SPECIAL ARTICLE
Teaching Residents Through Consultation Med Teach Downloaded from informahealthcare.com by Flinders University of South Australia on 01/11/15 For personal use only.
W. C . WILLIAMS W. C. Williams, PH. 0,is Associate Professor, School of Education, Baylor UniuersiQ, Waco, Texas 76703, USA. Some patients present problems which exceed a junior doctor’s ability to analyse and synthesize information o n which management decisions must b e made. As a result, he or she often consults with an attending physician or consultant. I n this article four types of consultation are identified and analysed, each of which has potential for use as a teaching strategy. A high level of motivation for applying knowledge, which has been gained over years of study, is often quite evident in medical residency centres where young doctors are given their first full-time opportunity to practise medicine. Most medical school graduates today are well prepared academically. In general, all that seems to remain is the gaining of supervised experience in applying the knowledge that has accumulated. Many of the patient complaints brought to the resident fall within hidher range of ability to diagnose and prescribe. Thus, while the new doctor may be required each day to present a given number of cases to an attending physician (consultant physician), the interaction that transpires between the two doctors often involves little more than ‘‘touching bases”. However, the demands of some patient situations may exceed the resident’s ability to analyse and synthesize the information upon which decisions must be made. At such times, a much more in-depth kind of consultation ensues wherein the attending physician’s years of practical experience provide a base from which to progress. Again, the resident may have the basic knowledge necessary for solving the problem but simply lacks the experience necessary for applying it. An important contribution to a young doctor’s ability to solve problems independently can be made through the variety of consultative encounters which occur between him/her and the attending physicians. One of the goals of consultation, as noted by Bindman (1964), is that “ ... of education, so the consultee (resident) can learn to handle similar cases in the future in a more effective fashion and, thus, enhance hidher professional skills”. The interaction between the attending physician and the resident 142
may have as much impact upon the resident’s final preparation for a career in medicine as anything that happens to himlher during the residency. Further, the extent and manner of provision for the resident’s continued involvement in patient care subsequent to consultative encounters is quite important. Relationships between Attending Physicians and Residents These are of four types. First, there are those situations in which the attending physician may feel justified in confiningheducing the resident’s involvement in a case to little more than that of observer, as the more senior doctor performs a selected procedure for which the resident seems unprepared. Second, in some emergency situations, a rapid sequence of events may terminate the resident’s involvement as the attending physician assumes full responsibility for the patient’s care. Early discharge of the patient could result in the young doctor having no further contact with the patient, especially if the attending physician prefers to manage any possible follow-up of the emergency. A third type of consultative relationship may, for all practical purposes, result in the attending physician working indirectly through the resident as the latter carries out the physician’s instructions/ advice. The attending physician’s influence may thus range from simply supplying information, to literally engineering most of the actions taken. Finally, many consultative encounters lead into a free flow of interaction between the two doctors as the attending physician facilitates the resident finding hidher own solution to a given problem. While these four types of consultative relationship are not mutually exclusive, each is suffkiently discrete to merit discussion.
The ‘Modelling of Services’ Method of Consultation The first of these four types of consultative relationships might be labelled the ‘modelling of services’ method of
Medical Teacher V o l 3 No 4 1981
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consultation. Here, the attending physician’s primary function is to demonstrate and elaborate a given procedure as the resident observes, asks and answers questions and stands ready to offer appropriate kinds of support. While the resident may or may not have assumed an active role in the patient’s care before the modelling of services by the attending physician, the resident’s learning something of value from the experience is not precluded. Howe (1980) proposed that “one way to learn is through watching other people behave, and in this way we can acquire habits, skills, and knowledge without having to directly experience the consequences of every single action. ” Learning from observation need not be limited to the focus of the demonstration only. Suppose that a demonstrated procedure is unsuccessful; can the observer still learn something worth while from the event? Although the outcome of modelled behaviour influences the likelihood of the observer repeating it, the consequences do not necessarily affect learning somethingfrom what the model did (Howe 1980). “Observation may lead to a person acquiring a rule that can be applied. ..” (Zimmerman and Rosenthal 1974). Howe (1980) notes that through observing others, we can acquire new concepts, rules, strategies and ways of remembering information. In general, the resident will not only learn the action components of the behaviour observed, but will also generate rules about how to, and how not to, approach the task.
Facilitating Learner Involvement Passive, unguided observation by a resident may seriously limit learning of the sort intended by the doctor doing the modelling. In a theory advanced by Bandura (1977) it was proposed that learning by observation increases when provision is made for learner involvement. Bandura (1977) suggests four ways to facilitate interaction of the learner with the focus of the learning. First, direction of the resident’s attention to distinctive features of the behaviour to be modelled is important. In complicated procedures the resident may not know ‘where to look’ in order to learn how to accomplish the task on hidher own. Second, if the procedure is especially involved, the doctor who is doing the modelling should identify each of the component activities and note any sequence of events that should occur. If an order of activity is to be rigidly followed, the rationale should be given. Third, the manner in which observed acts are represented in the on-looker’s memory will be affected by verbalizing what is observed. Even as memory-traces of things observed seem to involve images of what was experienced, so too are verbalizations about the activity also retained. Therefore, Howe notes that talking about perceived events serves as an effective strategy for facilitating learning by observation (Howe 1980). Time spent discussing the procedure to be learned, either during or after the demonstration, will not be wasted. Finally, the value of imitating a behaviour as well as the ‘attractiveness’ of the individual doing the modelling affects learning by the observer. The probability of a resident conducting a given procedure in a manner similar to that
Medical Teacher V o l 3 No 4 1981
modelled by the more experienced doctor will be increased if the outcome is seen as desirable, and if the doctor doing the modelling is perceived as a person worthy of emulation by the resident.
