ESME PORTFOLIO
BY
MARCH 2009
Section I. Four Statements
Statement that describes what I think and believe about teaching, learning, assessment and medical education
My personal vision statement is developed from my understanding of the importance of good primary health care as central to the quality of life of our whole community. I believe that the people we are training can have a major role in increasing “wellness” in our community. I desire to help registrars and medical students to strive to achieve patient centred care for better patient outcomes and be able to practice their profession in a competent, compassionate and skilful manner.
How do I see myself doing that?:
By paying attention tothe management, education and support roles of clinical supervision.
By acknowledging the complexity of clinical supervision and thereby keeping my own education – in clinical skills and clinical teaching/supervision skills - up to date.
By increasing my understanding of how to help clinical learners acquire and examine experience, judgement and skills in providing health care.
By understanding the needs, pressures and anxieties of the registrars and medical students I supervise – professionally, personally, culturally, socially etc. and then engaging with them in an open and non-judgemental manner. Developing positive relationships with those I supervise, demonstrating interest in and respect for them, is key to effective supervision.
By recognising that the registrars and medical students I teach/supervise are adult learners.
I believe experiential learning through clinical experience is the best teaching and learning method.
Affirmation is a much better encouragement to learning than criticism, but it is important to be able to confront error in ourselves and then help someone else confront their errors. Clear, constructive feedback is essential to guide development and for trainees to be aware of their strengths and weaknesses.
Competence in teaching should be part of the personal profile of every health professional. “It has simply been assumed that professionals … can automatically start teaching”1.
Statement of my current medical education responsibilities (who, what, when, where, how)
I work as a General Practitioner (GP) in a large group General Practice. I am involved with clinical teaching at different levels.
I am a GP trainer responsible for teaching and supervision of GP registrars assigned to the practice from the Institute of General Practice Inc. (IGPE) – an organisation providing general practice vocational training.The registrars (2 at any one time) are allocated to the practice for a 6-month period and are at various stages in their training. The registrars, having completed a minimum of two years in the hospital system after graduation, are required to do a further two years training in general practice. Upon completion of their training and successful completion of the college examination the registrar is admitted to Fellowship of the Royal Australian College of General Practitioners (FRACGP) demonstrating that they have reached the standard required for unsupervised general practice. Clinical supervision is challenging. In my role as a supervisor of GP registrars I am involved in direct teaching, both in an organised and planned way as well as in an ‘opportunistic’ way. I am available to advise, counsel and mentor the registrar when necessary, so that a graduated clinical experience and responsibility in general practice are achieved. I am also the clinical educator for the registrar, ensuring that the registrar gains confidence and competence through education and experience. I am responsible for negotiating, co-ordinating and planning teaching and learning opportunities for the GP registrars and medical students at the practice.
The medical students allocated to the practice are in the 3rd year of a 5-year PBL-based course at the University of Western Sydney (UWS). Their attachment is part of “Medicine in Context” (MiC) – An attachment providing an intensive introduction to the social and cultural contexts of health and disease through community immersion. This is the students’ first exposure to general practice, with a more intense general practice component to follow in Year 5, and they are in the practice one day/week for 6 weeks.
I am also a PBL tutor at the UWS. I have also been involved with the development and implementation of the MiC courseas the UWS medical school is new, now only in its 3rd year.
Reflective self-assessment of my goals in medical education
I have an ongoing commitment to providing high quality clinical education. I have recognised that I need to improve my clinical supervision knowledge and skills on a continual basis, in the same self-directed way as expected of the registrars.
I am passionate about helping the registrars/students fulfil their particular medical aspirations and assisting them in their career development. Working collaboratively with IGPE to maintain, develop and improve education standards for trainees is one way of achieving this.
I would like to become increasingly competent and confident in the use of a wide range of teaching and learning methods.
I seek to be assured that I can meet the challenge of integrating patient care and medical education.
To implement a more structured/more rigorously planned approach to teaching and student learning.
I recognise a need to develop and enhance my leadership skills, as good leadership is essential to effective clinical supervision.
To promote and encourage reflection (self-assessment) by the registrar on their clinical performance. While we usually reflect on our performance we infrequently communicate this to others and even less often do we do so in writing.
Statement of how my medical education responsibilities, philosophy and general goals are or can be linked in real life
In ‘grassroots’ general practice, where the majority of my medical education responsibilities lie, my teaching sessions are deeply immersed in ‘real life’. My goals of providing high quality medical education and assisting registrars with their career development are in line with developing competent, compassionate and skilful professionals. Setting aside regular time from clinical practice for education sessions models the importance of lifelong learning to ensure continuous quality improvement. Encouraging self-assessment by the registrar also supports ongoing professional development for the benefit of their patients. I will strive to maintain my enthusiasm and energy for teaching, despite many competing roles and responsibilities.
