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The Trainee in Difficulty. Prevalence 6-9% Lack of knowledge 48% Lack of knowledge 48% Poor judgement 44% Poor judgement 44% Inefficient use of time 44%

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Presentation on theme: "The Trainee in Difficulty. Prevalence 6-9% Lack of knowledge 48% Lack of knowledge 48% Poor judgement 44% Poor judgement 44% Inefficient use of time 44%"— Presentation transcript:

1 The Trainee in Difficulty

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

3 A tidy model and strategy for helping the registrar in difficulty? Afraid not! Afraid not! Disjointed selection of thoughts and observations Disjointed selection of thoughts and observations

4 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??? …..what really is in their best interest??? Crucial to this is deciding if there really is a problem or not, which is not easy

5 Anticipated progress Time Performance

6 …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

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

8 2. Characterise the problem Describe and diagnose Describe and diagnose

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

10 How do you characterise 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 problem History 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 problem Ascertain the learners views and insight into the problem Where does the problem lie? Where does the problem lie?

11 Whats the problem? Superficial description – what is a symptom and what is a diagnosis? Superficial description – what is a symptom and what is a diagnosis? Poor performance is a symptom, not a diagnosis Poor performance is a symptom, not a diagnosis Deeper diagnosis may be a lot more difficult – may be multi-factorial Deeper diagnosis may be a lot more difficult – may be multi-factorial

12 To maximise learning… Grounding knowledge Concentration Memory Problem solving ability Reflection Imagination Insight Strategy for learning Motivation Relate learning to experience Commitment Willingness Interest Organisation Intellect Time Facilities Absence of confounding factors Just get on with it!! Guidance Opportunity Stimulation/challenge Incentive

13 Environment and tools for learning and development of knowledge. Grounding knowledge Grounding knowledge(knowledge) Concentration Concentration Memory Memory Intellect Intellect Problem solving ability Problem solving ability Organisation Organisation Reflection Reflection Imagination Imagination Insight into own ability Insight into own ability Strategy for learning Strategy for learning Relate learning to experience Relate learning to experience(skills) Motivation/incentive Motivation/incentive Commitment Commitment Willingness Willingness Interest Interest(attitudes) But environment also important… Opportunity Opportunity Guidance Guidance Time Time Facilities Facilities (learning/educational environment) Absence of confounding factors Absence of confounding factors (psychological, social, physical environment)

14 Teacher Learner Environment Unsupportive Overly critical Unreasonable expectations Disinterested Non challenging Failure to meet learners needs Knowledge Skills 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 the problem lie? Steinert 2008:BMJ 336,

15 Going to focus on problems with the learner (because that is the subject of this workshop)

16 Models of learning Androgogy Androgogy Experiential Learning Theory Experiential Learning Theory Blooms Taxonomy Blooms Taxonomy

17 Androgogy vs. pedagogy PedagogyAndrogogy Need to know Know that they must know what the teacher teaches Need to understand relevance before learning Learners self-concept That of a dependent personality Responsible for own decisions and actions Role of experience Experience of limited value to learning process Value and use own experiences in learning Readiness to learn Ready to learn what the teacher tells them Ready to learn what they need to know Orientation to learning Topic oriented learning Life centred, problem centred learning Motivation External motivation (exams etc.) Internally motivated (self improvement etc)

18 Experiential learning theory Jung Jung Kolb Kolb Honey and Mumford Honey and Mumford

19 How do we learn? The Learning Cycle Reflective Observation Reflecting Concrete Experience Feeling Active Experimentation Doing Abstract Conceptualisation Thinking Processing Continuum how we do things MB – extroversion-introversion scale Perception Continuum how we think about things MB – 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

20 Blooms taxonomy 3 domains – cognitive, psychomotor, affective 3 domains – cognitive, psychomotor, affective Hierarchies in each domain, starting with most basic, ascending to most developed Hierarchies in each domain, starting with most basic, ascending to most developed

21 Blooms Taxonomy – cognitive domain Evaluation Synthesis Analysis Application Comprehension Knowledge High cognitive demand Low cognitive demand Low order skills These are a means to achieving fully functional knowledge Fully functional knowledge Learner has to make deep connections and meaning

