What Should We Teach Trainees?

I’m in the very privileged position of having a small amount of influence in the delivery of general practice training in my part of the world. I’ve been involved in a number of thought-provoking discussions recently about what is essential education for trainees on their pathway to independent practice.

I’m interested to find out from other recent graduates what they think were the most important and valuable things that they learnt during their training. Also, with the benefit of hindsight, is there any additional education that they think should have been included?

What better way than to put my questions out to the internet to get some crowd-sourced feedback?

This is a shout-out to all current trainees, recent graduates, educators, supervisors, and also those with a few more years under their belt. Please, share your thoughts! Input from both GP and other medical specialties is very much welcomed.

Here’s my take:

When I was a trainee I’m sure I would have said that what I really needed to be taught was how to manage hypertension, diagnose depression, work-up a patient with headaches and assess a febrile child. I wanted to quickly gain the clinical knowledge to be able to (a) pass my exams and (b) be a safe and effective GP.

There is no doubt that an important part of training is gaining the specific clinical knowledge and skills. However, the problem with focusing too much on knowledge is the risk that you graduate with a snapshot of the current way of practicing and get stuck there for the remainder of your career. We all know that medical knowledge is turning over at an alarming rate and one of our biggest challenges is maintaining a quality, up-to-date, evidence based practice while navigating the ever changing bureaucratic requirements.

I’ve now come around to thinking that the skills I really need are (and this is by no means a comprehensive list):

  • A practical approach to keeping my practice up to date
  • Ways to filter the overwhelming volume of new information
  • Interpretation of the quality of that information (ie, critical appraisal / evidence based medicine)
  • How to efficiently find answers to clinical questions as they arise
  • How to coordinate the health care team, identify and manage the resources available for my patients
  • How to be an advocate for my profession and my patients in the complex medico-political system
  • How to be an effective clinical teacher so I can pass my knowledge on to up-and-coming doctors and students
  • And, in the context of private Australian GP, some business and management skills might have also been handy

Some of the concepts I’ve seen recently about the cognitive processes of doctoring (like this one and this one) are also really important, and generally not touched on much in our formal medical training.

But this is all just my opinion and very much biased towards my own experience and interests.

Over to you, people of the internet! What are the most important things that we need to teach registrars during their training? And has your view changed over time?

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16 thoughts on “What Should We Teach Trainees?

  1. Hi Penny. Another great blog…

    I’m going to narrow down on a particular area that assisted my learning as a trainee (and that I feel will help those I train, being at the opposite end now as a consultant). The importance of receiving (and giving) effective feedback is an invaluable tool in ongoing education and professional development. Whilst future ‘independent’ practice may be inevitable for some of us, I strongly feel that we need to somehow seek peer review as part of the feedback process. This may be facilitated through discussion of cases, direct observation, multi-source (i.e. ward clerks, receptionists, other health practitioners), even blogs- as the case may be!
    I realise the concept of feedback may be difficult to ‘teach’, but the more we can give effective feedback to trainees, the more likely they are to develop, learn and retain knowledge – and hopefully as a result, be able to deliver effective feedback in their future practice.

    • Andy, we have a peer review process at our practice where we sit in on each others patients for an hour each month and provide feedback on the “good, the bad and the ugly” so to speak. It has been invaluable to see how other GP’s practice but also to receive direct critique on our clinical process and patient interaction.

  2. I think your points are very good. I’m in my sixth and final year of training now, and the new DSM-V is a perfect example of how knowledge alone is not sufficient. I did psych rotations in third and fifth year, and we worked with the DSM-IV. Now I’m on Psych again, and everyone is confused (and confusing US, which helps little for our exams) because the new manuals haven’t been finalised, apparently.

    Same concept: I know the basic treatment of hypertension and diabetes and asthma off by heart, but what if it changes, how will I know it has changed? How will I know whether it is applicable to my patients? It’s all a little scary.

  3. Hi.

    Thought provoking article. But it didn’t see what for me is a key feature of teaching. It stretches from dealing with uncertainty, clinical decision making to independent practice and the biggest issue which is about taking personal responsibility for patient care. This for me is done by effective role modeling and is an important transition from hospital work as a junior doctor to being a specialist GP. I think maybe all your points describe this one transition.

    Supervisor discussions occasionally revolve around the role of teaching to pass the exams or how to be a good GP. They aren’t the same thing. Most of us choose the latter and passing the exams becomes easy.