Section II. A personal plan for professional development in medical education
Aim: To enhance my clinical supervision and teaching through practicing direct observation and giving feedback.
Outcome: Frequent and structured direct observation of registrars achieved.
Aim: Participate in Continuing Professional Development (CPD) activities aimed at improving my performance as a general practice educator.
Outcome: Attended 2 supervisor workshops at IGPE. Participated in on-line CPD activities.
Aim: To develop a more planned approach to teaching within the practice.
Outcome: A more structured approach to teaching developed. Increased, regular time devoted to thinking and planning of clinical teaching.
Aim: Develop and enhance leadership skills.
Outcome: Attended 2-day Masterclass “Transforming General Practice: a Masterclass on Leadership”. Some knowledge and skills from masterclass implemented into teaching. Read books and articles on leadership and compiled a list of ‘recommended reading’.
Aim: To become increasingly competent and confident in the use of a wide range of teaching and learning methods.
Outcome: Attendance and participation at ESME. Wide variety of teaching methods used since attendance at ESME course. Enrolled in Masters of Clinical Education.
Section III. Evidence of and reflections
Effective Teacher
Small group methods
PBL group
My own undergraduate medical education was a PBL based course. Thus, in becoming a PBL tutor I was able to “activate pre-existing knowledge” of the PBL process. Prior to attending the ESME Course in Prague I had been a PBL tutor for one semester, having attended a workshop on “Becoming a PBL Tutor”. The ESME course gave much me much greater clarity in understanding my role as a facilitator. I found the description of the abilities of the teacher/tutor in the course notes - Facilitator, Resource, Evaluator – invaluable in giving me confidence in fulfilling my role on my return to Australia. Furthermore, I was also able to use this simple classification to ensure the students understood my role.
In addition, I was challenged at ESME of the importance of frequent self and group assessment. So, I have since set aside a few minutes at the end of each meeting to evaluate learning and group process. As a consequence it was much easier to perform the required mid-semester and end of semester assessments and, I believe, they were more meaningful.
Finally, applying the advice given at ESME to encourage students not to read their notes on learning issues, but rather tell the group about them has revolutionised the beginning of the second tutorial. I am more able to focus on what the student is saying, the student is more aware of whether they understand their research and there is much more interaction and questioning from other group members.
Importance of self-care for medical practitioners
Regular small group work forms a significant part of the teaching and learning at the practice.I facilitated a small group session about the importance of self-care for medical practitioners. This topic was chosen as the need for self-care is increasingly being recognised as an essential element of a medical practitioner’s professional life. In addition, the educational programs the learners are undertaking recognise that self-care knowledge and skills are required to become a competent practitioner. The group, drawn from within the practice I am a member of, consisted of GPs, GP registrars and medical students.
To a large extent the learning objectives could be achieved by drawing on pre-existing knowledge and commonsense. Hence, discussion was chosen as it provides a rich source of ideas and support. Discussion in small groups also increases the likelihood of participants engaging more deeply with the subject matter. Overall, I believe that the group was successful in achieving the objectives.
There were a number of reasons that I believe contributed to the group’s success. The affable and supportive climate of the group encouraged open discussion, as did its small size. As well as this I believe the participants were clear about the overall aim of the session. The attentiveness and willingness to contribute of all group members, combined with the opportunity for them to discuss their own experiences, ensured successful interchange of ideas. Also, I think the group could see that there was a need for learning on this subject (indicating relevance) and displayed genuine interest in discussing issues around it.
There were several aspects of my performance as a group learning facilitator that I thought were good. Firstly, I think I chose a subject that was stimulating and topical which encouraged participants to talk. Secondly, having a clear plan for the session meant that, mostly, discussion flowed well. There was the potential for the discussion to be aimless, but having an underlying structure meant that all key areas of the topic were covered. By developing a plan for the time I wanted to spend on each area of discussion I was aware when I needed to move the group on. Thirdly, by providing written learning objectives at the commencement of the session, I think I made it clear what outcomes were to be achieved. Halfway through the session I spoke about what I planned for the group to cover for the remaining time. Furthermore, I think I contributed positively to group climate. I considered myself to be open, warm and friendly and I was pleased that I was able to elicit contributions from everyone.
There were also aspects of my performance that could be improved upon. Some of my questions were ambiguous and I sometimes asked two questions without a gap. I will endeavour to use more direct and concise language. The questions I did not prepare in advance were more likely to require yes/no responses, so I will be more conscious of my questioning style in subsequent teaching sessions and may employ more clarification questions2. On some occasions I could have waited longer for a response to my questions. As well as this, I could have encouraged participants to take more time to consider a question before responding.
