practice based learning and improvement
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Medical knowledge
Communication
Doctors as managers of patient care
Doctors as managers of their environment
Systems based practice
P R O F E S S I O N A L I S M
Patient care
Doctors as managers of themsleves
Practice based learning and improvement
Professional competence is the habitual and
judicious use of communication, knowledge,
technical skills, clinical reasoning, emotions,
values, and reflection in daily practice for the
benefit of the individual and community being
served Epstein and Hubert
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A simple model of competence
Action Performance
Behaviour
Competence
Integrated knowledge
Cognition
Knowledge
Miller, G., The assessment of clinical
skills/competence/performance. Academic Medicine,
1990. 65 (Supplement) p. S63-S7.
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Dreyfus

• Novice
• Advanced beginner
• Competent
• Proficiency
• Expertise

"An expert is someone who knows more and more
about less and less, until eventually he knows
everything about nothing." Anon
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Content specificity

• Being good at one thing doesnt mean you are good
  at everything
• Implications for training
• Implications for assessment

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The challenge
And how do you you know they are a good doctor?
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Curriculum
There is a curriculum???

• Less emphasis on knowledge
• Competency based
• Defined outcomes
• Integration between different phases of
  education unitary approach
• Move away from traditional apprenticeship model
• Rapidly expanding medical evidence base
  (including a medical education evidence base)

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Reduced working hours

• US down to 80 hours
• UK
• 56 hours, August 2007
• 48 hours 2009
• Scandanavia
• 37-40 hours for years
• Reduced exposure to range and depth of clinical
  material

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Formal learning opportunities

• Outcome/Competency based curricula
• Discipline specific and generic
• Problem based learning
• Systems based programmes
• Lessons from other industries - e.g crew resource
  management
• Shifts can make access to formal learning
  difficult

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Learning on the job

• More structured
• Reflective practice encouraged
• More feedback and monitoring
• Greater focus on patient safety
• Integrate learning and assessment
• Just in time learning and teaching

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Emerging technologies

• E-learning
• Does not depend on everyone being in one place at
  once
• Can be interactive
• Needs driven by an individual
• Simulation
• Team roles
• Rare but important clinical problems
• Technical expertise

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Pattern recognition is important for efficient
clinical reasoning
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Key elements of clinical reasoning process
Patients story
Knowledge
Data acquisition
Accurate problem representation
Context
Generation of hypothesis
Search for and selection of illness script
Experience
Diagnosis
Bowen NEJM 2005
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Organisational culture critical
I never teach my pupils I only attempt to
provide the conditions in which they can learn."
Albert Einstein
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Clinical teacher

• Ensure delivery of curriculum
• Enhance reduced clinical experience
• Role modelling
• Assessment and feedback
• Encourage and facilitate reflection
• Maximise learning opportunities
• Promote a positive educational culture

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The challenge

• Clinical teachers differ from clinicians in a
  fundamental way. They must simultaneously foster
  high-quality patient care and assess the clinical
  skills and reasoning of learners in order to
  promote their progress towards independence in
  the clinical setting. Clinical teachers must
  diagnose both the patients clinical problem and
  the learners ability and skill

Bowen NEJM 2005
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The challenge continues
And how do you you know they are a good doctor?
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Training and learning
Assessment
Curriculum

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Overall assessment strategy essential
Work based assessment
Curriculum
Exams

Triangulate evidence
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What do you want to assess?
Action Performance
Work
OSCE
Competence
CCS
Integrated knowledge
Knowledge
MCQs
Miller, G., The assessment of clinical
skills/competence/performance. Academic Medicine,
1990. 65 (Supplement) p. S63-S7.
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Competence alone does not predict performance
Performance
Individual related influences
System related influences
Competence
Rethans, J. J., J. J. Norcini, et al. (2002).
"The relationship between competence and
performance implications for assessing practice
performance." Med Educ 36(10) 901-909.
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What is good assessment?

• Clarity of purpose
• Provides feedback
• Validated instruments
• Transparency
• Credibility
• Cost efficient
• Subject to quality assurance
• Use multiple methods

?
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The programme should be quality assured
importance
100
0
R
V
E
C
A
aspect
F
van der Vleuten C. The assessment of professional
competence developments, research and practical
implications. Advances in Health Sciences
Education. 1996141-67.
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Reliability sample error
Assessors
Content
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Reliability as a function of testing time
1Norcini et al., 1985 2Stalenhoef-Halling et al.,
1990 3Swanson, 1987
4Was et al., under editorial review 5Newble
Swanson, 1987 6Ram et al., 1999
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The programme should be quality assured
importance
100
0
R
V
E
C
A
aspect
F
van der Vleuten C. The assessment of professional
competence developments, research and practical
implications. Advances in Health Sciences
Education. 1996141-67.
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Houston - we have a problem
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Foundation trainees

• MSF ratings
• Highest ratings for
• Verbal communication with colleagues
• Accessibility/reliability
• Lowest ratings for
• Ability to diagnose patient problems
• Ability to formulate management plan
• MSF correlates more highly with mini-CEX and CbD
  than DOPS

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The programme should be quality assured
importance
100
0
R
V
E
C
A
aspect
F
van der Vleuten C. The assessment of professional
competence developments, research and practical
implications. Advances in Health Sciences
Education. 1996141-67.
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Help trainers give effective feedback
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Effective feedback

• Balanced
• Highlight strengths where appropriate as well as
  areas of concern
• Is directed at characteristics the individual is
  able to change
• Specific describes behaviour rather than make
  judgements
• Timely
• Credible
• Based on evidence/observation

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Prime trainees to expect feedback
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Rising to the challenge

• And how do you you know they are a good doctor?

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Medical knowledge
Communication
Doctors as managers of patient care
Doctors as managers of their environment
Professionalism in medical education
Systems based practice
P R O F E S S I O N A L I S M
Patient care
Doctors as managers of patient care
Practice based learning and improvement
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Utopia
Paediatrics
U-to-pi-a An ideal and perfect place or state,
where everyone lives in harmony and everything is
for the best
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The real world
Prag-ma-tism A straightforward practical way of
thinking about things or dealing with problems..
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Thank you

• The secret of getting ahead is getting started.
  The secret of getting started is breaking your
  complex overwhelming tasks into small manageable
  tasks, and then starting on the first one
• Mark Twain

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Quality assurance
Work based assessment
Shift working
Faculty development
Feedback
Public accountability
Learning technologies
Teaching and assessing clinical reasoning
Competency/outcomes based training
Professionalism
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Experiential learning
Experience
Reflection
Apply
Learn
Adapted from Kolb
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Help trainers give effective feedback
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Clinical reasoning

• It is likely therefore, that expertise in
  clinical reasoning should be considered an
  amorphous entity that enables competent
  clinicians to compensate for case-specific
  weaknesses. It allows one to adapt to the demands
  of the situation, flexibly (albeit often
  unconsciously) utilising the full armament
  available

Eva, Med Ed 2004 39 98-106