    Ian

  4. I agree with Andy . It’s not what you know . It’s not even knowing where to find the knowledge . It’s who you know and how you deal with them/people in general that is the true key to medicine . Osler was and still is right !
    The problem is that in the crucible of med school we are indoctrinated into the culture of individualistic competitive learning and that knowledge is power . If that were true why is it that nurses are consistently rated above doctors as being most trustworthy ???
    Bake your noodle , right ?

  5. Perhaps part of it is an awareness of Johari’s Window – being aware that there are things that you don’t know that you don’t know. I also think that it would be good if there was an imperative to prepare trainees for the messiness of dealing with patients holistically, and how to deal with the emotional fallout when you realise that sometimes you can’t make a difference.

    Great blog – thanks.

  6. It’s fascinating. My own journey in past 2-3 years has been for a re-invention of my knowledge, in terms of personal learning via the FOAMed community and use of SoMe….before that I was trundling along feeling comfortable – competent certainly, but by no means challenging my practice. So I try to inculcate the same enthusiasm into medical students, registrars and colleagues…

    …yet the sad reality is that :

    – students mostly just want to know what will get them through the exams…

    – trainees are a little more receptive, but equally remain exam-focussed for the most part (no real spare capacity to absorb information re: business of medicine nor networks, as too busy filling in miniCEX and other mindless RTP meducational criteria).

    – a tiny minority of Fellowed colleagues are open to FOAMed, but the majority are too busy trying to run their practice, deal with red-tape and just meet CPD criteria, with no perceived need for extending knowledge over-and-above that which is officially sanctioned by the usual bodies responsible for credentialling.

    What would I LIKE to impart?

    clinical domain

    – development of effective knowledge filters
    – understanding cognitive bias in medicine
    – use of regular sim training to explore impact of human factors in performance, risk and also embedding clinical skills inc decision-making
    – how to deal with uncertainty
    – effective use of FOAMed material to establish life-long learning
    – teaching skills, inc giving/receiving feedback
    – cement effective clinical skills and knowledge base by the above

    business-of-medicine skills

    – self-care
    – development of portfolio career that will last you through 25-30 years without monotony
    – effective tools to ensure a clear delineation between work and home life
    – recognising and pre-empting burnout in self, colleagues
    – succession planning
    – understanding business structure, family Trusts
    – establishing a desired annual income and working to that, not being slave to more $$$ = more happiness/prestige etc

    There was a document called ‘Tim’s Diamonds’ (a sort of counterpoint to Murtagh’s Clinical Pearls) – perhaps should’ve been given as a masterclass in advanced cynicism, but with many home-truths in the ups/downs of a post-Fellow clinician. I think it was outlawed by both RTPs in my home state…

    Most of all, the lessons I have learned are

    “the more I learn, the less I know”

    [hard truths in medical school give way to understanding uncertainty and navigating this as applied to individual, not population]

    and

    “ultimately it’s about the patient – not the cleverness of you or your ‘tribe'”

    [medical school selects ultra-competitive individuals, with these behaviours built upon in specialty training creating an “us/them” attitude between tribes. This is unhealthy. Too easy for ICU to criticise ED who criticise primary care…yet we see different populations with different resources/pressures. Such naivety re: the skills of other tribes and undermining benefits no-one]

    The problem of course is balancing this material with the perceived needs of trainees (who want to get the knowledge to get ahead) and the meducationalista (GP training seems to have a helluva lot of medical educators and trainees completing online documentation of education hoop-jumping)

    I don’t see the urologists or other specialty groups having a whole bunch of separate RTPs/GPET nor “medical educators” – yet they seem to churn out appropriately-skilled specialists.

    I do wonder if RTPs and GP-trainign bodies have too emphasis on meducational navel-gazing on training, yet not enough emphasis on practical hands-on advanced clinical skills and understanding tools for effective practice as a Fellow.

  7. Great discussion piece and thoughtful. I am a busy GP and Supervisor. I have reflected a lot on this lately. I have noted that, in studying for GP examinations, clinicians tend to reduce their patient load and focus on book learning.
    I think that the key issue for exam preparation is understanding context, and context cannot be gained from a Textbook.
    My recent advice is around refocussing on learning from your patients, an attitude of life long learning should grown from this. A classic approach to this is the PUN/DEN an exercise in self appraisal of patient consultations to identify educational needs. I think good experienced clinicians do this intuitively.The skill of self appraisal is critical.
    The partner to the above is external validation through peer review and feedback, as mentioned by others.

