The Registrar in Difficulty

1. The Registrar in Difficulty

2. Prevalence 6-9% • Lack of knowledge 48% • Poor judgement 44% • Inefficient use of time 44% • Attitudinal, interpersonal conflict, family stress, psychiatric illness, substance abuse

3. A tidy model and strategy for helping the registrar in difficulty? • Afraid not! • 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??? Crucial to this is deciding if there really is a problem or not, which is not easy

5. Anticipated progress Performance Time

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. • VTS – as above, counselling, psychology involvement, careers advice etc. • Deanery – governance, financial • NCAS – performance assessment • GMC – fitness to practice

8. 2. Characterise the problem • 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) • History of the learner – academic, social and psychological • History of the problem • Is it a problem that needs to be fixed? • Ascertain the learners views and insight into the problem • Where does the problem lie?

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

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

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

14. Steinert 2008:BMJ 336, 150-153 Where does the problem lie? Unsupportive Overly critical Unreasonable expectations Disinterested Non challenging Failure to meet learner’s needs Teacher 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) Knowledge Skills Attitudes Learner Environment

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

16. Models of learning • Androgogy • Experiential Learning Theory • Bloom’s Taxonomy

17. Androgogy vs. pedagogy

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

19. Concrete Experience Feeling How do we learn? The Learning Cycle Accommodating (feel and do) HM - Activist Diverging (feel and reflect) HM - Reflector Perception Continuum how we think about things MB – Feeling-thinking scale Reflective Observation Reflecting Active Experimentation Doing Processing Continuum how we do things MB – extroversion-introversion scale Converging (think and do) HM - Pragmatist Assimilating (think and reflect) HM - Theorist Abstract Conceptualisation Thinking

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

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

22. Levels of cognition

23. 3. Structured intervention

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

25. Learning plan/contract States… • What will be learned • How it will be learned • What resources are needed • How learning will be measured • 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 • Contract of educational objectives • Monthly review of performance compared to agreed objectives • Doing greater proportion of seminars myself • Fewer topic based seminars and more seminars focused on eP and PDP • 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 • Tendency to challenge more and take less for granted • Review all consultation records • Screen all referrals before sending • Markedly reduced registrar workload • Few home visits • All Cuedoc shifts supervised • More joint surgeries • More proactive in seeking feedback from colleagues • Exhaustive record of discussions from structured teaching sessions • Documentation in form of daily diary • 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 • CBD every month • COT every month • All referrals to be recorded on eP • Weekly joint consulting session • All learning points to go onto learning log • All learning objectives onto PDP • All PDP entries to be SMART • 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 • Documentation and record-keeping • Regular appraisal and feedback • Fairness • Confidentiality • 90% of problem learners succeed after structured intervention

29. Trainers responsibilities • Raise concerns • Clarify nature of the problem • Manage safety • Maintain confidentiality • Design and deliver intervention • Measure outcomes • Give feedback • To trainee - to train, not to assess (formative not summative) • To scheme/deanery - to give objective feedback, backed up by comprehensive documentation

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

31. Useful starting points • Recent series in BMJ • Northern Deanery website • National Association of Clinical Tutors • www.gp-training.net

32. (The End)