bmj-336-7645-prac-00667.pdf

PRACTICE Graves’ disease. Best Pract Res Clin Endocrinol Metab 18 Roy...

PRACTICE Graves’ disease. Best Pract Res Clin Endocrinol Metab 18 Royal College of Physicians. Radioiodine in the management of 2004;18:289-302. benign thyroid disease: clinical guidelines. Report of a working party. 12 Weetman AP. Graves’ disease. N Engl J Med 2000;343:1236-48. 2007. www.rcplondon.ac.uk/pubs/Listing.aspx 13 Lee YS, Loke KY, Ng SC, Joseph R. Maternal thyrotoxicosis causing 19 Azizi F, Khoshniat M. Bahrainian M, Hedayati M. Thyroid function and central hypothyroidism in infants. J Paediatr Child Health intellectual development of infants nursed by mother taking 2002;38:206-8. methimazole. J Clin Endocrinol Metab 2000;85:3233-8. 20 Major C, Nageotte M. Thyroid disorders. In: James DK, Steer PJ, 14 Nelson-Piercy C, Girling J. Essay questions. 4.3. Hyperthyroidism. In: Weiner CP, Gonik B, eds. High risk pregnancy management options. Nelson-Piercy C, Girling J, eds. Obstetric medicine: a problem based London: Saunders, 1994:315-23. approach. London: Springer, 2007. 21 Klasco RK. REPROTOX database [edition 2005]. Greenwood Village, 15 Kriplani A, Buckshee K, Bhargava VL, Takkar D, Ammini AC. Maternal CO: Thomson Micromedex, 2005. Available at www.reprotox.org. and perinatal outcome in thyrotoxicosis complicating pregnancy. Eur J 22 Luton D, le Gac I, Vuillard E, Castanet M, Guibourdenche J, Noel M, Obstet Gynecol Reprod Biol 1994;54:159-63. et al. Management of Graves’ disease during pregnancy: the key role 16 Sheffield JS, Cunningham FG. Thyrotoxicosis and heart failure that of fetal thyroid gland monitoring. J Clin Endocrinol Metab complicate pregnancy. Am J Obstet Gynecol 2004;190:211-7. 2005;90:6093-8. 17 Laurberg P, Nygaard B, Glinoer D, Grussendorf M, Orgiazzi J. 23 Muller A, Drexhage H, Berghout A. Postpartum thyroiditis and Guidelines for TSH-receptor antibody measurements in pregnancy: autoimmune thyroiditis in women of childbearing age: recent insights results of an evidence-based symposium organized by the European and consequences for antenatal and postnatal care. Endocr Rev Thyroid Association. Eur J Endocrinol 1998;139:584-90. 2001;22:605. THE COMPETENT NOVICE Lifelong learning at work P W Teunissen,1 Tim Dornan2 1 The importance of lifelong learning them as members of “communities of practice”5 in Institute for Medical Education, VU University Medical Centre, Van which interaction with other doctors, nurses, and allied der Boechorststraat 7, 1081 BT, in medicine is well recognised. professionals of various levels of seniority shapes their Amsterdam, Netherlands 2 This article explores how junior doctors personal and professional development.6 Learners, University of Manchester Medical School, Manchester M13 9PT can develop learning strategies for use however, are sometimes more aware of lectures and courses as learning opportunities than they are of the Correspondence to: P W Teunissen [email protected] throughout their working life “on the job” learning opportunities that they face all day. As a learner, you therefore need to capitalise on BMJ 2008;336:667-9 Most doctors are aware of the aphorism that learning such opportunities by soliciting feedback, seeking out doi:10.1136/bmj.39434.601690.AD should continue from the cradle to the grave. However, evidence of clinical effectiveness at the point of care, medical school does not prepare anyone fully for the and participating fully in the educational activities of responsibilities, long hours, and challenging tasks that whichever community of practice you are currently qualification brings.1 2 The fittest survive by learning working in. from their practice, whereas those who do not continue to learn become dissatisfied and burn out.3 Current Be in charge restrictions in working hours, changes in the organisa- To be an effective lifelong learner in the workplace, you tion of health care, shorter hospital stays, and the have to make a conscious decision to direct your own breakdown of the medical firm make it ever more development.7 Research in continuing medical educa- necessary to learn efficiently from practice.4 tion shows that doctors learn most when they are Numerous editorials and descriptive articles have motivated enough to identify their own learning needs stated the importance of lifelong learning, but research and meet those needs at their own pace.8 9 For trainees, has not yet provided a definitive answer to the