Postgraduate clinical teaching

Dear Sir

Two recent ‘Twelve Tips’ in the same issue of Medical Teacher provide an interesting contrast and the positions from which they are written identify a key issue for those learning and teaching in postgraduate medicine. Dennick (2012) considers three aspects of learning theory and from them draws conclusions about how learning opportunities might be best constructed. Of particular importance is a learner-centred approach, identifying and building upon previous knowledge, of relating learning to context and of reflecting upon experience.

Kirkham and Baker (2012) come from a different perspective. While acknowledging the importance of experience they are concerned that in practice, routine clinical work always takes precedence over anything else and may not itself be accompanied by much learning. They find themselves at odds with their colleagues who feel that trainees are best kept in the clinical environment. They may also be worried about being able to measure whatever learning that does take place. Based on a requirement for a formal generic teaching programme their proposals are for teaching sessions, which should be in protected time and compulsory. They outline a model syllabus around a number of common patient presentations and some more general topics.

I find a disconnect here. Is day-to-day clinical experience an opportunity or a threat? Or, if it is both how can we make it more of one and less of the other? Many years ago, I was an enthusiast for protected time for teaching but now I am not so sure. The risk I see is an attitude that protected sessions become the only teaching that matters and the rest of the time can all be devoted to uninterrupted service work without needing to worry about the much more complex and messy task of experiential learning that Dennick implies. We should not undermine the use of experience because the clinical environment appears too unfriendly for teaching. We should strive for better learning and teaching opportunities within the clinical encounter, recognising that every patient is different, every encounter a potential learning opportunity. Osler got this right more than a century ago. It may not always be measurable but then not everything that counts can be counted.

For example, for most doctors the consultation is their primary activity but how many hospital consultants (GPs do it better) watch our trainees conduct a ward round or an outpatient session, at least outside a formal assessment, and perhaps not even then? The one-minute preceptor idea has not yet crossed the Atlantic.

As a possible way forward, the General Medical Council (2012) has recently proposed the concept of Supervised Learning Events (SLE). Detail is thin and it needs to be seen if these will be more than a new bit of jargon for formative assessment. Nevertheless perhaps there is a valuable opportunity now to use the authority of the regulator to devise innovative ways of capturing the ‘teachable moment’ within the stochastic environment of clinical work which will satisfy everyone that necessary learning is being achieved without undue disruption to clinical work.