  8. Hi Minh – no doubt there are great educators out there. You know that, I know that. But there seem to be an awful lot of junkets with some RTPs; I wont go into details, but I hope you will trust me on this (DM me if interested – suffice it to say KI is SUCH a lovely place to visit for a ‘meducation’ weekend – shame never met up with the local training practice, registrars…plenty more examples)

    In GP-training, I see registrars having to jump through lots of hoops and do lots of self-reflection and form-filling in GP training – but I don;t see other specialty trainees doing this to the same mind-numbingly stultifying degree.

    There seems to be an industry in ‘medical education’ – and whilst I believe a good medical educator is worth his/her weight in gold, sometimes there is too much academic wankery for my liking, rather than a focus on delivery of core clinical skills.

    We see this in the pages of RRH and AJRH, as well as the usual conferences – lots of stuff on training pathways, recruitment, interns, medical student perspectives, medical education theory…but bugger all on practical GP skills, whether this be for rural or metro. I;m talking cutting edge on diagnosis, investigation, metacognition – all that good stuff we talk about in FOAMed.

    Which is why I believe in FOAMed. It has done far far more to educate me as a Fellow, and I believe has potential to do far more to train registrars than the current RTP system, which seems to duplicate services within a State, rather than have one properly run National body with local admin through the College.

    Having multiple RTPs just seems – wasteful. Urologists, opthalmologists, pathologists and all the other specialty groups don’t seem to need a plethora of RTPs, each with their own medical educators. Is training to be a GP THAT hard, that we need layers and layers of meducationalists, with different RTPs, each with own admin and bureaucracy?

    Please dont get me wrong – I aspire to be a good educator myself and fully respect the good ones (who invariably are those who still practice frontline medicine).

    But seeing some of the educational crap foisted on my PRCC students and RTP-registrars makes me despair…

  9. Tim , I appreciate your point but there is good and bad to anything . I could say same things regarding EMST but you are still heavily involved yet I try not to be critical of that ! Not to same level you are firing at the RTP and medical educators . GP training is better funded and resourced now for a good reason . I would not be comparing us to other colleges

    FOAMEd has a role for you . As for training GPs , who knows . Maybe . I am less evangelistic about its role in foundation training than you.

    You have a right to disagree on the content of teaching but I don’t think it’s helpful accusing current educators of wasting time and resources . At least not publicly !

  10. Great post on a subject very close to my heart. Thanks Penny. And wonderful to see so much discussion generated. Agree that the skills surrounding giving /receiving effective feedback are invaluable, as is the ability to work collaboratively and effectively with others. The human relationships in medicine are critical – with colleagues and patients. A drive for lifelong learning and self improvement is also so valuable. Ericsson’s work on the art of “deliberate practice” particularly resonated for me when I first came across it.

    Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med. 2004 Oct;79(10 Suppl):S70-81

  11. OK, thread risks getting de-railed

    Minh, I have been clear what I think would be useful to train trainees.

    I am critical of RTPs and the meducationalista….not critical of GOOD medical educators, but of a bureaucracy that surrounds them and a research focus from the Colleges that seems to focus more on training pathways than on genuine advances in care delivery by clinicians.

    Examples from my experience of RTPs :

    – one day ‘ATSI awareness’ saw a bunch of bored registrars standing around in an Adelaide park hearing about the stolen generation. Questions about Indigenous rates of disease, dealing with rheumatic heart disease or CSOM met with blank looks by meducationalists “why would registrars need to know about this?”

    – when I was a JCCA reg, I was seconded to a large NSW RTP as a condition of being an anaesthetic trainee. Lots and lots of form filling and the requirement to have a ‘nominated medical educator’…I was given to understand this was for funding purposes. Spent 12 months in NSW and never met my nominated RTP medical educator. Zip. No phone call, no letter. At the end I rang, asking how it was. She didnt even realise who I was, and instead gushed on about how wonderful the current anaes trainee was and what a shining example to others and what a great product of the RTP programme. When I explained that I was this protege, she didnt even know my name. Very hard to respect a system that creams the glory but doesnt engage with the trainee.