question that means turning workplace experiences into realistic “How can trainees develop lifelong learning strate- and achievable learning objectives. When you finish gies?” We have drawn on medical education theory rounds on the internal medicine ward, list the topics and empirical studies of both facilitating practice you need to learn more about; prioritise them, and change and the effectiveness of feedback for best write down one or two higher level learning objectives evidence on effective lifelong learning. Those sources for the weeks to come; and set a date to finish them by. show that one size does not fit all. Our article does not For example: therefore offer quick fixes such as organising group  You just saw four patients with diabetic compli- learning sessions or purchasing a personal digital cations; do you really know everything you need assistant, but rather it describes the continuous to know about regulating blood glucose? If not, personal endeavour that lifelong learners face. focus on diabetes This series aims to help junior  Do you feel defeated by that one patient who just doctors in their daily tasks and is based on selected topics from the Lifelong learning: how best to do it didn’t seem to understand your explanations? UK core curriculum for foundation Learn in the workplace Focus on communicating with patients years 1 and 2, the first two years Ideas about work based learning have moved from  Are your rounds running late for the fourth time after graduation from medical school. thinking of learners as solitary beings to thinking of this week? Focus on time management BMJ | 22 MARCH 2008 | VOLUME 336 667 PRACTICE but recognise the expertise of, say, an experi- Feedback Example portfolio heading: improve questions communication with “difficult” patients enced nurse. Try to understand how these people do what you aspire to do, discuss with them how Where was I going? Short reflection of the encounter What is your with the difficult patient that led you you might do it, and ask them to help you answer learning objective to focus on improving your the third question (where to next?) and why? communication skills  For feedback to be effective, it needs to be Description of plan of action—for example, ask consultant to observe directed at the task as a whole or at certain aspects you and give you structured feedback, of the task, and not at the person who performed ask hospital psychologist for advice, and give short presentation on the it. Various meta-analyses have shown that posi- topic tive or negative feedback about yourself (such as “great effort!” or “you’ll never be good at doing How did I get on? Thoughts on what you gained from rounds”) is largely ineffective.11 13 In the case of What activities did observing a consultant discussing you undertake, bad news with a patient finishing rounds on time, ask what it is that you including Two structured feedback reports of are doing that makes you run late (the task); ask assessments your communication with patients on the topic? Speak to hospital psychologist how to strike a balance between attention to next week individual patients and being fair to the whole Presentation planned a month from group of patients (processes needed to under- now stand the task); and ask how you can monitor and Where to next? Get advice from hospital psychologist adjust the pace of rounds as you go along (self Use the previous before preparing presentation regulation in performing the task). sections of your Make short note in portfolio of main portfolio to create messages so far about this topic a personal Use what you have learnt in future Use evidence at the point of care development plan patient encounters and further refine your communication skills The evidence based practice movement set out primarily to improve health care, but its aims provide an excellent model for learning from practice. It urges Answering the three feedback questions by using your portfolio doctors to use the challenges and surprises that they encounter in practice to formulate questions and find valid answers that they can then apply to patients.14  Did a teaching session identify a gap in your Evidence based practice at the point of care is not practical competence? Focus on clinical skills. necessarily straightforward, however. Green and Use input from peers and seniors to identify your colleagues showed that residents pursued only 80 of learning needs because a person’s