The Expert Method of Consultation Moving up from the ‘modelling of services’ method of consultation to a level where the probability of the resident’s direct involvement increases, Kurpius and Robinson (1978) propose three methods of consultation for consideration. In the first of these, the consultee, who finds himself in a difficult situation, defers to a consultant who then becomes the problem-solver and assumes responsibility for ‘cure’. Schein (1969) refers to this approach as the expert method of consultation. Thus, in the medical setting the resident (as consultee), who is confronted with an especially complicated patient situation, defers to an attending physician (consultant) who in turn provides direct services to the patient. In some instances very little or no further treatment of the patient by the resident follows after consultation/referral. Several questions should be answered before an attending physician assumes the ‘provider of services’ role (Kurpius and Robinson 1978): was the resident able to gather enough information from the patient to justify the attending physician’s ‘taking over’? Is the resident’s perception of the situation accurate? T o what extent are the resident’s assumptions, knowledge, values and own defences incorporated in the data presented to the attending physician? Who will claim ownership of the problem after consultation/referral? Will major responsibility be permanently, or only temporarily, transferred to the attending physician? Finally, will the attending physician or the resident follow-up on patient compliance and evaluate the effectiveness of treatment? As in the case of some emergencies, direct treatment of a patient by an attending physician may be the most appropriate alternative. However, it is generally advisable for both the attending physician and the resident to agree that this is the best approach. Without such agreement, and without addressing the questions listed above, the self-confidence of the resident may be seriously threatened and the parameters within which he/she assumes responsibility in the future may be left without adequate definition. Several indiscriminate interventions by an attending physician over a period of time could decrease a resident’s motivation for thoroughness, strain the relationship between the two doctors, disrupt the continuity of care given to patients, increase patient fears relative to their illness and deprive the resident of important opportunities to learn how to deal with anything other than routine situations. If at all possible, rather than excluding the resident from further care of the patient, a triadic relationship (attending physician/resident/patient) should be established at the time that the intervention becomes necessary. Such an arrangement would surely include an explanation acceptable to the patient for the attending physician’s involvement. Some form of continued treatment of the patient by the resident would impress upon
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the resident that a degree of responsibility to a patient may be in order even after the negotiation of referral. When the need for the attending physician’s direct intervention has passed, helshe would do well to discuss the case thoroughly with the resident and return the patient to the junior doctor’s care. Provision for the resident to gain first-hand experience with a similar situation should then be made as early as possible.
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The Prescriptive Method of Consultation It is not uncommon in the medical setting for residents to approach an attending physician with a quick review of their patient’s history and chief complaint and then ask for information related to the problem, help with a diagnosis and/or suggestions for managing the patient’s situation. Such encounters may lead directly to the attending physician’s supplying the resident with whatever the focus of the request has been. On other occasions, the attending physician may press for substantially more information about the whole situation before responding to the resident’s request. I n either event, this kind of interaction often leads into the second of the three types of consultation proposed by Kurpius and Robinson (1978). It is referred to as the ‘prescriptive mode of consultation’: the consultant does not always respond immediately to the resident’s query with a ‘prescription’. While the consultant (attending physician) might use the consultee’s (resident’s) information as a useful point of departure to develop further the process of diagnosis, the validity of the resident’s information is not immediately accepted or rejected as presented. Rather, the attending physician may investigate the situation further by interrogating the resident, examining more closely the records on the patient and possibly re-examining any available laboratory data. When the attending physician is satisfied that the real problem has been identified, helshe recommends a best approach for the resident to follow. This means that final control of the situation is essentially vested in the attending physician as the resident carries out the directives of the more experienced doctor. When compared with the provider of services method of consultation, the prescriptive form registers several advantages. First, in that the resident does not cease direct contact with the patient, continuity of care is enhanced. Second, the occasional necessity for using the prescriptive mode c6uld well serve to encourage the resident’s thoroughness in taking the history of the patient’s illness. The resident should recognize that quality input is required by the attending physician for accurate diagnosis. Third, in emergencies where timely action is of an essence, the attending physician’s involvement will bring the system’s power/authority/obedience structure into immediate play. The resident acting alone would have difficulty engineering the situation in a similar manner. Some Problems
In spite of the above-mentioned advantages, the prescriptive method of consultation can impose unnecessary 146
limits on the resident’s opportunity to learn. Unless the attending physician explains the problem-solving process applied and hidher rationale for directives given, the resident may gain little more than experience in gathering information and carrying out orders. Thus, two problems may possibly arise. On the one hand, over a period of time a resident’s repeated deference to an attending physician could result in a form of dependency difficult to extinguish. At the other extreme, a second kind of problem might arise if a resident were unable or unwilling to carry out an attending physician’s directives. A resident’s ineffective management of a situation could work to the distinct disadvantage of the patient. It is therefore important that the resident not only agrees with the attending physician’s method of managing the situation but also that the resident is taken into the confidence of the more experienced doctor to the extent that he/she knows what to expect as a result of actions taken. Monitoring change in the patient’s condition could then be an important learning experience for the resident. In sum, the prescriptive approach is effective as a clinical teaching strategy only to the extent that the resident is taught the process through which the attending physician has progressed in solving the problem and selecting a method for managing the situation. If such teaching does not occur, and if the resident’s dependency on the attending physician increases, gradual movement toward a modified ‘provider of services’ approach could occur. The young doctor would thus be deprived of experiences vital to eventual independence in private practice.
