This blog is a little different, a bit more personal than usual as it’s about my experience in learning something new. If you’re not that interested in skills teaching feel free to skip this one and wait for the next blog. If you are interested in skills teaching then I hope you find it useful.
Let’s start with Damian Roland’s blog on, the rolobot rambles . It’s a great read around PEM and MedEd, and I especially like the WILTW (what I learned this week) sections which illustrate how learning never stops in medicine. The unending learning cycle is both a challenge, but arguably the greatest joy of our craft. Our current knowledge will prove to be right and wrong in pretty even measure (Ed – well probably, though we don’t really know that either). The point is that if you have a curious mind then medicine offers the opportunity for lifelong intellectual stimulation, investigation and frustration. I think Damian’s blog clearly shows this and I’d recommend you follow it.When teaching it can sometimes appear that the instructors are the ‘cleverest’ in the room, but of course this is unlikely to be true. They be the most experienced and skilled at that particular moment, but that’s a function of time served rather than intelligence. The point is that when we see a senior clinician, a great resuscitationist or a role model, their journey and struggles to get to that point are rarely apparent.
All too often we hear from senior docs that the younger generation ‘don’t work as hard’, or don’t know what a ‘real on call‘ is, or deride the idea of a life in outside of medicine. Time has clearly dimmed their experience of the training path.
Am I guilty of this? Yes of course, although I’m trying hard not to descend into that particular stereotype, but how? What’s the antidote to such complacency? Perhaps it is to become a learner once again, to try something that is new and challenging, and perhaps to struggle. Arguably by the time you’re a consultant or attending you tend to either learn in areas where you are already expert. You are in control of what you learn building on prior knowledge but never really struggling (Ed – perhaps that’s why we see some, senior clinicians become increasingly out of date?).
Let’s get back to the WILTW principles. What have I learned this week? It’s not emergency medicine, it’s not even clinical, it’s physical. I’ve been back to Bude in Cornwall to surf, swim, cycle and generally get out and about on the wonderful coastline.
A few years back I decided to take up surfing with my two girls. I’m not very good. Maybe it’s age, strength, flexibility, or perhaps it’s just not my thing. The point is that it’s been a real lesson on what it’s like to not find things easy, a time machine of experience back to the days when I was a junior learner and when I had to learn from scratch. Some days the experience has felt as though my achievements, bruises and lack of progress could have been reproduced by spending 3 hours in a washing machine holding a plank, but the memory is always great. Much of this is down to the coaching team at Big Blue and that’s made me reflect on what they do that works, and whether there is anything we can learn from them to bring back to our clinical teaching in Virchester.
Here are my top 8 points that I’ve picked up from the Big Blue surfing team
The best surfer on the beach is the one who is having the most fun.
It’s tempting to go into a teaching session and think that the person who is achieving the best results is also the person learning the most, or that they are having the best experience. That’s probably not true. Imagine your teaching intubation on a life support course. The consultant anaesthetist who is already highly skilled in the technique is unlikely to get that much out of the session, whereas the junior EM trainee may learn loads, even if they don’t fully achieve by the end of the session. However, if they are supported, if they have a great time and if they enjoy making progress then they are arguably the best learner there. The best surfer on the beach analogy means that it’s not always about the pinnacle of achievement, but also about the journey. For example, think about how your learners experience your sim training, is it fun, or is it painful? As an instructor the message is clear, it’s not just about the final result, but also the journey and the experience.
Identify and celebrate waypoints.
You’re not going to be pulling aerials and surfing barrels on day one,(or day 2056 in my case), and that’s OK. In surfing, catching broken waves and standing up come before mastering pop-ups and turns. Beyond that there is so much more that could be learned, but for most of us the waypoints that exist between beginner and master will be enough. Most skills can be broken down into different levels of complexity. Getting an IV into a plastic mannequin is a waypoint to real people, which is a waypoint to difficult veins, which is a waypoint to difficult IV access in a time critical setting. We should celebrate and identify these as we progress as they are all equally important. The first time you stand up on a board is just as important as the first time you catch a green wave. Each step is equally important and should be celebrated. Do we do this enough in medicine? Perhaps not. In airway care do we educationally value simple airway management in the same way that we value video-laryngoscopy? I’m not sure we do, but we should.
