Diary of an FY1-Elephant in the room: teaching

 

The end of FY1 reaches its climax in the ARCP, an assessment based on the e-Portfolio to determine whether or not we progress (or really whether we progress without a number attached to our name). The e-Portfolio being designed as an online resource to track our progress and ensure that we are achieving the necessary milestones to progress. Whilst no more difficult to do than harassing people to sign forms that you send them online, bar meeting absentee supervisors, it can be a stressful event as it requires faith that people will actually fill the forms in (alternatively you can harass them daily with reminders).

One of the key areas in order to pass is a 70% teaching attendance score, as well as a teaching and learning segment where one must aim to make a presentation to show that they are furthering the learning of others. This is of course on top of the 15 learning experiences that are meant to be taught ad hoc with other more senior members of staff.

What this does of course mean is that there is actually a huge jumble of experiences that are meant to make up our training experience rather than simply sitting an exam and saying, “Hey, look at all this theory I know.” Instead, there is a combination of lectures and clinical experiences (and mainly the latter) that make up our abilities as doctors.

Notably however, is that people have to actually be able to facilitate these learning experiences which is the point of the teaching and learning exercise. Whilst it is usually a presentation (because when else can a consultant find time to watch you teach), there is actually a scope to teach medical students on the ward.

If there is anything I remember about my medical student days, it was usually not spending much time on the ward and rather much more in textbooks. Quite often I remember being told that ward experience was fundamentally about being proactive and finding things to do, although working on the ward reveals the reality that things happen at random times because that’s when people get around to doing it. For example, blood returns don’t happen until the phlebotomist comes back, patient reviews don’t happen until the nurses do their four hourly obs, and correction of pathology doesn’t happen until either the bloods are chased or Mr Alzheimer decides to climb out of bed and fall. So the aimless time spent on the ward is completely reflective of how things happen. Sure, you can go clerk a patient or two, but the reality of clinical medicine is that a lot of it is reactive to changes, unlike primary care which aims to be a lot more proactive.

There is of course the fact that as soon as anything begins to happen, doctors suddenly become too busy to possibly teach students. Students will often excuse themselves at this point in order to let the busy doctor get on with the business.

In my own personal view, this is all wrong. The simple fact of the matter is the fact that FY1 is an utter nightmare in the first few days if not weeks. There must therefore be some kind of experience that we all acquire in that interim time period when the job suddenly becomes bearable and not just a stressful 8/9/12 hours of purgatory between waking up and going to sleep.

Of course, some could answer that it is a simple question of experience. And yes, to an extent it is, because only experience gives us the faith to know that what we are doing is not only correct but that it will work. But experience is the ability to relate to the past narrative of things that have already happened that we can draw upon to predict how things will change. But this is the precise thing that can be taught: a narrative. For example, the simple fact of the matter that people don’t just become sick and that the reality is that much of medicine is about responding to changes as they occur and that changes tend to be small and incremental rather than massive and mortal.

There is a common derogatory saying that, ‘Those that do: do. Those that can’t: teach.’ Anyone that has attempted any amount of teaching will soon realise that teaching is it’s own specialised skill that does not simply manifest after learning enough. Indeed, like clinical medicine, one learns teaching by experiencing it.

What stops us teaching medical students on the ward is often the reality that most doctors are simply unsure how to teach. The huge disconnect between undergraduate medicine that is more focused on learning small pieces of information rather than the reality of practising medicine which is about responding to changes and rectifying them.

How can we reconcile these two approaches? Well, one effective manner is to simply talk through what we are doing as we do it. For example, how do we actually decide which jobs are bullshit or not? Is it because we know that particular nurse over-escalates every small change in the obs chart? What about the key parts of an examination? It is one thing to tell students that yes, OSCEs are over-rehearsed pieces of acting, but why are clinicians able to ignore so many steps and still know more about the pathology of a patient than the student can manage?

These are all questions that we have taken for granted but they all have something to teach students new to the world of medicine that only have diagrams of things in their minds rather than terrifying real life people.

But the most important lesson to take is that anything can be taught. One forgets the knowledge that they take for granted and it takes a step back to realise how much we have to offer those less experienced than us. The skill of teaching has to learnt, and even 1st year clinical students can learn a lot simply teaching each other. We all become specialised in the end, and have our own strengths and weaknesses. So go out there and teach! You never will unless you try.

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