    – weekend meducator ‘residential’ for a group of med eds. Two hour bus trip down from Adelaide, ferry across to KI and a night in hotel. Yet never met up with local training practice, supervisors or registrar as the seafront hotel was 80km from the hospital and clinic. Looks more like a junket than a genuine medical education visit to me…

    – one day registrar training. Our KI registrar is forced to join a group on the Yorke peninsula – poor bugger has to fly off KI, stay overnight, drive hire car up to Kadina, spend the day doing face-to-face then repeat in reverse. Two nights away from hime, cost of hire car, hotel, flights. For a few hours face to face. Could be done cheaper with another study group closer on mainland or even…shock horror,..via skype. Wasting money.

    – annual College conference. I blogged about this in 2012…a programme that was top heavy with educational theory and wonderfully innovative stuff on registrar training pathways, but had bugger all clinical content.

    I do wonder if we have lost or way, with too much focus on the process, not the outcome. Most RTPs seem to be very uptodate on reg training and assessment, but a little lost when it comes to actual clinical content.

    Medical educators need to be credible. I do worry when I see newly. Fellowed doctors taking up positions as medical educators. I think need a few more years under belt to be effective. Ditto content delivered by mostly metrocentric educators (this may well be a South Australian thing). But without credibility or experience in the field…well, hard to take seriously..

    So…back to training

    – cut the bloat in RTPs
    – focus on good delivery of core GP skills
    – remunerate supervisors properly for training ( as a practice we lose money on a registrar, it fills a workforce gap only)
    – focus on the clinical and business domains I outlined a few posts above

    clinical domain

    – development of effective knowledge filters
    – understanding cognitive bias in medicine
    – use of regular sim training to explore impact of human factors in performance, risk and also embedding clinical skills inc decision-making
    – how to deal with uncertainty
    – effective use of FOAMed material to establish life-long learning
    – teaching skills, inc giving/receiving feedback
    – cement effective clinical skills and knowledge base by the above

    business-of-medicine skills

    – self-care
    – development of portfolio career that will last you through 25-30 years without monotony
    – effective tools to ensure a clear delineation between work and home life
    – recognising and pre-empting burnout in self, colleagues
    – succession planning
    – understanding business structure, family Trusts
    – establishing a desired annual income and working to that, not being slave to more $$$ = more happiness/prestige etc

    Finally

    Re EMST. I am one of its harshest critics. Still involved (for now) but desperately trying to improve the course content. Feel free to criticise the programme; I am first to say that it is entry-level only and not the be-all and end-all. Seriously, criticise it. I do…

    Re FOAMed evangelicism. I think is useful for the advanced registrar or Fellow. It is not the sole way to deliver curriculum to newbies. Gotta walk before you can run..

    • Thanks Tim and Minh for your comments. I think the debate is useful.

      Tim – I certainly understand your frustration and agree with a lot of the points you make, particularly with regards to the bureaucratic hoop jumping which often happens. In my RTP role I’m trying to see if I can make a positive difference, and this conversation is part of that. Let’s also keep in mind that there is considerable variation between RTPs so I hope your experiences aren’t universal across Australia.

      My only quarrel is with your comments re: newly-fellowed medical educators. I think that like all areas of medicine, we need junior people to get into it to be mentored up by more senior people. Also – those who were recently registrars have insights into the needs of trainees that the more experienced educators might not have, and hopefully would also have some innovative ideas to contribute. I do however agree that there needs to be a good amount of experienced leadership within the medical education team.

      Thanks again for your input!

      • Continue to be engaged and informed by your discussion. I however don’t work in Australia and was wondering if someone would be so kind as to explain the acronyms? I sense that we have the same issues in the UK. I am not yet an educator but hope to be one day…

        Many thanks

        Sam

  12. Thanks Tim and Penny
    Another advantage of newly qualified GPs becoming educators is that they are less likely to be cynical and burnt out .
    I don’t know why you brought up ATSI training and the stolen generation as an example of poor education . I know at least two of my colleagues here in the Far North would be offended if they read your comment , Tim . Please consider retracting that statement . It would have been better if you had simply stated in your opinion that Aboriginal Health training should be comprehensive including those clinical topics you cite , but your comment comes across as a lack of respect for the importance of the stolen generation in the culture of Indigenous Australians .
    To imply that registrars are bored by hearing of Indigenous history shows a lack of cultural awareness . You might not think that is important . I do . Cultural awareness is very important as a GP .
    Thankyou

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