2014, 36: 655–656

COMMENTARY

Are we nearly there yet? TRUDIE E. ROBERTS University of Leeds, UK

If one uses the analogy of a journey to describe the development of professional competence from novice to expert, then arguably three of the most important elements of this journey would be: a map to guide the traveler, regular feedback on their progress and the provision of appropriate increasing responsibility over the course of the journey. The three papers presented here by Crossley, Watling and van Loon et al., come from presentations at the AMEE symposium entitled, ‘‘On becoming a doctor, the state of affairs’’, in Prague 2013. They cover the journey of professional medical development and discuss those elements. In the first of these papers, Crossley presents the case for presenting learners with a road map for learning. He describes the disorientation that medical students feel when entering medical programme due to not knowing what they are becoming. Is this completely accurate? From engagement with new students over two decades it has always seemed to me that students enter medical school with very definite and usually erroneous ideas of what it means to be a doctor, usually gleaned from television soap operas such as ER. Consequently, Faculty often spend the first few months of the course re-orientating students to a reality grounded in every day experience of a medical role. However, Crossley is completely correct that students often struggle with the transition that for many of them marks the change to tertiary education and the ‘‘putting away of childish things’’. ‘‘Liminality’’ is a term coined in twentieth century anthropology by Victor Turner of the University of Chicago. Limen in Latin means threshold, and anthropologists like Turner have become interested in a certain state experienced by individuals as they pass over the threshold from one stage of life to another. He notes that the rite of passage at puberty has three phases: separation from one’s status as child in a household, then a liminal stage, and finally reintegration into society as a full and independent adult member with rights and responsibilities that the initiate did not have before. During the liminal stage, the between stage, the individual’s status becomes ambiguous; (s)he is ‘‘neither here nor there’’ (Turner 1974, p. 232), and thus the form and rules of both his/her earlier state and the state-to-come are suspended. For this time, (s)he is an outsider; on the margins, in an indeterminate state. Turner is fascinated by this marginality,

this zone of indeterminacy which individuals can find particularly stressful. When I read about the concept of liminality several years ago it struck me that although this idea may apply to all university students, to some extent it was particularly applicable to medical students. On entering the medical course, due to their interactions with illness and death, they undergo a series of intense emotional experiences, that few other young adults have. They are still not yet fully accepted into the medical profession and so consequently they do undergo an identity crisis. If Crossley’s road map can help student navigate this ‘liminal’ period then perhaps it would become less traumatic. Watling also uses the road map metaphor in his paper ‘‘Feedback at the crossroads’’. In this paper he argues that although feedback is known to be a powerful factor in directing, shaping and supporting learning, it often fails to live up to its potential. Whereas many studies largely reflect the notion that feedback is a process only between the feedback giver and the feedback recipient; other literature has demonstrated the influence of the context on feedback-seeking behavior (Whittaker et al. 2007). In addition to addressing the culture in which feedback takes place, Watling also concentrates on the learner’s perception and response. Whittaker and colleagues (cited above) in their study on feedback in business organisations found that perceptions of a positive supervisor and coworker feedback environment led to increased feedback-seeking behavior. Additionally, clarity of what was expected of the employee in their role provided a positive relationship between feedback-seeking behaviors and job performance. Linking these findings back to Watling and Crossley’s papers implies that more clarity of what is expected of students and trainees combined with a positive learning culture would enhance the effectiveness of feedback and potentially enhance performance. The environmental culture also plays an important part in the last paper by van Loon et al., on entrustable professional activities (EPAs) by van Loon and colleagues. It is a timely critical analysis of this relatively new concept within medical education. There is an interesting English proverb which also incorporates the metaphor of travelling. ‘‘The road to the hell is paved with good intentions’’1 which is perhaps apt to use here. Van Loon et al. examined the potential and pitfalls of EPAs.

Correspondence: Prof. Trudie Roberts, Medical Education Unit, University of Leeds, Level 7, Worsley Building, Clarendon Way, Leeds LS2 9NL, UK. E-mail: [email protected] ISSN 0142-159X print/ISSN 1466-187X online/14/80655–2 ß 2014 Informa UK Ltd. DOI: 10.3109/0142159X.2014.931934

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They point out that EPAs offer the potential to link teaching of abstract competencies to curricula based on real-life professional activities. They also emphasise that the workplace is crucial for EPAs to function as intended. The clinical working environment as we know can be a chaotic and pressured environment and these authors are concerned that many clinical situations in which trainees find themselves working will not be able to live up to the description of an educationally prepared environment. Consequently, they are concerned that like many good intentions EPAs will fall by the wayside. Interestingly, similar to the points made above, this group also points to work from organizational management research as having important messages for medical education. Thus, the answer to the question ‘‘Are we nearly there yet’’ with respect to medical education and training it would appear not. However, to paraphrase the modern Greek poet Cavafy2 it is not arriving at Ithaca, but the journey towards it that is more important. These papers are the final ones from a series of symposia at four AMEE meetings beginning in 2010. These sessions have covered topics of curriculum, assessment, feedback and finally professional development. I am grateful for the stimulating talks given by all the participants, the challenging discussions with the audiences at these events and also for the hard work and support from my co-presenter Cees

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van der Vleuten. The journey has been an exciting and fascinating one, and I have been privileged to have been part of it.

Notes on contributor TRUDIE ROBERTS, BSc (Hons) MBChB, PhD, FRCP, FHEA, is the Director of both the Leeds Institute of Medical Education and the Medical Education Unit in the School of Medicine at the University of Leeds, UK.

Notes 1. People who intend to do good can end up doing bad (the law of unintended consequences). 2. Ithaca by C.P. Cavafy, Collected Poems Princeton University Press 1992

References Turner V (editor). 1974. Passages, margins, poverty. In: Dramas, fields, and metaphors: Symbolic action in human society. Ithaca: Cornell University Press. p 232. Whittaker BG, Dahling JJ, Levy P. 2007. The development of a feedback environment and role clarity model of job performance. J Manage 33: 570–591.

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