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TRAINING MATTERS

REVIEW

Teaching and learning on the ward round Brian T Johnston,1 Roland Valori2 1 Department of Gastroenterology, Royal Victoria Hospital, Belfast, UK 2 Department of Gastroenterology, Gloucestershire Royal Hospital, Gloucester, UK

Correspondence to Professor Brian T Johnston, Department of Gastroenterology, Royal Victoria Hospital, Grosvenor Road, Belfast, BT12 6BA, UK; brian.johnston@belfasttrust. hscni.net Received 7 October 2011 Accepted 28 November 2011

Abstract Because of the European Working-Time Directive and ‘the New Deal’, there has been a significant reduction in opportunities for training. To address this deficit, consultants and junior doctors will need to alter their approach, making greater use of the learning opportunities that arise ‘on the job’. This paper provides some ideas on how to maximise learning without radically increasing workload. The paper first looks at attitudes and behaviours that influence the learning environment. If the senior doctor encourages discussion and shows enthusiasm during clinical duties, junior doctors will learn more. Second, the paper focuses on key skills that can be adopted to ensure appropriate learning. These attitudes, behaviours and skills can help consultants and senior doctors improve the effectiveness of their teaching in an era when the time available for junior doctors to learn has been reduced.

The recent review of the impact of the European Working-Time Directive (EWTD) on learning opportunities states that ‘the New Deal when combined with the EWTD adversely impacts on training opportunities’.1 Temple1 suggests that to address this deficit, consultants will need to alter their working practices and in particular have recognition of their training role explicitly documented in their job plan in view of the other competing demands on their time. In a survey of trainees in gastroenterology, 41% reported that they were not often or rarely taught on ward rounds. When they were taught, they rated the teaching as ‘so-so’ to ‘poor’ 46% of the time.2 There is much that consultants can do without radically changing work practices or allocating more time for formal teaching. Using small changes to the way they approach ‘work’, it is possible for consultants to make much greater use of the multitude of learning opportunities 112

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that arise. This paper provides some ideas on how to maximise learning without a significant increase in workload. The ward round is used as an example to highlight teaching opportunities—‘teaching as we work’. The principles can be applied to other settings such as outpatient clinics, multidisciplinary teams, after formal learning events such as grand rounds and in other opportunistic learning encounters (such as breaking bad news). Scenario The foundation year 1 (FY1) doctor has taken more than 10 min to present a comprehensive (perhaps overly comprehensive) history and physical examination of a patient on the ward round. Within 2 min, the consultant has asked a couple of clarifying questions, performed a targeted examination, made a plan for the patient’s management and moved onto the next patient. How effective was the learning for the FY1 doctor and what was the difference between the approach of the trainee and the consultant? The FY1 doctor probably gained very little from the episode, certainly much less than was possible. There is a clear gap between the competency of the consultant (as a doctor, not trainer) and that of the trainee, and there was little attempt to bridge it. First, the FY1 doctor has spent up to an hour gathering all the information, conducted a full systemic enquiry, performed a comprehensive examination and may still have a limited idea of how the patient should be managed. The consultant on the other hand brings to the ward round his/her considerable previous knowledge accumulated over many years of experiencing similar presentations, complemented by ongoing professional development with reading, conference attendance and other educational opportunities.

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TRAINING MATTERS The consultant has the benefit of all the information provided by the trainee, but in addition the consultant has the ability to prioritise key pieces of information (by identifying the most discriminating responses) and target examination to the appropriate area. (S)he then makes a judgement on the likely diagnosis, the necessary investigations and the appropriate treatment. All of this occurred within 2 min and usually without the consultant consciously thinking of possibilities, probabilities or options for next steps. The correct outcome for the patient will usually be achieved, but none of this consultant’s learning and experience has been passed on to the trainee on the ward round. The gap remains as wide as it was before the ward round started. Several issues are highlighted by this scenario: first, the consultant has to want to help the trainee develop their clinical skills; second, (s)he has to believe that this can be achieved without compromising the primary goal of completing the ward round; and finally the consultant has to understand how to make the most of the opportunity. All ward rounds contain learning opportunities that can be identified and used. A fundamental requirement for the consultant is to be consciously aware of how (s)he reaches decisions. Only then can (s)he verbalise this and help raise the awareness of the trainee and develop their understanding. The trainee should feel valued on the ward round and not an impediment to its completion. Their contribution should be acknowledged and their learning needs should be explicitly identified. Doing these few things will significantly improve learning, with only a small investment in time. This paper explores further a few simple things that will enhance learning as we work (Box 1). Attitudes Adopt an approach that ‘working is learning’. There is a role for the traditional teaching ward round, which is separate from the business round, the focus of all participants being on education rather than trying to combine it with clinical work.3 However, recent educational theories of workplace learning have sought to break down the distinction between working and learning. Such theories suggest that our attitude should be one of regarding each patient encounter as a learning opportunity, as well as a clinical task. In the scenario above, every member of the ward round team can, potentially, be involved in the decisionmaking process. This inclusive approach needs to be led by the consultant. (S)he should model a willingness to learn, regularly asking questions rather than providing answers, and explaining to trainees the benefit of being involved in the process of on-the-job learning.4 Enthusiasm

