How do Doctors Learn??
That’s such a big question and this post is inspired by a few experiences this week upon which I am reflecting.
Firstly I had to do my first major presentation of my PhD topic this week to Monash University academics and non-academic clinical GP Teachers. A mixed audience. Keeping it both interesting and academic is not always easy. There is no point delivering knowledge if everyone is asleep. I was a bit scared.
Secondly we are negotiating with the Royal Australian College of General Practitioners on trying to document and allocate learning points for GP’s utilising the online social media spaces that have had an umbrella term of FOAMed. Free Open Access Medical Education which is now becoming a world wide movement especially in emergency medicine and critical care but gaining traction within Primary Care and General Practice. Interestingly the name was derived over a pint of Guinness in a Dublin Pub.
See here for Critical Care http://lifeinthefastlane.com/foam/
See here for General Practice http://foam4gp.com/
Thirdly I work with some dedicated General Practitioners who do not consider the online environment networks and forums a learning space. I had a meeting about disseminating some new information within the General Practice Space on a 21st Century emerging medical problem that the College is currently working on delivering as a guideline and module. These otherwise excellent clinicians deride social media medical forums as being just “social” and not suitable as a learning space.
Fourthly and on the same head smashing day I attended the Monash University Teaching Awards Dinner whereby Medical Students sang the praises of their GP mentors from clinical placements. I am also one of those clinical teachers in an age old apprenticeship model, whereby I bring a medical student into my consulting room and teach as we go. It’s a great experience and I usually learn as much as I teach. I’m not the only one with that experience.
See Here for a reflection on GP Teaching and Learning.
So what is learning? Is it the accumulation and regurgitation of facts familiar to University Students? If that was the case there would be no need for internships or “clerkships” or ongoing Continuing Medical Education. I really think that accumulation of facts is about getting on the learning curve and if we are going to flog a metaphor which I have a particular penchant for it would be the equivalent of building the car before being able to drive it.
There is something unique about adult learning about the experiential application of knowledge that creates the wisdom from the accumulated facts. In high stakes professions such as Medical Practice, the benchmarking of standards is important, so that minimum safety levels are set. However with such a vast body of knowledge that is endlessly changing and at times in a state of limbo with no clear evidence base emerging from the academic literature one has to often rely on the experiential learning. On the wisdom. This is where peer review and transparency of practice has such a great deal to offer. Hospital Medicine ideally demonstrates peer review with ward rounds, multiple handovers, and ready access to peers and active learning on case studies and tutorials. Not so for General Practice.
General Practice can be isolating whether one is rural or urban and access to colleagues under time poverty and duress can be difficult. Isolation in General Practice is academically defined as Structural, Professional and Social.
|GP Isolation Type||What that means|
|Structural||Relates to the one room, one Doctor, and one Patient concept with immediacy of care.|
|Professional||Relates to clinical decision back up, and need for debriefing.|
|Social||Relates to separation from family networks and friends which is applicable especially to rural and remote setttings. It could include however emotional exhaustion factors in a busy urban GP attempting to establish a practice and the relative time poverty and fatigue this can cause.|
How do established General Practitioners gain wisdom? One way is to know your limits. Provide safety netting on your known areas of non-expertise. This often comes down to reflective practice, personal ethics and that ephemeral sometimes overused concept of emotional intelligence. Saying
“I don’t know- but I know where I can find out or who might know”
is one of the greatest sayings a Doctor needs to cultivate. It really doesn’t make you stupid. I would hope most Doctors agree that particular phrase is an indication of the beginning of wisdom.
Traditionally we have had drug company sponsored events which are now fading into historical insignificance and this is probably a good thing. The absence of drug company sponsored events however does mean the cost of education is now becoming exhorbitant for many GP’s and educational providers are now scrambling to find corporate sponsorship to subsidize that cost. The affordability issue of education for part time practitioners is a particular concern of mine and I think there are some short sighted assumptions on income levels that contribute to this. Most conferences will cost near to $1000 AUD for 2-4 days, with accommodation costs another burden and then there is the time away from work which is usually a weeks lost income as most GPs are independent contractors. The travel costs of transport are also potentially high. Practice led small group learning however often doesnt happen due to the time or space to provide this as a regular event and it does require the dedication of the facilitator all of which is unpaid. Journals are plenty, but expensive for multiple subscriptions and require protected time to read.
