INTRODUCTION
Vocational training courses test every aspect of an individual's ability and strength of character; trainees go through intensive training that expects a large degree of learning ‘on the job’. They are expected to turn optimistic theory into reality and can feel they are being made to jump through hoops. Like learning to drive with your hands at 2 and 10 o'clock — do all instructors and examiners really do that? The risk is that once trainees are farmed out to the school or practice they can feel isolated while trying to achieve the impossible. By recognising models of professional growth, the trainer can develop an understanding of how best to support their trainee and the trainees have the opportunity to see that they are not alone, that it is normal to feel overwhelmed, and that it will not last forever!
The Furlong and Maynard stages of professional growth for trainee teachers1 can be usefully applied to GP trainees as a framework for personal reflection throughout training (Figure 11).
Figure 1 Stages of professional growth for trainee teachers, adapted from Furlong and Maynard.1
EARLY IDEALISM
When many teachers begin training, their only experience of school has been as a pupil, they have fond memories of their favourite teachers and are very clear about what makes a good teacher from the pupil's perspective. In general practice, trainees have their own memories of the family doctor who gave them a lolly after their injection. This early idealism is, unfortunately, a case of rose-tinted glasses. Your favourite teacher made it look very easy but they were performing a carefully judged balancing act and, with ‘being healthy’ in Every Child Matters,2 that lolly is no longer allowed — apples only! For teachers this idealistic (and often unrealistic) viewpoint usually does not last beyond their first experience in front of a class; teenagers are particularly adept at removing those rose-tinted specs (and even jumping up and down on them in some cases). However, for GP trainees this idealism could potentially last longer and it is likely to be tied to the length of their appointments. With 30-minute appointments the trainee has the opportunity to really talk with their patient, to uncover the hidden agenda, illicit their ideas, concerns, and expectations, and meet any QOF targets. The trainee feels they are building up a relationship, particularly since, with that amount of time, the patient may request to see the trainee again. This is the television GP, the one who has time to go chasing after an older patient who seemed a little distressed about their daughter's marital arrangement because the grandson hates the new step father … (and so on for half an hour). But it is not a reality that can be sustained.
SURVIVAL
Teacher trainees rapidly move onto the next stage once reality hits: survival, and it becomes a desperate battle to keep their heads above water. Hours are put into planning activities and creating resources that, if behaviour is an indicator, pupils do not appreciate. Teacher trainees suddenly realise that experienced teachers make it look easy. As the class are coming in they somehow manage to keep 30 15-year-olds quiet while dealing with the forgotten books, untucked shirts, pupils leaving for music lessons, pointedly saying hello to miscreants, and still getting the whole class quickly settled to the starter activity. Trainees cannot see how they will ever navigate their way through this calm chaos. They rapidly learn to judge their lessons according to the pupils' behaviour rather than how much learning took place. For a GP trainee, the pressure is not the number of patients arriving at once (30 patients at once may be an interesting new appointment system but, I think, not one that would last, although who knows what the outcome of a coalition government could be …) as much as it is the length of the appointment. As the appointments get shorter, GP trainees struggle to fit in all the checks they are meant to include, their trainers are busy pointing out that the trainee didn't offer chlamydia screening or assess for depression in the middle-aged diabetic. The trainees meanwhile are just grateful that there have been no complaints made against them, they judge their success by the behaviour of the patients rather than by the amount learned. This could be the GP learning new information about the patient or the patient learning about their treatment options or healthy lifestyle choices. Either way, it is actually the learning that is important, but, like trainee teachers, they cannot see the learning for the panic.
It is a trainer's responsibility to at least shorten this survival stage, for teachers this involves a programme of collaborative teaching and if GP trainees are given preplanned small reductions in appointment times they can feel prepared for each step. The support-challenge grid proposed by Daloz3 is a useful tool for trainers to consider (Figure 2).
Figure 2 Daloz's Support-Challenge grid.3
The balance between support and challenge is delicate and must be adjusted to cater for individual trainees (and to some extent the trainer as well). With a combination of high challenge and lots of support the trainee is able to progress within a positive environment, they are given specific and challenging targets with adequate opportunity to meet them. A high level of challenge without support could lead to a disheartened and demoralised trainee who feels they cannot possibly achieve the targets set for them and, at the extreme, may give up entirely. If, however, there is not enough challenge a trainee will begin to believe they have already achieved the level required of them. They are not asked to improve in any significant way so, not unreasonably, they believe there are no significant improvements to be made. If this is combined with a high level of support, previous misconceptions will be confirmed rather than challenged. Trainers need to recognise where they lie on this grid, but it is also a useful reflective exercise for trainees to understand the style of training they are receiving.