22 Levels of cognition Cognitive level Sample activities EvaluationAppraise, critique, evaluate, justify SynthesisCompose, create, design, devise AnalysisCompare, contrast, differentiate, relate ApplicationDemonstrate, construct, prepare, predict ComprehensionSummarise, interpret, explain, translate KnowledgeRecall, reproduce. identify, match

23 3. Structured intervention

24 Structured intervention Change the environment (training practice etc.) Change the environment (training practice etc.) Change the trainer Change the trainer Draw up a learning contract Draw up a learning contract Define objectives, communicate expectations Define objectives, communicate expectations Additional teaching/support, mentoring Additional teaching/support, mentoring Counselling, sick leave Counselling, sick leave Further information gathering (psychology report, previous teachers, etc.) Further information gathering (psychology report, previous teachers, etc.) Reduce workload Reduce workload Protected time Protected time Regular feedback on progress against agreed objectives Regular feedback on progress against agreed objectives Dismissal…..in association with careers advice, support, constructive feedback etc., etc! Dismissal…..in association with careers advice, support, constructive feedback etc., etc! Directed at the source of the problem (learner, environment, teacher) and to the nature of the problem

25 Learning plan/contract States… What will be learned What will be learned How it will be learned How it will be learned What resources are needed What resources are needed How learning will be measured How learning will be measured How long it will take How long it will take Joint responsibility, between trainer and registrar

26 What have I been doing differently? Informed partners and PM but no other staff Informed partners and PM but no other staff Contract of educational objectives Contract of educational objectives Monthly review of performance compared to agreed objectives Monthly review of performance compared to agreed objectives Doing greater proportion of seminars myself Doing greater proportion of seminars myself Fewer topic based seminars and more seminars focused on eP and PDP Fewer topic based seminars and more seminars focused on eP and PDP More proactive in teaching, rather than reactive 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 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 Tendency to challenge more and take less for granted Review all consultation records Review all consultation records Screen all referrals before sending Screen all referrals before sending Markedly reduced registrar workload Markedly reduced registrar workload Few home visits Few home visits All Cuedoc shifts supervised All Cuedoc shifts supervised More joint surgeries More joint surgeries More proactive in seeking feedback from colleagues More proactive in seeking feedback from colleagues Exhaustive record of discussions from structured teaching sessions Exhaustive record of discussions from structured teaching sessions Documentation in form of daily diary Documentation in form of daily diary Switch emphasis from training in general practice to training to learn and study Switch emphasis from training in general practice to training to learn and study

27 Contract of educational and performance objectives Undergo assessment by educational psychologist Undergo assessment by educational psychologist CBD every month CBD every month COT every month COT every month All referrals to be recorded on eP All referrals to be recorded on eP Weekly joint consulting session Weekly joint consulting session All learning points to go onto learning log All learning points to go onto learning log All learning objectives onto PDP All learning objectives onto PDP All PDP entries to be SMART All PDP entries to be SMART Self appraise at least one video every week and record on eP Self appraise at least one video every week and record on eP (Takes a lot of time though)

28 Evidence and objectivity at all stages Evidence and objectivity at all stages Documentation and record-keeping Documentation and record-keeping Regular appraisal and feedback Regular appraisal and feedback Fairness Fairness Confidentiality Confidentiality 90% of problem learners succeed after structured intervention 90% of problem learners succeed after structured intervention

29 Trainers responsibilities Raise concerns Raise concerns Clarify nature of the problem Clarify nature of the problem Manage safety Manage safety Maintain confidentiality Maintain confidentiality Design and deliver intervention Design and deliver intervention Measure outcomes Measure outcomes Give feedback Give 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 objective feedback, backed up by comprehensive documentation To scheme/deanery - to give objective feedback, backed up by comprehensive documentation

30 Other considerations…. Your own workload Your own workload Partners workload Partners workload Reimbursement Reimbursement

31 Useful starting points Recent series in BMJ Recent series in BMJ Northern Deanery website Northern Deanery website National Association of Clinical Tutors National Association of Clinical Tutors

32 (The End)


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