Large Group Presentations
I have given 3 large group presentations since attending the ESME course. On each occasion I used “The Plan” suggested in the course notes. The time I spent planning and preparing for these presentations was significantly more than previously and I started preparation far earlier than I used to. I came away from the ESME course challenged to be more creative. Thus, I paid particular attention to the set and in all 3 presentations I was able to engage the audience. I used an initial joke when I presented on the AMEE conference to a group of fellow supervisors and I could sense the audience becoming increasingly engaged and relaxed as the joke unfolded. I was careful to change the stimuli during the body of the presentations and limited the number of major points I made. I was grateful that I had heeded the advice given at ESME to assume PowerPoint isn’t going to work as on one occasion the audiovisual equipment failed. I am still practicing asking for questions before closure.
Individual
‘Opportunistic’ case discussions are a frequent part of my supervision of the GP registrar. Instituting the The One Minute Preceptor, outlined during the ESME course, has improved the efficiency and effectiveness of corridor consultations. The registrar’s have now been ‘trained’ to commit to a diagnosis, rather than expecting me to provide an answer after they present the case. Use of the other 4 techniques then flows naturally and timely feedback is ensured.
Informed Assessor/Evaluator
Direct Observation Teaching Sessions
Ultimately as a trainer I need to ensure that the registrar is capable of working as an independent professional. The goal is safe and effective practice by the registrar requiring accurate diagnosis and an appropriate management plan, efficient collection of accurate clinical data and effective communication with the patient, patient satisfaction (questions and concerns handled adequately at both cognitive and emotional levels)3 etc.
Thus, I have increased my use of the method of direct observation of the registrar, having been convinced of it’s unique advantages from attending the ESME course, to observe and assess how they are performing with patients. Structuring observations of the registrars in a systematic way helps to gather accurate information about their performance and thus develop an understanding of their performance. I have now instituted these sessions on a regular basis (at least monthly), because of their high validity. There is no way of adequately assessing highly complex clinical performance other than by direct observation or video review.4Furthermore, when carried out regularly, as a planned educational activity, direct observation engenders an environment where reflection (self-assessment) on practice is encouraged and allows the supervisor to give specific feedback to (and share observations with) the registrar that enables them to continue to improve in their clinical performance.4
Feedback provides the GP registrar with information about what they actually do (present performance) and provides examples, strategies and motivation (hopefully) for improving their clinical and consulting skills (bringing up to required standard). Prior to implementing the activity I attempted to enhance my skills in giving feedback. Reading the ESME course materials and references enabled me to develop my knowledge of how to give feedback successfully and I also arranged to be given a teaching session on giving feedback by a medical educator from IGPE. It was also very useful to have thought about appropriate ways of providing feedback, especially encouraging the registrar to analyse their own performance and identify the positives first. I think this reduced some (but not all) of the anxiety associated with appraisal.
An important task was for me to develop an inventory/checklist of specific actions that I wished to observe during the registrars’ consultations. The intention was to be able to assess their performance against explicit ‘best practice’ criteria. Reading which explicated the consultation process, developed my understanding of ‘best practice’. I also reviewed the criteria that external clinical teachers from IGPE assess against when they undertake direct observation visits of the registrars. Specifically, I used a checklist to assess the registrar’s performance in the following: communication and rapport, history taking, physical examination, problem definition, management plan, preventative care and health promotion and record keeping.
Furthermore, having developed a prior safe relationship (built on many positive, helpful experiences throughout the term) with the trainees allowed for honest praise and criticism.
Documentation of observations and plans for further learning avoided ‘discussions in the air’.5
Although I made notes on the components of the consultations, in future I will also make medical notes as I observe the registrar and compare them with the registrar’s notes (medical records) at the end of the consultation. This will enable me to assess their medical record keeping more effectively.
Feedback from trainees
Both the current registrars feel that direct observation is beneficial. One commented that they would like to be observed “every couple of weeks” and the other felt it was good preparation for being observed in the RACGP Fellowship examination – an example of the linkage between formative and summative assessment. This also emphasised to me the fact that trainees are intrinsically strategic learners.5 The skills evaluated were directly related to their work as professionals.
Both registrars felt that from the process they were able to develop working knowledge about what to do in future consultations. The registrars identified specific learning goals as a result of undertaking the activity.
Feedback from professional peer
Dr George Kostalas, CEO/Director of GP Training at IGPE reviewed a videotape of my giving feedback. He commented, “You implemented the listen and help solve mode of giving feedback. You were very attentive maintaining eye contact except on occasions when you were giving negative comments when you looked down. It is always difficult to give negative comments but I thought you did it very sensitively encouraging the registrar to comment on your comments.”