How Doctors Think and Learn

191 Pages·2020·3.45 MB·English

by  Derek Burke

How Doctors Think
and Learn
Derek Burke
123
How Doctors Think and Learn
Derek Burke
How Doctors Think
and Learn
Derek Burke
Head of Clinical Governance and General Medical Council Suitable Person
Gibraltar Health Authority
St Bernard’s Hospital
Gibraltar
Gibraltar
ISBN 978-3-030-46278-9 ISBN 978-3-030-46279-6 (eBook)
https://doi.org/10.1007/978-3-030-46279-6
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To my mother and father who taught me the
value of learning
To my wife who, with good humour year on
year, accepted my assurance that it was
“nearly there”.
Preface
When I graduated from medical school in 1983, medicine was a science based craft
acquired through apprenticeship. There was no formal system of competency-based
training or assessment. Skills were acquired on the basis of “see one, do one, teach
one”. At the end of higher specialist training, a system of accreditation determined
successful completion of training. There was no system of appraisal or annual review.
Since then, medical training has become highly structured and comprehensively
assessed. Achieving competence is now seen as the measure of medical attainment.
But competence was not a term which would have been in general use in medical
practice in 1983.
The graph below shows a plot of Medline citations for the term "clinical compe-
tence” for the period 1980–2018 (the last full year of citations available). From
reviewing that graph and from my own personal experience of training and practis-
ing in that period, I have set the start date for competency-based medical practice in
the UK as 1990.
Clinical Competence
Citations Medline 1980-2018
7000
6000
5000
4000
3000
2000
1000
0
20182016201420122010200820062004200220001998199619941992199019881986198419821980
Competence
vii
viii Preface
Additional supporting evidence for that date is that it coincides with the intro-
duction of structured resuscitation courses into the UK. The American Heart
Association Advanced Cardiac Life Support Course was introduced in the USA in
1975 and in the UK in 1985 (the Resuscitation Council Course was first run in
1991/93). The American College of Surgeons Advanced Trauma Life Support
Course was first introduced in the USA in 1978 and in the UK in 1988. Paediatric
resucitation courses were introduced into the UK in 1990. At first, these courses
were few and far between and it took a number of years for a significantly large
number of doctors to attend at least one course.
These courses were the earliest structured approach to competency-based train-
ing and assessment in the UK where the possibility of failure existed. They led,
slowly, to a whole generation of doctors acquiring the skills to teach in a structured
manner and to assess successful acquisition of those skills to an agreed level of
competence.
Over the past 30-years competency-based training and assessment has pro-
gressed to encompass the whole of undergraduate and postgraduate medical educa-
tion and training. This development coincided with a reduction in working hours
from a basic 83 hours per week to a basic 48 hours per week and a reduction in years
of training from graduation to consultant appointment from about 14 years to about
10 years. It would not be going too far to propose that the reduction in the hours and
years of training required to attain the skills to practise as a consultant would not
have been possible without the development of structured competency-based train-
ing and assessment programmes.
We may consider the period 1990–2020 as the “age” of competency-based prac-
tice in UK Medical practice. We have made great strides in standardising the outputs
of medical training schemes over that period, but what of higher levels of attainment
beyond competence?
Dreyfus and Dreyfus describe a five-stage model of skill acquisition: Novice,
Advanced Beginner, Competent, Proficient and Expert. The Novice/Advance
Beginner stages are typified by those in the clinical stages of undergraduate training
to the earlier years of postgraduate training. The competent stage typifies those in
the later stages of postgraduate training. The proficient stage is only attained by
senior practitioners with many years of experience. As not all practitioners attain the
expert stage I will not consider that stage further. The graph below shows a plot of
Medline citations for the period 1980–2018 for the terms “clinical competence” and
“clinical proficiency”. We can see that citations for the term “clinical proficiency”
made up only 3% of citations in 1980 and rose to only 10% of citations in 2018.
Preface ix
Clinical Competence and Clinical Proficiency Citations
Medline 1980-2018
7000
6000
5000
4000
3000
2000
1000
0
20182016201420122010200820062004200220001998199619941992199019881986198419821980
Proficiency Competence
I would propose that just as a structured approach to the delivery and assessment
of competency-based practice has facilitated shorter training periods while main-
taining standards, then a structured approach to the delivery and assessment of
proficiency- based practice should reduce the time to achieving a proficient level of