The Collaborative Consultation The final approach to consultation, as described by Kurpius and Robinson (1978), calls for a form of collaboration in the problem-solving process. While consultees may need little more than an assessment of the tenability of their assumptions on one occasion, at other junctures they may seek a more sustained type of collegial relationship wherein diagnosis develops from contributions made by both parties. In either event, the consultant’s active participation contributes not only to the solution of the problem at hand, but may also teach the consultee to focus upon important units of content as the problemsolving process unfolds (Blake and Moulton 1976). In collaborative consultation, the consultant’s authority is de-emphasized from the beginning as helshe engages in an informal, but goal-directed, give-and-take. The interaction often begins with the consultee describing the problem. The consultant listens carefully, assisting in the establishment of a goal for the encounter and supplying information needed for illumination of selected aspects of the problem. The consultant carefully structures questions designed to bring more of the consultee’s knowledge into the interaction (Kurpius 1978). Alternative courses of action are generated and discussed freely as the consultee moves toward making a decision based upon an increasingly accurate perception of the situation. In the medical setting, the attending physician as the collaborative consultant contributes to eventual problem
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solution as needed and also attempts to facilitate the resident’s self-direction by bringing into play as much of the young doctor’s ability to diagnose and prescribe as possible. In so doing, the attending physician not only supports the resident’s efforts to manage the situation, but also challenges hidher observations, asks about the need for laboratory data and x-rays to support tentative diagnoses, and draws attention to factors possibly being neglected. Again, the collaborative consultant does not serve as the solver of problems. Rather, the consultant provides the framework within which plans and solutions are generated and an informal kind of teaching is conducted.
Some Definitions Using the collaborative mode of consultation, an attending physician thus emphasizes both content and process when working with residents who come for counsel. Some definition of each seems in order at this point. Basically, process refers to the series of phases through which a consultant and a consultee progress in defining a problem, subdividing it for analysis, attacking it and eventually reaching a solution. Content refers to the array of information applied in development of each phase of the process. Repetition of process, and possibly content to a lesser degree, can often be observed in medical settings where a form of collaborative consultation is routinely used. An attending physician’s repeated modelling of thoroughness of process can do much to teach the same to residents. Collaborative consultation lends itself easily to modelling of desired behaviours by the consultant.
Steps in the Collaborative Consultation Although the process in collaborative consultation involves to a large extent a series of mental events on the part of each participant, the consultee often comes to internalize the format as it relates to repetition of content. Kurpius and Robinson (1978) have proposed that six steps generally typify the process used in collaborative consultation : 1. The building of a workable relationship between consultant and consultee. 2. Gathering information. 2 . Identifying the-problem. 4. Exploring possible solutions. 5. Implementing an intervention. 6. Evaluating the effectiveness of the intervention.
The building of a workable relationship between an attending physician and a resident will be a function of several factors. It is important that the attending physician accepts the resident as a person of worth and maintains an openness to the variety of problems brought by the resident for discussion. Acceptance is conveyed in eye contact, active listening, alert posture, requests for clarification, summary statements and so forth. The attending physician must be psychologically as well as physically available. While some attending physicians
Medical Teacher V o l 3 N o 4 1981
may perceive themselves as being ‘psychologically’ available, their services go unused because they accept other commitments that conflict with ‘prime times’ for consultation. The importance of specifying a location where consultation can be conducted with some degree of privacy, and at a time when the resident can be assured of making contact with the attending physician, cannot be overemphasized. T h e doctor who is physcially present, but who is engrossed in making out hisfher own reports, is generally not seen as being accessible. Stritter, et al. (1975) identified accessibility as characterizing a consultant’s genuine interest in consultation. An atmosphere of trust and cohesion is essential in building a workable relationship. While the attending physician generally has the advantage of experience, he/ she must be aware that the resident may have the advantage of up-to-date knowledge. T h e attending physician should ’resist ‘authority’ behaviours. This is especially true of the resident is to continue ownership of the problem brought for consultation. Before continuing with the six-step process mentioned above, it might be well to note that rigid adherence to any system of problem-solving may limit, if not seriously impede, progress toward a favourable outcome from the interaction. Even as patient complaints vary from individual to individual, so too will the approach used in arriving at a best treatment for each. However, to demonstrate the possible conjugation o f content with process, a n array of content items that are often included in a collaborative consultation between attending physician and resident could be superimposed upon our sixstep process. Note the opportunities for sharing information, for comparing perceptions, indeed for teaching, as the areas of content shown in Figure 1 are brought into focus. Again, the list is included only t o exemplify the combining of content with process and to draw attention to the teaching potential inherent in the collaborative approach. I would not be so presumptuous as to propose foci for medical concentration.
