Working, training and being assessed in different medical contexts is challenging.
With the publication of RACGP exam results, there is always a vibrant discussion regarding the validity and reliability of assessment, exploration of ‘near misses’, and an understandable spectrum of emotion extending from exhilaration related to a high mark, elation and surprise at an unexpected pass, and despair for those unexpected results. A recent article in Australian Doctor has highlighted the disparate assessment performance of various groups training in Australian GP, and in particular International Medical Graduates (IMGs) whose pass rate is just 37%.
A few weeks ago I started a new position as a GP with Special Interest (GPSI) in a hospital. I haven’t worked in a public hospital since I was a JHO 20 years ago. I am a specialist now – an ‘experienced’ GP.
But, now there are:
- new systems and hierarchies;
- new networks;
- new acronyms and languages;
- new IT processes;
- new training processes;
- new models of practice; and
- the challenge of practising medicine through a different lens.
Yet, I am still in Australia. Imagine if I had embarked upon this adventure in another country where I had little or no prior experience of the learning and practising environment?
Just imagine if you were starting a new job in General Practice in Australia, and perhaps in addition if you had previously been a specialist in another discipline? Imagine you are working in a town that you had not heard of before, and are relatively culturally, socially, professionally and educationally isolated? And then consider that you may not be eligible for funded training and you’re working in a practice where your employer is your supervisor, and any complaints or difficulties may mean withdrawal of supervision and potentially your Provider Number!
Don’t forget you now have to find the time and funds to study and sit for GP Exams.
Where would you start? On the proverbial back foot potentially…
It is timely that organisations involved in GP training and education are recognising the unique situations in which IMGs are placed, and their difficulties navigating the Australian GP landscape. Eminent Australian GP Educators have recently published an insight into the aforementioned issues – IMGs and GP training: How do educational leaders facilitate the transition from new migrant to local family doctor? New initiatives such as the RACGP Practice Experience Program are aimed at providing additional supporting for doctors unable to participate in the AGPT pathway.
Living and working in an unfamiliar environment is not however the only contributor to assessment performance in General Practice. For the majority of IMGs, the ways in which they were taught medicine, are in contrast with the ways in which they are examined in Australian General Practice. GP Fellowship examinations in Australia are problem-based, in addition to knowledge-based. So lets look at didactic and socratic learning, and what that means.
For the majority of Doctors who have gained their primary medical qualification outside of Australia, their education has been delivered in Didactic methods (actually so was mine in Australia 20 years ago!) versus Socratic methods. Basically the difference in the delivery methods is akin to filling the learning vessel (didactic) and facilitating learning to find the water source (socratic). As an introduction, the GPSA Communication Skills Toolkit has an excellent module on didactic (Confucian) and Socratic methods. One model alone will not work, as baseline knowledge is required to inform active learning.
The following comparative list outlines the differences clearly.
Perhaps the most eloquent explanation is in a Blog I found looking at training race-car drivers – please read Didactic vs socratic teaching for a pragmatic insight and to demonstrate that this issue is not just limited to GP training. In the blog, the author talks about the difficulty of training a driver on a race course, and the need for them to ‘experience’ their learning, rather than it be dictated.
Most learners of course default to continuing to learn (and wanting teaching) in the method with which they are most familiar. Structured and mapped learning, ‘spoon-feeding’ of resources, and direction as to what should be known are all a part (and sometimes necessarily) of didactic processes. However, where is the thinking? Where is the problem-solving as the car does not predictably corner around the bend when you thought you were an experienced driver? How do you interpret what you ‘thought’ was the diagnosis when it just doesn’t fit?
And academically, what is the role of knowledge regurgitation to assess competency when in fact the purpose is to assess safety to see patients in a clinical setting in any context in Australia? Competent independent practice requires knowledge interpretation, problem-solving, and study approaches that contribute to constructive patient management and safety.
Active interventions to align learning methods include recognition of clinical and contextual biases, and the use of diagnostic and therapeutic clinical reasoning frameworks both in clinical practice and assessment.
I have been enamoured by a quote from an article in Academic Medicine from 1932:
“…the student may be given a better orientation in a subject that he can acquire for himself from his case teaching and textbooks alone. The lecturer can emphasise the important things and minimise the unimportant. He can also present and issues recent knowledge in his field and criticise new ideas, so that the student may be thoroughly exposed to the current of medical thought.”
So how do we ensure that didactic and socratic learning processes are used synergistically?
- Recognise there is a problem: Learning methods incongruent with assessment methods. Are there other ways in which we can perform assessment that may be more valid and reliable? I’m sure programmatic assessment has the answer.
- Define the learning methods: Ask the learner – How were you taught? How do like to learn (and ask yourself if a Medical Educator or GP Supervisor, How do I like to teach?)
- Close the GAP: Make a plan to bring the learning and teaching perspectives together. Explore supervision and Mentorship opportunities.
Ask, Share and Tell of your Learning and Teaching Experiences.
If you are a GP Trainee, think about how you fill your learning vessel, and how adept you are at finding the source of knowledge. And what if the vessel was different?
If you are a GP Educator or Supervisor, consider how much you fill your learner’s vessel, and how much you allow them to explore possibilities to connect to the source.
Disclaimer: Please note that any comments or opinions within this post are independent of my employed and representative positions.