There is always something more to learn.
Learning a skill is not always about being perfect straight away, the waypoints are important, but then it’s important to identify the next task to master. A great teacher is able to analyse where your skill level has got to and then add the next step to work on. In medicine we often stop coaching when trainees have reached a minimum standard. What we should be doing is celebrating that and then guiding them onto the next step, complexity or challenge.
As skills improve time appears to extend
Many of the skills in emergency medicine have a frisson of time pressure associated with them. Putting a chest drain in, lines, intubations even just examining a patient take time and we want to be efficient and ‘slick’. As a novice there are so many things to remember, so many mental checklists and notes that we often struggle to have time to ‘think’ rather than just ‘do’. Catching a wave requires a memorable sequence, wave selection, paddle, position, speed, hands, head, feet, pop up, feet, look, move etc. At the beginning the sequence is everything, the understanding minimal. Only with time and practice does the sequence become natural and as that happens time extends around the process to allow thought and adaptation. I’ve learnt that in surfing the as elements of the process become natural the time available to analyse and reflect extends. In medicine this means that when teaching there is probably little to be gained from microanalysing skills until the basics of the sequence have been established. For me this means that we really should establish the process through simulation (even if that’s mental simulation) before we try and coach the minutiae of micro skills. Don’t teach too much too soon.
There is absolutely no substitute for enthusiasm from a teacher. No matter what your rate of progress is, no matter if you’re getting a bit stuck, or if you are flying fast on progressing really well, you will get more out of the session with positive feedback. How much more progress would we make if we were persistently positive about our trainees efforts and progress? A surf school is commercial and so they know that how a learner ‘feels’ about the session is a real determinant of whether they come back. If we felt the same about our learners, would they want to come back again and again, and would we harder to improve our presentations? The success of SMACC over traditional courses and conferences suggests that it does. I still see too many sessions where border being mean to the trainees. We can’t let that continue and should call it out when we see it.
….but you need to be honest with your feedback
Being positive is not about platitudes and participation awards. When a learner is not doing something right you need to tell them what it is and be honest about it. This week I’ve been working hard to correct and improve my turning on a new board. I’m moving from one skill set to another and it’s tough. I need the honest feedback to tell me where it’s going wrong and how to improve. Do we do that often enough in medicine? When we are teaching we must be able to identify what’s not going well, but more importantly why it’s not going well and what can be done to improve.
When the learning gets tough, back off and practice where you are.
All learners plateau at times. This week I just failed to progress for a few days. I was working hard but getting frustrated. We’d been through the what/why/how process above but it was just not working. I tried to push through and try harder, but I was going nowhere. The right advice was to stop worrying about it, go back to the previous waypoint/achievement and just enjoy the waves. In medicine we are always pushing ourselves to the next step, the next challenge, but sometimes it’s ok to pause and consolidate for a while. I recently expressed surprise that a colleague was really struggling to surgically hand tie when putting in a chest drain. Did that really matter? Was there any real point in pushing them to do that there and then or should we have celebrated their achievement about getting the drain in and left that micro-skill until later. In retrospect the latter option would have been best.
Lastly, as an educator it’s good to struggle at something.
If you’re an educator (and we all are) reflect on the last time that you struggled to achieve. Do you have a clear memory of what it felt like to be making slow progress, to be falling behind your colleagues who appear to find a skill or a topic easy to grasp? We’ve all been there at some point in our training, but with seniority we tend to move away from the struggles and increasingly reside in our comfort zones. For the more senior amongst us the idea of struggle is a distant memory that we view through the adjustment of time. We imagine that we got through stuff in a way that the current generation cannot, but this is an arrogant and untrue illusion of the past. My challenge to you is to try something new, something that’s a struggle, a challenge, something difficult and complex. Not only will you hopefully learn and have fun, you’ll also feel what it’s like to learn again and I think you’ll be a better educator as a result.
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