RECOGNISING THE DIFFICULTIES
In the ‘recognising the difficulties’ stage, teacher trainees are able to make sense of the classroom, they don't always get it right but, by carefully focusing on particular areas of improvement (SMART targeting of course), they begin taking steps forward. They can see more clearly what they need to improve as the challenge before them is divided up into small, manageable chunks. As appointment time decreases, a GP trainee will recognise more specific areas of improvement and begin to develop their own techniques for the patients who would like a long chat or inappropriate sick note.
It is during this stage that trainees, both teaching and GP, start to develop their ability to critically reflect on their performance. Schulman's reflection cycle4is a useful tool to structure the process (Figure 3).
Figure 3 Shulman's reflection cycle.4
When the trainee receives information — this may be new factual knowledge from a lecture or learned skills from a bad consultation or lesson, they must take some time to digest this information. Once they have absorbed the knowledge they have the opportunity to use it and evaluate it. During this evaluation process, they consider what went well and what did not, deeper reflective skills will develop as this superficial internal discussion becomes an analysis of exactly what small triggers caused the overall consultation to work or fail. However, reflection is meaningless if the new knowledge is not fed back into the cycle to allow further development. For many trainees, the forced process of reflection is frustrating, they feel they do not gain anything and are once again jumping through hoops. However, with careful guidance and questioning this superficial and ‘fake’ reflection process will become instinctive. A new teacher will walk out of a lesson and say ‘That lesson went badly because the pupils were really hyper’, the more experienced teacher will say ‘That lesson went badly because they had just had a PE lesson and I had the wrong equipment so the lesson lost pace.’ A similar step is taken by GPs as they narrow down from ‘She didn't seem to respond to me’ to ‘I hadn't considered how difficult she finds leaving the house since her husband passed away — had I just acknowledged this she would have felt understood.’
HITTING THE PLATEAU
At this point trainees become secure, their ability to superficially reflect is in place, they are comfortable with their 15-minute appointments and 9C are no longer giving them as much trouble. A trainee should recognise this as the point at which it starts to get easier, for trainee teachers this is often near the end of their teaching course, for GP trainees it is likely to be in their ST3 year. It is important for trainer and trainee alike to recognise this stage, it is a very comfortable position for both but the trainer needs to provide new challenges for the trainee (although the push could come from an internally-motivated trainee). This could be a new class or trying alternative consultation models, or it may be an opportune time to introduce some of the overwhelming administrative work that comes with both jobs.
MOVING ON AND THE PERPETUAL CYCLE
So, the trainees are moved onward and upward, ultimately (we hope) they learn to manage the new challenge and hit another plateau, when additional challenge is again required. This cycle will continue throughout training and, likely, throughout their career as individuals stretch themselves and take on new responsibilities.
There is also a likely reversion to the survival stage at certain points in a career. For teachers this is usually as soon as they begin their first full year of teaching — a full timetable, a new school, reports to write, exams to mark, it becomes a case of surviving again until difficulties are recognised and dealt with. For GPs it is not as straightforward, they may become salaried GPs in which case, although the safety net has been removed, there may be little additional challenge. However, once they become a partner, the administration and additional stresses of running a small business, as well as being a full-time GP, could easily lead them into another survival stage. By dividing it up into manageable chunks (as they have been taught throughout their training) they will spot the difficulties and deal with them one at a time.
SUMMARY
Study of professional growth is useful for reflective purposes at any time during a career. The concept of known knowns and unknowns with a training twist can be used to summarise the overall stages of any trainee (Figure 4).
Figure 4 Stages of a trainee.
At the start of vocational training the trainee does not know what they do not know, they have not yet recognised how much they have to learn. This happens in the second stage (that could be equated to survival) when they begin to understand the vast array of skills they must develop to make it look easy. With time and practice they will reach the point where they know what they have to do — not always getting it right but then who does? Finally, and it is particularly important that trainers recognise this, an individual will reach the point where everything is so automatic they are no longer aware of the intricacies of the skills they have acquired. This is where most trainers, both for teachers and GPs, find themselves and this can be frustrating for both trainee and trainer as they find they are unable to communicate effectively. A good trainer will spend time dissecting and ‘unlearning’ their skills so they are able to teach their trainees successfully. Trainees, meanwhile, must realise that, one day, they will have their own unknown knowns, but they cannot expect it to happen overnight or without substantial effort.
In moving forward from our training it is how we deal with repeated survival stages that determines if we can keep doing the job, it is how we deal with the plateau that determines if we will be any good at it — effective on-the-job training leads to lifelong on-the-job learning.
Notes
Provenance
Freely submitted; not externally peer reviewed.
- © British Journal of General Practice 2011