ability to assess his or 277 identified questions and used very few evidence her own performance is limited.10 Keep a personal based practice sources.15 Research into information portfolio on an electronic organiser (and always keep seeking behaviour on the internet found that only 9% of that in your pocket) so you can note new goals and new 2500 physicians in the United States searched for learning points. information during a patient encounter.16 The greatest barriers were a lack of available information or a glut of Seek input from others it. How can we improve the application of evidence Observing how other staff and patients respond to a based practice at the point of care? situation can reinforce an existing perspective or open The classic approach (critical appraisal of primary up a different one.6 It is up to you to examine and literature using the “populations, intervention, com- question your routines and interpretations. parison, outcome” format) is impractical for bedside However, not all types of feedback lead to use.17 Slawson and Shaughnessy suggested that doctors improvements.11 A synthesis of 12 meta-analyses need several skills to use evidence based practice at the (196 studies and 6972 effect sizes) on the effectiveness point of care: the ability to select and use “foraging” of feedback defined some rules of play (see box)12: and “hunting” tools and to make “sensible decisions  Feedback can only build on previous experience. by combining the best patient-oriented evidence with So if regulation of blood glucose is a new area for patient-centered care.” 17 The authors described you, ask somebody skilled to show you how to do it rather than hoping you’ll just pick it up as you go  Seek feedback on your learning objective(s) to Directions for feedback enable you to answer each of three inter-related Challenge yourself, look for feedback, but remember: questions (where am I going? how am I getting  If you are inexperienced, first get instructions, then get on? where to next?) If the first of those three feedback questions relates to improving your communica-  Feedback answers three questions: where am I going? tion with patients, then to answer the second how am I getting on? where to next? question you need to ask someone to observe you  Get feedback directed at: (a) the task, (b) processes and discuss with you their views on what you did. needed to understand the task, (c) self regulation in Select anybody you can learn from. Consultants performing the task or registrars may be the most obvious choices, 668 BMJ | 22 MARCH 2008 | VOLUME 336  PRACTICE foraging tools as those that filter information for What are the challenges? relevance and validity (such as DailyPOEMs (www. Throughout their career, doctors need to work hard at infopoems.com) and Journal Watch (www.jwatch.org)) taking advantage of the constant learning opportunities and hunting tools as those that “present prefiltered that arise. Lifelong learners’ biggest achievement is information easily at the point of care” (such as finding the motivation to keep questioning their actions Dynamed (www.ebscohost.com/dynamed) and and knowledge. Lifelong learning means striking the InfoRetriever)). right balance between confidence and doubt. It is easiest to find this balance if you work with people who Stay on track support and value questioning behaviour.18 If that Work related activities are both a starting point for working culture does not exist, it is difficult for a trainee learning and an opportunity to refine and consolidate to create it. Nevertheless, it is essential to develop the what you learnt earlier.5 A portfolio can help you to confidence to doubt your own practice even when formulate and structure your learning targets and patients, nurses, and peers expect you to behave with keep track of how well you are meeting them. For apparent certainty.2 19 example, you can make a short note of the rules of Contributors: Both authors contributed to the conception and writing of thumb you developed to regulate the blood glucose this article. PWT is the guarantor. levels of patients with diabetes. Writing a case report Competing interests: None declared. for your portfolio on a patient who had his left foot Provenance and peer review: Commissioned and externally peer reviewed. amputated as a result of neuroischaemic ulceration can lead to “management of deep tissue infections” as 1 Prince KJ, Boshuizen HP, van der Vleuten