Advantages According to Kurpius (1978) there are several advantages associated with the collaborative approach:
1. Most people become more effective if they participate in defining and selecting an appropriate solution for solving a problem. 2. While collaboration sometimes produces conflict, it generally builds lasting trust and respect among professionals. (On occasion, a n attending physician’s thoroughness may threaten a resident by revealing possible oversights.) 3. Collaboration de-emphasizes authority and power. The emphasis is more on, the different roles of the consultant and the consultee than disparities in status. 4. Latent problem-solving capabilities of consultees are activated. 5. Decisions made in collaboration are more thorough and thus have a higher probability of being appropriate. 147
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Figure I. A n array of content items to be superimposed upon the six-step process of the collaborative consultation.
Additional advantages may be gained as follows:
I . The consultee is given an opportunity to observe, in action, the reasoning process of the more experienced consultant. 2. The consultee sometimes becomes aware of an expanded array of options rather than the limited possibilities upon which he/she had focused (Ragawski 1978). 3. Collaboration tends to disrupt themes that the consultee may have allowed to form on the basis of a limited view. Perception is broadened. 4. Collaborative consultation allows the consultee to take ‘time out to think’. In a climate of mutual respect, where defensiveness is unnecessary, the consultee becomes increasingly aware of hislher own resources. 5 . Decisions are based on a more adequate sampling of data. Seldom are collaborative decisions made on im148
pulse. The thoroughness often found in collaboration teaches the consultee that effective intervention is many times a function of allowing adequate time for the process. Summary
Descriptions of, and some of the advantages and precautions associated with four general modes of consultation have been presented and are summarized in Table 1. Each has its application. Each has its potential for use as a teaching strategy. While the collaborative mode of consultation seems to enjoy an increasing subscription at the present time, selection of a best approach for a given situation must reflect the interaction of variables brought into the situation by the attending physician, the resident and the focus of the consultation.
Medical Teacher V o l 3 No 4 1981
Table 1. Summary of the advantages and precautions associated with the four modes of consultation.
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~~~
~
~
Method of Consultation
Role of Attending Physician
Role of Resident
Advantages
Disadvantages
Modelling
Active. Demonstrates how to do it
Passive/observer supporter. Asks and answers questions
Opportunity to model complex skills
Can limit learning. Resident may not know where to look or what is being done, or why
Provider of services
Very active. Takes over patient care
Passive/referrer
Limits visits to patient
Very limited learning. Discourages initiative requires dependency. Resident may 'lose' patient. Discourages thoroughness. Disrupts continuity of care
Prescriptive
Active. Questions direct. Supervises
Active, under supervision
Resident shares patient Can limit learning, limit contact and responsibility. initiative, foster dependency Encourages thoroughness and qualitylstandarda. Continuity of care is maintained
Collaborative
Active, in formal. Problem-based discussion with colleague
Active, informal. Colleague
Resident retains contact Few and responsibility. Encourages independence, responsibility, standards. Continuity maintained
References
Bandura, A., Social Learning Theoy, Prentice-Hall, Englewood Cliffs, 1977. Bindman, A. J., Mental health consultation: theory and practice, Journal of Psychiatric Nursinp, 1964, 2, 367-380. Blake, R . R . and Moulton, J. S., Consultation, Addison-Wesley, Readinp, Mass., 1976. Howe, M . J . , The Psychology o f H u m a n Learning, Harper and Row, New York, 1980, pp. 129, 130, 137, 153.
Kurpius, D., Consultation theory and process: an integrated model, The Personnel and Guidance Journal, 1978, 5 6 , 335-338. Kurpius, D. and Robinson, S., An overview of consultation, The Personnel and Guidance Journal, 1978, 56, 321-323. Ragawski, A , , The Caplan model, The Personnel and Guidance Journal, 1978, 5 6 , 324-327. Schein, R . , Process Consultation: Zts Role in Organizational Deuelopment, Addison-Wesley, Reading, Mass., 1969. Stritter, F., Hain, J. and Grimes, D., Clinical teaching re-examined, J o u m l ofMedical Eduation, 1975, 50, 876-882.. Zimrnerman, B. J . and Rosenthall. T. L., Observational learning of rule governed behavior, Psychological Bulletin, 1974, 81, 29-42.
BMA/BLAT Film Catalogue Every three years the British Life Assurance Trust for Health and Medical Education, and the British Medical Association publish a catalogue with details of 16 mm films available from the BMAIBLAT film library as well as 16 m m films distributed from other sources. T h e latest one has recently been published.' All the films listed have received the BLAT certificate of educational commendation or are award winners in the BMA Film Competition. Each entry contains details of intended audience level, educational purpose, synopsis of content a n d brief critical comment. T h e entries are clearly set out in subject groupings to which there is an index. There is also a helpful film title index. These two indexes make location of relevant material verv auick and easy. A third useful index is a list of films withdrawn from stock' This list makes it possible to keep One'' teaching to date by selecting a substitute for a well-liked film which subject experts consider no longer meets desirable 2
Medical Teacher V o l 3 No 4 1981
expectations. A fourth index, of distributors and copyright holders, supplies a list of useful addresses of companies, associations a n d individuals with whom medical educators can liaise in the development of educationally sound teaching materials. The BMA/BLAT catalogue is a model of its kind. Few lists are vetted for their educationalpalue, largely because of time and money factors; so this is a valuable contribution to medical education. At 24 it is money well spent by any medical library, learning resource centre, teaching department or individual medical educator. T h e films can only be loaned to borrowers in the UK.
