Aspiring to Excellent Medical Practice

1. Aspiring to Excellent Medical Practice - The role of the doctor; the implications for postgraduate medical education and doctors in training Professor David Sowden SRO MMC

2. When a man reasoneth, hee does nothing else but conceive a summe totall, from addition of parceles; or conceive a remainder, from subtraction of one summe from another….for reason….is nothing but reckoning. Thomas Hobbes 1588-1679 Leviathan

3. Why are we here: “there is currently no strong consensus on the role of the doctor at various career stages” “the policy objective of postgraduate medical training is unclear.” Sir John Tooke Aspiring to excellence

4. And!: “consensus on the role of the doctor needs to be reached by the end of 2008 (and the service contribution of trainees better acknowledged)”

5. distilling and dealing with complexity ability to make decisions in the face of (considerable) uncertainty and/or difficult circumstances effective and efficient problem solving taking legitimate risk via a process of professional judgement capability to lead in clinical settings, especially in emergency situations capability to demonstrate an intuitive grasp of clinical situations based on a deep, tacit, understanding of the specialist or generalist areas of practice capacity for intellectual leadership The expert medical clinician:

6. a commitment to evidence based innovation in clinical care, and to establishing an evidence base where none or insufficient evidence exists commitment to the health of the population as well as the individual patient capability to support patients through the clinical pathway for example as care navigator and as an expert translator commitment to patient safety technical expert (relevant to some specialties only) experience

7. Current problems with postgraduate medical education (not exclusive !) : • language and meanings poorly understood (competence, competences, competency) • trainer preparation and time to train, supervise and assess • doctors are either trained or not trained • time (Calman, MMC, EWTD, New Deal etc)

8. Current problems continued: • Competence paradigm risks creating an inflexible, reductionist approach to professional learning. • Does it aspire to produce expert practitioners, partners and leaders?

9. Consequences: • Since assessment drives learning competence acquisition may become a “tick box” exercise • Focus moves to ensuring competency but not proficiency or expertise • Language needs clarifying • Competences may be acquired but at expense of confidence and experience

10. [ The medical professional is ]…..someone with a wide range of interventions available and who can move cleanly and elegantly amongst them. Cleanly and elegantly; I like that: we don’t see the joins or hear the machinery creaking. The least we owe [trainees] is to keep the possibility of [this] delight and elegance alive and to defend time and space to discover them. ROGER NEIGHBOUR The Inner Consultation

11. Miller’s Pyramid Does Performing Shows how Competent Knows how Knowledge/understanding Knows

12. Summary of the Dreyfus Model of Skills Acquisition Level 1 Novice • Rigid adherence to taught rules or plans • Little situational perception • No discretionary judgement Level 2 Advanced Beginner • Guidelines for action based on attributes or aspects (aspects are global characteristics of situations recognisable only after some prior experience) • Situational perception still limited • All attributes and aspects are treated separately and given some equal importance

13. Level 3 Competent • Coping with crowdedness • Now sees actions at least partially in terms of longer-term goals • Conscious deliberate planning • Standardised and routinised procedures Level 4 Proficient • See situations holistically rather than in terms of aspects • See what is most important in a situation • Perceives deviations from the normal pattern • Decision-making less laboured • Uses maxims for guidance, whose meaning varies according to the situation Level 5 Expert • No longer relies on rules, guidelines or maxims • Intuitive grasp of situations based on deep tacit understanding • Analytic approaches used only in novel situation or when problems occur • Vision of what is possible Eraut, M (1994) Developing Professional Knowledge and Competence