CP, Scherpbier AJ. Students’ a new learning objective. A portfolio can help you opinions about their preparation for clinical practice. Med Educ decide whether your previous learning outcomes 2005;39:704-12. have been of use in practice; if not, you need to 2 Brown J, Chapman T, Graham D. Becoming a new doctor: a learning or survival exercise? Med Educ 2007;41:653-60. reconsider your learning habits. A portfolio provides 3 Becker JL, Milad MP, Klock SC. Burnout, depression, and career you (and your educational supervisor) with evidence satisfaction: cross-sectional study of obstetrics and gynecology residents. Am J Obstet Gynecol 2006;195:1444-9. to look back on your learning and evaluate it (see 4 Bannon M. What’s happening in postgraduate medical education? figure): Arch Dis Child 2006;91:68-70.  “Where was I going?” This can be a short 5 Wenger E. Communities of practice: learning, meaning, and identity. Cambridge: Cambridge University Press, 1998. reflection on, say, an encounter with a “difficult” 6 Teunissen PW, Scheele F, Scherpbier AJ, van der Vleuten CP, Boor K, patient that led to you to focus on improving your van Luijk SJ, et al. How residents learn: qualitative evidence for the communication skills pivotal role of clinical activities. Med Educ 2007;41:763-70.  “How did I get on?” You can think about, for 7 Ericsson KA. Deliberate practice and the acquisition and maintenance of expert performance in medicine and related domains. Acad Med example, what you gained from observing a 2004;1988:S1-12. consultant discussing bad news with a patient, 8 Davis DA, Thomson MA, Oxman AD, Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical and two structured feedback reports of your education strategies. JAMA 1995;274:700-5. communication with patients 9 Mazmanian PE, Davis DA. Continuing medical education and the  “Where to next?” The information collected in physician as a learner: guide to the evidence. JAMA 2002;288:1057-60. your portfolio helps to make your development 10 Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, more tangible and provides the input for discuss- Perrier L. Accuracy of physician self-assessment compared with ing your personal development plan with an observed measures of competence: a systematic review. JAMA 2006;296:1094-102. educational supervisor. 11 Kluger AN, DeNisi A. The effects of feedback interventions on Do not invest energy in the pursuit of goals that are performance: historical review, a meta-analysis and a preliminary irrelevant to practice or personal development. Port- feedback intervention theory. Psychological Bulletin 1996;119:254-84. folios can keep you on track. 12 Hattie J, Timperley H. The power of feedback. Review of Educational Research 2007;77:81-112. 13 Wilkinson SS. The relationship of teacher praise and student KEY POINTS achievement: a meta-analysis of selected research. Dissertation Abstracts International 1981;41:3998. Lifelong learning is a process of continuously scrutinising 14 Sackett DL, Straus SE, Scott Richardson W, Rosenberg W, Haynes RB. and building on your practice to be the best doctor you can Evidence-based medicine: how to practice and teach EBM. Edinburgh: Churchill-Livingstone, 2000. be 15 Green ML, Ciampi MA, Ellis PJ. Residents’ medical information needs Always have three questions in your mind: where am I going? in clinic: are they being met? Am J Med 2000;109:218-23. how am I getting on? where to next? 16 Bennett NL, Casebeer LL, Zheng S, Kristofco R. Information-seeking behaviors and reflective practice. J Contin Educ Health Prof Use electronic tools that provide filtered information at the 2006;26:120-7. point of care because you cannot hope to stay up to date on 17 Slawson DC, Shaughnessy AF. Teaching evidence-based medicine: should we be teaching information management instead? Acad Med everything 2005;80:685-9. Keep a learning portfolio so that you can see how you have 18 Dornan T, Boshuizen H, King N, Scherpbier A. Experience-based already developed and how you can develop in the future learning: a model linking the processes and outcomes of medical students’ workplace learning. Med Educ 2007;41:84-91. Keep your learning efforts alive by discussing them with your 19 Teunissen PW, Boor K, Scherpbier AJJA, van der Vleuten CPM, van peers and supervisors Diemen-Steenvoorde JAAM, van Luijk SJ, et al. Attending doctors’ perspective on how residents learn. Med Educ 2007;41:1050-8. BMJ | 22 MARCH 2008 | VOLUME 336 669