1
1BMA/BLAT Medical films 1980 selected for their educational value. 1 volume and supplement. London: British Life Assurance Trust for Health and Medical Education with the British Medical Association, Tavistock House, Tavistock Square, London WCI .
149
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W. C . WILLIAMS W. C. Williams, PH. 0,is Associate Professor, School of Education, Baylor UniuersiQ, Waco, Texas 76703, USA. Some patients present problems which exceed a junior doctor’s ability to analyse and synthesize information o n which management decisions must b e made. As a result, he or she often consults with an attending physician or consultant. I n this article four types of consultation are identified and analysed, each of which has potential for use as a teaching strategy. A high level of motivation for applying knowledge, which has been gained over years of study, is often quite evident in medical residency centres where young doctors are given their first full-time opportunity to practise medicine. Most medical school graduates today are well prepared academically. In general, all that seems to remain is the gaining of supervised experience in applying the knowledge that has accumulated. Many of the patient complaints brought to the resident fall within hidher range of ability to diagnose and prescribe. Thus, while the new doctor may be required each day to present a given number of cases to an attending physician (consultant physician), the interaction that transpires between the two doctors often involves little more than ‘‘touching bases”. However, the demands of some patient situations may exceed the resident’s ability to analyse and synthesize the information upon which decisions must be made. At such times, a much more in-depth kind of consultation ensues wherein the attending physician’s years of practical experience provide a base from which to progress. Again, the resident may have the basic knowledge necessary for solving the problem but simply lacks the experience necessary for applying it. An important contribution to a young doctor’s ability to solve problems independently can be made through the variety of consultative encounters which occur between him/her and the attending physicians. One of the goals of consultation, as noted by Bindman (1964), is that “ ... of education, so the consultee (resident) can learn to handle similar cases in the future in a more effective fashion and, thus, enhance hidher professional skills”. The interaction between the attending physician and the resident 142
may have as much impact upon the resident’s final preparation for a career in medicine as anything that happens to himlher during the residency. Further, the extent and manner of provision for the resident’s continued involvement in patient care subsequent to consultative encounters is quite important. Relationships between Attending Physicians and Residents These are of four types. First, there are those situations in which the attending physician may feel justified in confiningheducing the resident’s involvement in a case to little more than that of observer, as the more senior doctor performs a selected procedure for which the resident seems unprepared. Second, in some emergency situations, a rapid sequence of events may terminate the resident’s involvement as the attending physician assumes full responsibility for the patient’s care. Early discharge of the patient could result in the young doctor having no further contact with the patient, especially if the attending physician prefers to manage any possible follow-up of the emergency. A third type of consultative relationship may, for all practical purposes, result in the attending physician working indirectly through the resident as the latter carries out the physician’s instructions/ advice. The attending physician’s influence may thus range from simply supplying information, to literally engineering most of the actions taken. Finally, many consultative encounters lead into a free flow of interaction between the two doctors as the attending physician facilitates the resident finding hidher own solution to a given problem. While these four types of consultative relationship are not mutually exclusive, each is suffkiently discrete to merit discussion.
The ‘Modelling of Services’ Method of Consultation The first of these four types of consultative relationships might be labelled the ‘modelling of services’ method of
Medical Teacher V o l 3 No 4 1981
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consultation. Here, the attending physician’s primary function is to demonstrate and elaborate a given procedure as the resident observes, asks and answers questions and stands ready to offer appropriate kinds of support. While the resident may or may not have assumed an active role in the patient’s care before the modelling of services by the attending physician, the resident’s learning something of value from the experience is not precluded. Howe (1980) proposed that “one way to learn is through watching other people behave, and in this way we can acquire habits, skills, and knowledge without having to directly experience the consequences of every single action. ” Learning from observation need not be limited to the focus of the demonstration only. Suppose that a demonstrated procedure is unsuccessful; can the observer still learn something worth while from the event? Although the outcome of modelled behaviour influences the likelihood of the observer repeating it, the consequences do not necessarily affect learning somethingfrom what the model did (Howe 1980). “Observation may lead to a person acquiring a rule that can be applied. ..” (Zimmerman and Rosenthal 1974). Howe (1980) notes that through observing others, we can acquire new concepts, rules, strategies and ways of remembering information. In general, the resident will not only learn the action components of the behaviour observed, but will also generate rules about how to, and how not to, approach the task.
Facilitating Learner Involvement Passive, unguided observation by a resident may seriously limit learning of the sort intended by the doctor doing the modelling. In a theory advanced by Bandura (1977) it was proposed that learning by observation increases when provision is made for learner involvement. Bandura (1977) suggests four ways to facilitate interaction of the learner with the focus of the learning. First, direction of the resident’s attention to distinctive features of the behaviour to be modelled is important. In complicated procedures the resident may not know ‘where to look’ in order to learn how to accomplish the task on hidher own. Second, if the procedure is especially involved, the doctor who is doing the modelling should identify each of the component activities and note any sequence of events that should occur. If an order of activity is to be rigidly followed, the rationale should be given. Third, the manner in which observed acts are represented in the on-looker’s memory will be affected by verbalizing what is observed. Even as memory-traces of things observed seem to involve images of what was experienced, so too are verbalizations about the activity also retained. Therefore, Howe notes that talking about perceived events serves as an effective strategy for facilitating learning by observation (Howe 1980). Time spent discussing the procedure to be learned, either during or after the demonstration, will not be wasted. Finally, the value of imitating a behaviour as well as the ‘attractiveness’ of the individual doing the modelling affects learning by the observer. The probability of a resident conducting a given procedure in a manner similar to that
Medical Teacher V o l 3 No 4 1981
modelled by the more experienced doctor will be increased if the outcome is seen as desirable, and if the doctor doing the modelling is perceived as a person worthy of emulation by the resident.