performance. The problem we face is that the thought processes underpinning pro-
ficient practice are qualitatively different to those required for competency-based
practice. We cannot simply translate the techniques which have given success in
competency-based training to training in proficiency.
Having trained under the craft-based system and been a trainer of doctors and
nurses, both undergraduate and postgraduate during the age of competence I came
to realise that although I knew how to teach, I had very little notion of how students
became fully fledged professionals as a result of that teaching. I reasoned that if we
were to develop successful techniques for training doctors to be proficient, then we
had to understand how doctors learn to be doctors. This is akin to the development
of new treatments. The more we understand the pathophysiology of the underlying
condition we want to treat, the more likely we are to develop new and successful
treatments. Trial and error may eventually give us the result we want, but that pro-
cess is likely to take a lot longer than a rational knowledge-based approach.
This book is the result of that work. It took nearly 13 years to write rather than
the six months I had originally planned it to take. If left to my own devices, it would
take another 13 years. However, there comes a time when you have to drop the pen
and expose your thoughts to the wider world for good or bad.
x Preface
This book is split into three parts. Part I considers the elements underpinning
thinking, learning and professional practice by reviewing the available literature.
Part II provides a synthesis of the information from Part I and adds my thoughts and
perspectives. Part III presents a conceptual framework for how doctors acquire,
develop and refine their knowledge and skills based on the elements in Parts I and
II. Because of the interdependance of the parts I would recommend reading them, at
least on first reading, in the order as presented.
The book is deliberately written in non-technical language to make it available to
the widest possible audience. I suggest that it would interest anyone who is involved
in professional education or training The model is generic and covers the develop-
ment of professionals rather than just healthcare professionals. Because of my back-
gound in medicine I have used clinical examples, but other than that the framework
would be equally applicable to lawyers and accountants as it is to doctors or nurses.
It is my hope that this book will contribute to work on the development of a
structured approach to training postgraduate practitioners in proficiency-based
practice and that the next 30 years will come to be seen as the age of proficiency-
based medical practice in the UK just as the last 30 years were the age of compe-
tency-based medical practice.
May 2020 Derek Burke
Gibraltar
Acknowledgements
I would like to thank my colleagues Dr Alison Smith and Professor Prasad Godbole
for reviewing earlier drafts of this book and Professor Amaka Offiah and Dr John
Tripp for reviewing the final draft. Their input significantly improved the readability
of the book.
A special mention to Dr Tom Beattie for not only reviewing the book but also for
kindly inviting me to be external examiner for the Edinburgh University MSc in
Paediatric Emergency Medicine. The 6 years I undertook this role provided invalu-
able insights into the cognitive development of postgraduate doctors and crystal-
lised my thoughts on Bloom’s taxonomy of the cognitive domain, Anderson and
Krathwohl’s revision of Bloom’s taxonomy and also Krathwohl’s taxonomy of the
affective domain.
Particular thanks to Dr Daniel Cassaglia, consultant paediatrician, medical direc-
tor and chief executive of the Gibraltar Health Authority for inviting me to give a
talk on tacit knowledge to the Paediatric Visiting Club meeting in Gibraltar in
September 2018. The preparation for that talk and the discussion with that group in
the following two days enhanced my understanding and conceptualisation of the
nature of tacit knowledge and led to the development of the model of the structure
of knowledge used in the book.
Thanks also to Dr Ruth Brown and Dr Jacky Hanson with whom I was involved
in some of the early work on revalidation for the College of Emergency Medicine.
This experience helped formulate my thoughts on reflection and skill acquisition
and my early thoughts on skill sets.
My understanding of the structure of skill sets and complex skill sets was greatly
enhanced by a very useful discussion with Dr Rachel Tattersall.
Dr Alistair Pickering suggested the term abstention in relation to the application
of Piaget’s schemas to postgraduate trainees.
Thanks also to Dr Pete Driscoll. I first met Pete in about 1988 when I was a
senior house officer and he was senior registrar in the Accident and Emergency
Department at Whipps Cross hospital. Our paths crossed a number of times in the
intervening years in particular when examining in the College of Emergency
Medicine Objective Structured Clinical Examinations when Pete was the Dean of
the College. Even in the 1980s, Pete was an inspiration to those who had an interest
in medical education, and he continues to inspire a new generation of practitioners
xi