Enthusiasm is a key feature that can be exhibited and encouraged by the consultant, setting the tone for the rest of the ward round team. The consultant’s attitude towards both the patient and the learners sets an example. Although modelling such attitudes is not part

of the formal curriculum, it is an integral part of the hidden curriculum observed (and later copied) by all on the ward round.5 In contrast, the consultant’s body language will often transmit a subliminal message during a ward round: one of wanting to get it finished as soon as possible. Behaviours Walton and Steinert6 have highlighted the minimal involvement of many of those participating in the ward round. Many medical students and junior members of medical staff believe that they have nothing to contribute to the ward round and that they do not have a ‘voice’. Participants in a ward round may need ‘permission’ or be encouraged to make a contribution. If the consultant in the scenario explains at the start of the ward round the value (s)he places on verbal participation and collaborative learning, contributions and a positive learning environment are much more likely to follow. A positive learning environment may be a better measure of a good teacher than the degree of actual knowledge that is communicated. Research by Griffith et al7 has shown that being taught, even briefly, by an inspirational teacher is enough to improve the exam results of those students. These highly rated teachers create ‘a learning climate that makes learning fun, enjoyable and exciting’ and their modelling of lifelong learning is adopted by their students. Research in other contexts has confirmed that learning can be enhanced by creating a positive, encouraging atmosphere, rather than a negative, critical one; for example, tasks can be more easily remembered when learnt with humour.8 9 Skills Key skills to facilitate learning are listed below. Identifying the previous experience and learning needs of the learner

If this is the first ward round with the trainee, it is worth exploring what situations they have previously worked in and whether there are particular patients they have found difficult. Dedicating a few minutes to this before the start of the ward round can allow the trainee to highlight their perceived learning needs, taking responsibility for their own learning. It can also help identify a suitable case for subsequent case-based discussion or mini clinical examination. Exploring a trainee’s understanding

When a trainee arrives at a conclusion, explore what led them to make that diagnosis or management plan. Similarly, talking through and explaining why the consultant came to a different conclusion is an important learning process. If the atmosphere is one of a ‘safe place’, the junior doctors will feel free to share their thinking. The careful choice of open, non-threatening questions is an effective way of stretching learners and their understanding. This approach can be extended in the case of a senior trainee, with the consultant ahead of time agreeing that the trainee conducts the ward Frontline Gastroenterology 2012;3:112–114. doi:10.1136/flgastro-2011-100055

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TRAINING MATTERS Box 1 1. 2. 3. 4. 5. 6. 7. 8. 9. 10.

Tips for teaching as we work

Adopt an approach that ‘working is learning’. Be willing to learn and teach. Demonstrate enthusiasm. You are a carefully observed role model. Identify the needs of the learner. Encourage input from everyone. See and highlight the learning opportunities. Explore a trainee’s understanding, using open questions. Think out loud, verbalising the decision-making process. Discuss the cases afterwards over a cup of coffee. Clarify how the trainee is going to address their DENs (doctor’s educational needs).

Conclusion Both the New Deal and the EWTD have reduced the time available for junior doctors to learn. By adopting a few new skills, consultants can improve the effectiveness of their teaching. By adjusting our attitudes and behaviours, we can improve the impact of learning experienced during routine work. For further development of this concept of optimising learning opportunities in the workplace the London Deanery offers an online course entitled ‘Facilitating learning in the workplace’,14 see also Hargreaves et al.15 Competing interests None.

round and the consultant observes. Such an approach can be the basis of a 360 degree assessment.10

Provenance and peer review Commissioned;

Thinking out loud

References

Consultants have often reached the stage of ‘unconscious competence’ in diagnosing patients. To be able to teach students and trainees effectively consultants need to step back into the ‘conscious competence’ zone. Being able and willing to articulate how a judgement is made, effectively ‘thinking out loud’ can help the trainee move into the conscious competence zone more quickly. For example, what were the key factors that enabled the consultant to allow this patient with haematemesis home without endoscopy, or determine that the abdominal pain is functional and needs no further investigation?

