When I saw this section on the TTC programme I was immediately intrigued. I have spent a lot of time thinking about what makes a great team leader, a great doctor or a great teacher – but I realised I rarely bother to think about what makes a good learner or how I can be better at it, despite my public commitment to lifelong learning. It’s easy to forget when you’re meded obsessed that the learner makes up 50% of the incredibly important dynamic of the learning relationship.
So I thought about me. I know I don’t approach learning and my own development in the same way since I stepped into the world of FOAM and after some reflection and some research I’m going to tell you the ways I think you can become a better learner (and hopefully help you to start that journey yourself). I think there are three key dimensions which, together, make a good learner – I’ve split these over three blog posts just like I split my talk at the Teaching Course into three sections.
- Physician! Know Thyself
- Physician! Teach Thyself
- Physician! Enjoy Thyself
Disclaimer: this advice holds true for other healthcare professionals as well as physicians – but my titles wouldn’t be quite as snappy if I had to include everybody 🙂
PHYSICIAN, KNOW THYSELF
Know Your Limits
Consider self-assessment, motivation and ambition
The first step is to know who you are and what you want. Sounds simple but have you thought about it? What does your ideal career look like? What do you enjoy most about your job? Where do you want to work?
We spend remarkably little time thinking beyond the next twelve months, but Stephen Covey tells us that one of the habits of successful people is to start with the end in mind. There are lots of practical things you can do to determine what matters to you and where you want to go. At the teaching course we finished this session with a prioritisation exercise; some people find the Myers-Briggs personality inventory a helpful framework for understanding themselves; keeping a diary of the things you have enjoyed or felt passionate about can help focus you; and asking people who know you well what you are good at is a great way to understand your hidden competencies (like the JoHari window – we did a modified version of this at the Teaching course too).
Cognitive offloading and multitasking
Studies have suggested that multitasking actually has a negative impact on learning, memories and judgement (yes, even if you’re a woman, multitasking is a myth). It isn’t actual multitasking, it’s continuous partial attention, or doing several things badly at the same time. We need to learn to recognise when we are overloaded and when there’s too much going on and, more importantly, how to manage this in clinical situations. It comes with practice and reflection.
Resilience is incredibly important and what’s more, you can’t build resilience from a state of emergency – you need to be resilient before the emergency occurs (so start today!). Resilience is the capacity to absorb negative experiences and to recognise things that we can’t change – and move on.
Stress releases oxytocin which attracts us to other people to keep us safe – connectedness is at the heart of resilience. Experiences which are unpleasant, even if another person intends them to be so, don’t have to be experienced that way. Key to resilience is self-understanding, interaction with others and the world, meaning beyond oneself and having a positive approach and all of these feed into successful learning.
Question everything – be sceptical
My good friend, Skeptic Ken (he gets a K in skeptic – respect to our American/Canadian colleagues), reminds us frequently to:
Be skeptical of everything, even if you heard it on the Skeptics Guide to Emergency Medicine.
For many of us, this means rethinking the way we approach clinical uncertainty, moving from “I don’t know what to do. What do you do? I’ll do that.” to:
“Here is a problem. What is the question I’m asking?
What does the evidence say?
What do I currently do – and why?
How and why should I adjust my current practice?
What do my peers think about what I have come up with?”
Think about the trading floor at the New York Stock Exchange. It’s busy, it’s noisy, it’s messy and chaotic. It can be just like this in the Emergency Department. There are decisions to be made, under pressure, with minimal information and there is huge uncertainty.
Nothing in medicine is certain (that haemoglobin count? Is the patient’s Hb concentration definitely 113g/dL? How certain are you?).
We’ve talked before about the Dunning-Kruger effect – the illusory superiority bias – which makes us think a few months into our EM careers that it’s easy. Our ignorance gives us confidence. We start thinking we know some things and move quickly to the time when we think things are easy and complex – our heuristics are in overdrive. We are one big shortcut. Then sooner or later we come crashing back to earth as we realise everything has a confidence interval. Everything.
Like the NYSE, people sink or swim in this environment. Our eyes are opened to the huge amount of knowledge we don’t possess and it can be crippling.
It doesn’t have to be that way. We can embrace critical appraisal and staying up-to-date with the literature. We can learn how to structure a three-part-question, to seek out the best evidence and to critically assess its application to our own practice. And we can discuss this with colleagues and with patients, not seeing re-attendances as failure but as successes. We can thrive as we embrace uncertainty. We need to be sceptical – but also curious.
But sometimes things will go wrong and when that happens our natural inclination may be to panic, to run, to hide.
We must not do that.
Michelle Johnson spoke about the importance of failing spectacularly at smacc earlier this year in Chicago.
We can learn to embrace failure, inadequacy and mistakes, by striving for organisational culture which celebrates process, not outcome and recognises that success can be accidental and error is almost always unintentional. We can recognise the value in learning from the everyday, not just the extremes of our practice.
Be Self Aware
Chew over what you know. Test it, feel it, taste it, experiment with how it fits with other knowledge. It may be helpful to have facilitated critical reflection to begin with, if this is new to you. Under good guidance, critical reflection can lead to high level analysis, questioning, and reframing of existing knowledge. Transfer of learning is a hallmark of Emergency Department working – it means using existing knowledge to solve unfamiliar problems, acting effectively beyond past experience and learning; reflection is key to developing this.
Critical reflection can be most useful for disorientating dilemmas which test your existing knowledge – for example:
- a completely unfamiliar situation
- one which went well but you don’t know why
- a complex, surprising or uncertain situation
- one where you felt personally or professionally challenged
Critical reflection can be structured or unstructured and there are benefits to both approaches. What is important is to decide what you will do with reflections afterwards. Feedback and follow-up are useful if you are reflecting with a supervisor or mentor.
Know what you don’t know (metacognition)
We are terrible at judging ourselves (if you don’t believe me, believe Chris Nickson). We can try to understand our biases. First, read about cognitive theory (Kahneman and Crosskerry are great for getting to grips with these ideas).
Learn to develop cognitive check points – train yourself to ask yourself “how do I know this isn’t a life threatening condition?”
And the stuff you really need to know, like the dose of PGE2 for neonates? Store it in your phone. Make it easy to access, offline, in an emergency. You won’t remember every fact, completely accurately, every time.
Seek meaningful feedback
When it comes to feedback we know there is a disconnect between learners and teachers: learners say it doesn’t help, teachers say it’s too hard.
As a learner, in order to get meaningful feedback, think about what you want from the interaction and articulate it. Do you want to know what you are doing well? Are you seeking reassurance? Feedback should lead to change so investment in learning needs and seeking feedback on areas which need improvement are more likely to lead to behaviour change and benefit for the learner.
Feedback can be incredibly useful for both improving performance and establish a frame of reference for more accurate self assessment.
We know that learners are more likely to seek out and value feedback from providers whom they see as having expertise and who have their best interests at heart. Relationship also matters and having a consistent trusting relationship with continual assessment will be more fruitful. We do need to feel safe, as though there won’t be negative consequences from feedback and this is best developed with a robust sense of self-efficacy. As teachers we also need to recognise that feedback does not equal and should not equal summative assessment.
So that’s how I think you and I, as learners, can know ourselves better and thus get better at learning. Next up: Teach Thyself!
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