The Expert Method of Consultation Moving up from the ‘modelling of services’ method of consultation to a level where the probability of the resident’s direct involvement increases, Kurpius and Robinson (1978) propose three methods of consultation for consideration. In the first of these, the consultee, who finds himself in a difficult situation, defers to a consultant who then becomes the problem-solver and assumes responsibility for ‘cure’. Schein (1969) refers to this approach as the expert method of consultation. Thus, in the medical setting the resident (as consultee), who is confronted with an especially complicated patient situation, defers to an attending physician (consultant) who in turn provides direct services to the patient. In some instances very little or no further treatment of the patient by the resident follows after consultation/referral. Several questions should be answered before an attending physician assumes the ‘provider of services’ role (Kurpius and Robinson 1978): was the resident able to gather enough information from the patient to justify the attending physician’s ‘taking over’? Is the resident’s perception of the situation accurate? T o what extent are the resident’s assumptions, knowledge, values and own defences incorporated in the data presented to the attending physician? Who will claim ownership of the problem after consultation/referral? Will major responsibility be permanently, or only temporarily, transferred to the attending physician? Finally, will the attending physician or the resident follow-up on patient compliance and evaluate the effectiveness of treatment? As in the case of some emergencies, direct treatment of a patient by an attending physician may be the most appropriate alternative. However, it is generally advisable for both the attending physician and the resident to agree that this is the best approach. Without such agreement, and without addressing the questions listed above, the self-confidence of the resident may be seriously threatened and the parameters within which he/she assumes responsibility in the future may be left without adequate definition. Several indiscriminate interventions by an attending physician over a period of time could decrease a resident’s motivation for thoroughness, strain the relationship between the two doctors, disrupt the continuity of care given to patients, increase patient fears relative to their illness and deprive the resident of important opportunities to learn how to deal with anything other than routine situations. If at all possible, rather than excluding the resident from further care of the patient, a triadic relationship (attending physician/resident/patient) should be established at the time that the intervention becomes necessary. Such an arrangement would surely include an explanation acceptable to the patient for the attending physician’s involvement. Some form of continued treatment of the patient by the resident would impress upon
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the resident that a degree of responsibility to a patient may be in order even after the negotiation of referral. When the need for the attending physician’s direct intervention has passed, helshe would do well to discuss the case thoroughly with the resident and return the patient to the junior doctor’s care. Provision for the resident to gain first-hand experience with a similar situation should then be made as early as possible.
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The Prescriptive Method of Consultation It is not uncommon in the medical setting for residents to approach an attending physician with a quick review of their patient’s history and chief complaint and then ask for information related to the problem, help with a diagnosis and/or suggestions for managing the patient’s situation. Such encounters may lead directly to the attending physician’s supplying the resident with whatever the focus of the request has been. On other occasions, the attending physician may press for substantially more information about the whole situation before responding to the resident’s request. I n either event, this kind of interaction often leads into the second of the three types of consultation proposed by Kurpius and Robinson (1978). It is referred to as the ‘prescriptive mode of consultation’: the consultant does not always respond immediately to the resident’s query with a ‘prescription’. While the consultant (attending physician) might use the consultee’s (resident’s) information as a useful point of departure to develop further the process of diagnosis, the validity of the resident’s information is not immediately accepted or rejected as presented. Rather, the attending physician may investigate the situation further by interrogating the resident, examining more closely the records on the patient and possibly re-examining any available laboratory data. When the attending physician is satisfied that the real problem has been identified, helshe recommends a best approach for the resident to follow. This means that final control of the situation is essentially vested in the attending physician as the resident carries out the directives of the more experienced doctor. When compared with the provider of services method of consultation, the prescriptive form registers several advantages. First, in that the resident does not cease direct contact with the patient, continuity of care is enhanced. Second, the occasional necessity for using the prescriptive mode c6uld well serve to encourage the resident’s thoroughness in taking the history of the patient’s illness. The resident should recognize that quality input is required by the attending physician for accurate diagnosis. Third, in emergencies where timely action is of an essence, the attending physician’s involvement will bring the system’s power/authority/obedience structure into immediate play. The resident acting alone would have difficulty engineering the situation in a similar manner. Some Problems
In spite of the above-mentioned advantages, the prescriptive method of consultation can impose unnecessary 146
limits on the resident’s opportunity to learn. Unless the attending physician explains the problem-solving process applied and hidher rationale for directives given, the resident may gain little more than experience in gathering information and carrying out orders. Thus, two problems may possibly arise. On the one hand, over a period of time a resident’s repeated deference to an attending physician could result in a form of dependency difficult to extinguish. At the other extreme, a second kind of problem might arise if a resident were unable or unwilling to carry out an attending physician’s directives. A resident’s ineffective management of a situation could work to the distinct disadvantage of the patient. It is therefore important that the resident not only agrees with the attending physician’s method of managing the situation but also that the resident is taken into the confidence of the more experienced doctor to the extent that he/she knows what to expect as a result of actions taken. Monitoring change in the patient’s condition could then be an important learning experience for the resident. In sum, the prescriptive approach is effective as a clinical teaching strategy only to the extent that the resident is taught the process through which the attending physician has progressed in solving the problem and selecting a method for managing the situation. If such teaching does not occur, and if the resident’s dependency on the attending physician increases, gradual movement toward a modified ‘provider of services’ approach could occur. The young doctor would thus be deprived of experiences vital to eventual independence in private practice.