1. Temple J. Time for Training. A Review of the impact of the European Working Time Directive on the quality of training. NHS Medical Education England, 2010. http://www.mee. nhs.uk/PDF/14274%20Bookmark%20Web%20Version.pdf (accessed 15 Feb 2012). 2. Wells CW, Inglis S, Barton R. Trainees in gastroenterology views on teaching in clinical gastroenterology and endoscopy. Med Teach 2009;31:138–44. 3. Rees J. Take a teaching ward round. BMJ (Clin Res Ed) 1987;295:424–5. 4. Melo Prado H, Hannois Falbo G, Rodrigues Falbo A, et al. Active learning on the ward: outcomes from a comparative trial with traditional methods. Med Educ 2011;45:273–9. 5. Chen PW. The Hidden Curriculum of Medical School. http:// www.nytimes.com/2009/01/30/health/29chen.html (accessed 15 Feb 2012). 6. Walton JM, Steinert Y. Patterns of interaction during rounds: implications for work-based learning. Med Educ 2010;44:550–8. 7. Griffith CH III, Georgesen JC, Wilson JF. Six-year documentation of the association between excellent clinical teaching and improved students’ examination performances. Acad Med 2000;75(10 Suppl):S62–4. 8. Schmidt SR. Effects of humor on sentence memory. J Exp Psychol Learn Mem Cogn 1994;20:953–67. 9. Gifford H, Varatharaj A. The ELEPHANT criteria in medical education: can medical education be fun? Med Teach 2010;32:195–7. 10. Lakshminarayana I, Wall D. 360° Tool assessing ability of specialist registrar to lead ward rounds. Arch Dis Child 2011;96:A25. 11. Stanley P. Structuring ward rounds for learning: can opportunities be created? Med Educ 1998;32:239–43. 12. Anglia Deanery. Educational aspects of mentoring. February 2011. http://www.gp-training.net/training/communication_ skills/mentoring/educate.htm (accessed 15 Feb 2012). 13. Greenberg LW. Medical students’ perceptions of feedback in a busy ambulatory setting: a descriptive study using a clinical encounter card. South Med J 2004;97:1174–8. 14. London Deanery. Facilitating learning in the workplace. 2012. http://www.faculty.londondeanery.ac.uk (accessed 15 Feb 2012). 15. Hargreaves DH, Southworth GW, Stanley P, et al. (eds) On-the-training for physicians. London: Royal Society of Medicine Press, 1997.

Post-ward round debriefing

Making time for a cup of coffee together after the ward round can be a useful, informal learning opportunity, providing a chance to discuss further issues that arose during the round. Going over the patient list also ensures there is a plan in place for each patient. Stanley11 has emphasised the importance of using the time pre and postward round to maximise learning opportunities. Guiding future learning

The various e-portfolio systems introduced to record junior doctor learning experiences emphasise the need for case-based discussions and mini clinical examinations. Every patient encounter is an opportunity for using these tools. However, for this to be more than a tick box exercise, it is important to identify what the trainee believes they have learnt from the episode and what gaps they have identified for further learning. General practitioners use the term ‘DEN’ (doctor’s educational need) to define formally the need and then record the learning required to meet the need.12 Highlighting the learning

Often trainees do not believe that they have either learnt anything or been given any feedback without the learning point being directly highlighted and emphasised. Simply providing ‘cue cards’ to clinical teachers highlighting areas for feedback improved the learning experienced by students on the ward round.13

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externally peer reviewed.

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Teaching and learning on the ward round Brian T Johnston and Roland Valori Frontline Gastroenterol 2012 3: 112-114

doi: 10.1136/flgastro-2011-100055 Updated information and services can be found at: http://fg.bmj.com/content/3/2/112

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Teaching and learning on the ward round.

Because of the European Working-Time Directive and 'the New Deal', there has been a significant reduction in opportunities for training. To address th...
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