Online education is therefore coming into its own and if you did look at the link on FOAM you can come to appreciate that this provides multiple journal access through community collaboration. A GP can set learning needs and goals depending on patient presentation, on perceived gaps in knowledge or more likely to enhance and refine an already established knowledge base. Or maybe they haven’t yet discovered that they do have a knowledge gap until they go FOAM cruising or participate in the online community and brain trusts. Much of this literature is international and may not necessarily relate however to the Australian context. Peer review in the forums is an excellent way to benchmark and refine existing knowledge and it has the added benefit over time of developing a community of practice which reduces isolation in the General Practice setting. Comments on blogs, on opinion pieces, on highly academic statements or evidence based practice provides a way of learning that is reflective and often reviewed by your peers. My previous blog for instance described my reaction to the Evidence Based Guidelines on the management of Prostate Screening in Australian GP. This was a hotly debated topic at that time and the comments I received from the blog, statements on Twitter, and from multiple stakeholders have helped me refine my practice when I see a patient regarding this issue. No doubt the evidence will move on with time, new research and new innovations and I will need to refine again.
The French Salon of the Enlightenment.
Now its a Facebook Forum, or Twitter chat with a Hashtag, or a Google Plus community.
So was I being Social? Trust me when I tell you medical prostate guidelines are not the topics I discuss with my non-medical friends. Are the social media FOAM peers I discuss these issues with my new found friends? Not really although I have met many of them now in person; I would consider them my professional colleagues whom I mostly highly regard and trust. Friendly yes, but so far we haven’t had the Aussie BBQ together. However trust and personal support are an important part of these new learning environments. I wouldn’t not invite them to a BBQ; some do seem like people I would like to call friends. The beauty and the tyranny is that most of those in my virtual community of practice colleagues are scattered far and wide over Australia and the world. Much of our interaction is asynchronous with hours minutes or days between replies as the conversation carries on. I hope especially for my rural and remote colleagues that these conversations are helpful at reducing the sense of isolation that can occur in remote places noting that isolation is not confined to rural communities.
This article found its way into my stratosphere today. More evidence that in the professional workplace learning is social, informal and networked.
Workplace learning through peer groups in medical school clerkships
Via an online community I subscribe to. For free. It describes for medical students how the community of practice enhances the workplace in simply knowing where to find things as well as clinical knowledge. Again a hospital setting but there are many non-clinical discussions that go on in forums and online learning spaces that are about the art of medicine; the application of professional practice; of etiquette; of business practice; it can be about managing personal stressors or even on a medical mums forum how to manage the afternoon naps of toddlers whilst studying for fellowships and favourite double quantity cooking tips to enable the practitioner to simply do her Doctoring job.
I think I’m flying since I became an actively engaged learner in the online learning space. There is a word for it. Its my word of the year: Heutagogy. Apparently this word was developed also at a Social Event. Its an Australian word derived from Hase and Kenyon a derivative of Double Loop learning pioneered by Harvard Business School Professor Chris Argyrius.
Classic from the Business Literature https://hbr.org/1991/05/teaching-smart-people-how-to-learn
Review of Heutagogy and Lifelong Learning http://www.irrodl.org/index.php/irrodl/article/view/1076/2087
Learning is Social. Learning requires emotional safety; anyone who has had children or who has been a child in school would recognise that. Adult learning requires reflection upon knowledge and previously held beliefs informing professional action. Professional learning is grounded in experience. That experience notably and in medical practice ideally, can be the collective experience of your peers. That experience and reflection can occur over multiple views and reviews of a single body of knowledge and is not necessarily linear or synchronous in its timing or place.
Tell me I’m wrong but this train is leaving the station. Its time to get on board. Experiment with this learning and engagement in the Digital Enlightenment. Look at Twitter; Google Plus; Facebook groups like GPs down under, Medical Mums and Mums to be, Start small; chunk it down. Medical Practice is a commitment to lifelong learning. This learning is just another way of doing what we have always done, with improvements. Its turbo charged, its user defined, its free and its most definitely peer to peer with equipotent participants and its definitely thank God for that; social