The Collaborative Consultation The final approach to consultation, as described by Kurpius and Robinson (1978), calls for a form of collaboration in the problem-solving process. While consultees may need little more than an assessment of the tenability of their assumptions on one occasion, at other junctures they may seek a more sustained type of collegial relationship wherein diagnosis develops from contributions made by both parties. In either event, the consultant’s active participation contributes not only to the solution of the problem at hand, but may also teach the consultee to focus upon important units of content as the problemsolving process unfolds (Blake and Moulton 1976). In collaborative consultation, the consultant’s authority is de-emphasized from the beginning as helshe engages in an informal, but goal-directed, give-and-take. The interaction often begins with the consultee describing the problem. The consultant listens carefully, assisting in the establishment of a goal for the encounter and supplying information needed for illumination of selected aspects of the problem. The consultant carefully structures questions designed to bring more of the consultee’s knowledge into the interaction (Kurpius 1978). Alternative courses of action are generated and discussed freely as the consultee moves toward making a decision based upon an increasingly accurate perception of the situation. In the medical setting, the attending physician as the collaborative consultant contributes to eventual problem
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solution as needed and also attempts to facilitate the resident’s self-direction by bringing into play as much of the young doctor’s ability to diagnose and prescribe as possible. In so doing, the attending physician not only supports the resident’s efforts to manage the situation, but also challenges hidher observations, asks about the need for laboratory data and x-rays to support tentative diagnoses, and draws attention to factors possibly being neglected. Again, the collaborative consultant does not serve as the solver of problems. Rather, the consultant provides the framework within which plans and solutions are generated and an informal kind of teaching is conducted.
Some Definitions Using the collaborative mode of consultation, an attending physician thus emphasizes both content and process when working with residents who come for counsel. Some definition of each seems in order at this point. Basically, process refers to the series of phases through which a consultant and a consultee progress in defining a problem, subdividing it for analysis, attacking it and eventually reaching a solution. Content refers to the array of information applied in development of each phase of the process. Repetition of process, and possibly content to a lesser degree, can often be observed in medical settings where a form of collaborative consultation is routinely used. An attending physician’s repeated modelling of thoroughness of process can do much to teach the same to residents. Collaborative consultation lends itself easily to modelling of desired behaviours by the consultant.
Steps in the Collaborative Consultation Although the process in collaborative consultation involves to a large extent a series of mental events on the part of each participant, the consultee often comes to internalize the format as it relates to repetition of content. Kurpius and Robinson (1978) have proposed that six steps generally typify the process used in collaborative consultation : 1. The building of a workable relationship between consultant and consultee. 2. Gathering information. 2 . Identifying the-problem. 4. Exploring possible solutions. 5. Implementing an intervention. 6. Evaluating the effectiveness of the intervention.
The building of a workable relationship between an attending physician and a resident will be a function of several factors. It is important that the attending physician accepts the resident as a person of worth and maintains an openness to the variety of problems brought by the resident for discussion. Acceptance is conveyed in eye contact, active listening, alert posture, requests for clarification, summary statements and so forth. The attending physician must be psychologically as well as physically available. While some attending physicians
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may perceive themselves as being ‘psychologically’ available, their services go unused because they accept other commitments that conflict with ‘prime times’ for consultation. The importance of specifying a location where consultation can be conducted with some degree of privacy, and at a time when the resident can be assured of making contact with the attending physician, cannot be overemphasized. T h e doctor who is physcially present, but who is engrossed in making out hisfher own reports, is generally not seen as being accessible. Stritter, et al. (1975) identified accessibility as characterizing a consultant’s genuine interest in consultation. An atmosphere of trust and cohesion is essential in building a workable relationship. While the attending physician generally has the advantage of experience, he/ she must be aware that the resident may have the advantage of up-to-date knowledge. T h e attending physician should ’resist ‘authority’ behaviours. This is especially true of the resident is to continue ownership of the problem brought for consultation. Before continuing with the six-step process mentioned above, it might be well to note that rigid adherence to any system of problem-solving may limit, if not seriously impede, progress toward a favourable outcome from the interaction. Even as patient complaints vary from individual to individual, so too will the approach used in arriving at a best treatment for each. However, to demonstrate the possible conjugation o f content with process, a n array of content items that are often included in a collaborative consultation between attending physician and resident could be superimposed upon our sixstep process. Note the opportunities for sharing information, for comparing perceptions, indeed for teaching, as the areas of content shown in Figure 1 are brought into focus. Again, the list is included only t o exemplify the combining of content with process and to draw attention to the teaching potential inherent in the collaborative approach. I would not be so presumptuous as to propose foci for medical concentration.
Advantages According to Kurpius (1978) there are several advantages associated with the collaborative approach:
1. Most people become more effective if they participate in defining and selecting an appropriate solution for solving a problem. 2. While collaboration sometimes produces conflict, it generally builds lasting trust and respect among professionals. (On occasion, a n attending physician’s thoroughness may threaten a resident by revealing possible oversights.) 3. Collaboration de-emphasizes authority and power. The emphasis is more on, the different roles of the consultant and the consultee than disparities in status. 4. Latent problem-solving capabilities of consultees are activated. 5. Decisions made in collaboration are more thorough and thus have a higher probability of being appropriate. 147
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Figure I. A n array of content items to be superimposed upon the six-step process of the collaborative consultation.
Additional advantages may be gained as follows:
I . The consultee is given an opportunity to observe, in action, the reasoning process of the more experienced consultant. 2. The consultee sometimes becomes aware of an expanded array of options rather than the limited possibilities upon which he/she had focused (Ragawski 1978). 3. Collaboration tends to disrupt themes that the consultee may have allowed to form on the basis of a limited view. Perception is broadened. 4. Collaborative consultation allows the consultee to take ‘time out to think’. In a climate of mutual respect, where defensiveness is unnecessary, the consultee becomes increasingly aware of hislher own resources. 5 . Decisions are based on a more adequate sampling of data. Seldom are collaborative decisions made on im148
pulse. The thoroughness often found in collaboration teaches the consultee that effective intervention is many times a function of allowing adequate time for the process. Summary
Descriptions of, and some of the advantages and precautions associated with four general modes of consultation have been presented and are summarized in Table 1. Each has its application. Each has its potential for use as a teaching strategy. While the collaborative mode of consultation seems to enjoy an increasing subscription at the present time, selection of a best approach for a given situation must reflect the interaction of variables brought into the situation by the attending physician, the resident and the focus of the consultation.
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Table 1. Summary of the advantages and precautions associated with the four modes of consultation.
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Method of Consultation
Role of Attending Physician
Role of Resident
Advantages
Disadvantages
Modelling
Active. Demonstrates how to do it
Passive/observer supporter. Asks and answers questions
Opportunity to model complex skills
Can limit learning. Resident may not know where to look or what is being done, or why
Provider of services
Very active. Takes over patient care
Passive/referrer
Limits visits to patient
Very limited learning. Discourages initiative requires dependency. Resident may 'lose' patient. Discourages thoroughness. Disrupts continuity of care
Prescriptive
Active. Questions direct. Supervises
Active, under supervision
Resident shares patient Can limit learning, limit contact and responsibility. initiative, foster dependency Encourages thoroughness and qualitylstandarda. Continuity of care is maintained
Collaborative
Active, in formal. Problem-based discussion with colleague
Active, informal. Colleague
Resident retains contact Few and responsibility. Encourages independence, responsibility, standards. Continuity maintained
References
Bandura, A., Social Learning Theoy, Prentice-Hall, Englewood Cliffs, 1977. Bindman, A. J., Mental health consultation: theory and practice, Journal of Psychiatric Nursinp, 1964, 2, 367-380. Blake, R . R . and Moulton, J. S., Consultation, Addison-Wesley, Readinp, Mass., 1976. Howe, M . J . , The Psychology o f H u m a n Learning, Harper and Row, New York, 1980, pp. 129, 130, 137, 153.
Kurpius, D., Consultation theory and process: an integrated model, The Personnel and Guidance Journal, 1978, 5 6 , 335-338. Kurpius, D. and Robinson, S., An overview of consultation, The Personnel and Guidance Journal, 1978, 56, 321-323. Ragawski, A , , The Caplan model, The Personnel and Guidance Journal, 1978, 5 6 , 324-327. Schein, R . , Process Consultation: Zts Role in Organizational Deuelopment, Addison-Wesley, Reading, Mass., 1969. Stritter, F., Hain, J. and Grimes, D., Clinical teaching re-examined, J o u m l ofMedical Eduation, 1975, 50, 876-882.. Zimrnerman, B. J . and Rosenthall. T. L., Observational learning of rule governed behavior, Psychological Bulletin, 1974, 81, 29-42.
BMA/BLAT Film Catalogue Every three years the British Life Assurance Trust for Health and Medical Education, and the British Medical Association publish a catalogue with details of 16 mm films available from the BMAIBLAT film library as well as 16 m m films distributed from other sources. T h e latest one has recently been published.' All the films listed have received the BLAT certificate of educational commendation or are award winners in the BMA Film Competition. Each entry contains details of intended audience level, educational purpose, synopsis of content a n d brief critical comment. T h e entries are clearly set out in subject groupings to which there is an index. There is also a helpful film title index. These two indexes make location of relevant material verv auick and easy. A third useful index is a list of films withdrawn from stock' This list makes it possible to keep One'' teaching to date by selecting a substitute for a well-liked film which subject experts consider no longer meets desirable 2
Medical Teacher V o l 3 No 4 1981
expectations. A fourth index, of distributors and copyright holders, supplies a list of useful addresses of companies, associations a n d individuals with whom medical educators can liaise in the development of educationally sound teaching materials. The BMA/BLAT catalogue is a model of its kind. Few lists are vetted for their educationalpalue, largely because of time and money factors; so this is a valuable contribution to medical education. At 24 it is money well spent by any medical library, learning resource centre, teaching department or individual medical educator. T h e films can only be loaned to borrowers in the UK.
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1BMA/BLAT Medical films 1980 selected for their educational value. 1 volume and supplement. London: British Life Assurance Trust for Health and Medical Education with the British Medical Association, Tavistock House, Tavistock Square, London WCI .
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