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As doctors we are now obliged to provide evidence of our fitness to practice through the process of annual appraisal and revalidation (Department of Health, 2006). One of the key components of this is continuous professional development, with self- directed learning being a key skill. As health professionals, General Practitioners (GPs) are relatively isolated and hence rely heavily on this type of learning (Jennings, 2007). A significant amount of planning is inherent in the success of self-directed learning, and it is in this capacity that the Professional Development Plan (PDP) has become increasingly important. PDPs have been generally well received by GPs as having a positive impact on development (Evans et al, 2002). By encouraging autonomous reflective practice it has been suggested that PDPs make GPs more selfâ€directed, and thereby improve health outcomes (Jennings, 2007).
Self-directed learning is synonymous with adult learning (Knowles, 1976), which has undergone an evolution in recent years. There is a growing emphasis on improving the learning experience by applying research, in what has been called "the new science of learning" (Bransford et al, 2000). Over a similar period there has been a transition in medicine, where demographics, attitudes and career paths have evolved (Ebrahim, 1999; Newman and Peile, 2002). These changes have resulted in a greater diversity of learners and an encouragement of lifelong learning (Ralhan et al, 2008).
Medical education needs to evolve to keep pace with these changes (Academy of Royal Medical Colleges (ARMC), 2009), and the expectation is that doctors take on this responsibility and undergo formal training in teaching. The development of effective teaching techniques is now a requirement for doctors, as highlighted by the General Medical Council (2006); and there is a growing and widely accepted view that teaching skills can be learnt and perfected (Ralhan et al, 2008). The author's increasing appreciation of this, and desire to become a better educator has influenced his personal development objectives.
These objectives cover three broad areas; analysis and development of my current learning style, developing teaching skills focused towards adult learners, and the evaluation of the workplace-based assessment (WBPA) as an assessment tool.
Section 1: Review and development of my current learning style
Learning theories provide a foundation for understanding how we learn. As individuals we all have a preference on how we acquire and interpret information. This preference refers to our learning style, and is most comprehensively defined as "characteristic cognitive, effective, and psychosocial behaviours that serve as relatively stable indicators of how learners perceive, interact with, and respond to the learning environment" (Curry, 1981).
An understanding of one's learning style can be empowering (Cohen, 1995). It enables individuals to develop techniques to enhance learning as well as allowing them to focus on areas requiring development. There are an array of models and instruments developed specifically to help classify and categorise learning preferences. A recent review by authors from the University of Newcastle identified 71 different theories of learning styles (Coffield et al, 2004). It identified 13 'major models' including Kolb's influential Learning Style Inventory (LSI) (Kolb, 1985).
Kolb (1984) describes individual's approaches to learning using the LSI, in which he identifies four distinct stages requiring specific abilities. (Discussed in more detail in section 2). It focuses on learner's preferences in terms of concrete versus abstract, and action versus reflection. Learners are subsequently described as divergers, convergers, assimilators, or accommodators.
Based on Kolb's theories, Honey and Mumford (1986) developed the Learning Styles Questionnaire (LSQ) and suggest four basic learning styles (Figure 1). The author completed the LSQ to gain a better understanding of his learning style. It failed to highlight a strong preference, but showed a relative deficiency as an activist. Interestingly, this is in marked contrast to a previous LSQ completed at the beginning of his medical career, which showed a strong activist preference.
Both the LSI and LSQ models assume that learning entails a cycle with four components, and that a learner is likely to feel most comfortable in one of the four modalities (McLeod, 2010). Proponents of these models argue that learning styles are not determined by inherited characteristics, but develop through interaction (Omrod, 2008; Montgomery and Groat, 1998). This may explain the relative shift in the author's perceived learning preference with experience. Learning styles are, therefore, not necessarily fixed and can change over time, even from one situation to the next. (Kolb, 1984; Honey and Mumford, 1986).
Critically, there is no learning style theory that is universally accepted (Coffield et al, 2004), and little evidence to support their use (Pashler, 2009). Coffield et al (2004) reviewed the most popular learning style theories and identified a lack of independent research and validation as a major weakness. They concluded that "the idea of a learning cycle, the consistency of visual, auditory and kinaesthetic preferences and the value of matching teaching and learning styles were all highly questionable." Similarly, Bloomer and Hodkinson (2000) argue that learning styles are not a major determinant of how people learn and that the influences of culture, context and relationship are much greater. In any teaching environment it is therefore important to appreciate the complex dynamics which influence an individual's potential to learn, and avoid applying simplistic "labels". By delivering learning that focuses exclusively on one "style" or on perceived "strengths" one could disadvantage students (Romanelli et al, 2009). We should be promoting the development of learning which recognises individual learning preferences, but simultaneously challenges their weaknesses, and hence developing more holistic adult learners.
As Romanelli et al (2009) suggest; it is essential not to pigeon-hole students on the basis of their perceived learning styles and to consider the context in which the learning takes place. Knowledge of learning styles is potentially a great asset to both students and teachers; and as a prospective trainer unlocking this potential and applying some of the overarching principles should prove valuable. We should aim to use various teaching techniques depending on the situation and the individual to provide optimal learning. As Grasha (1996) argues, the problem is not that mismatches sometimes occur, but it is rather the failure to acknowledge and resolve these misunderstandings that undermine student learning.
Inevitably students will display a variety of learning styles; some may have a dominant style of learning, whilst others will find that they use different styles in different circumstances. Critically, there is no correct mix; however an awareness can enhance the student experience. Realistically we cannot develop different ways of teaching for individual students, and there is a lack of evidence to suggest we should; but we can provide a variety of learning experiences so that different styles are addressed.
Section 2: Developing teaching skills focused on the adult learner
There are a number of theoretical frameworks which look at the development of adult learning in more detail. The most well known is Knowles' concept of andragogy (Knowles, 1980). This refers to the art and practice of teaching adult learners, as a distinct concept from pedagogy which focuses on the learning of childhood. It is not really a theory; but more a set of assumptions that describe the adult learner (Hartree, 1984).
The concept of androgogy assumes that adult learners are autonomous and driven by their own aims, and therefore more likely to be "self- directed learners" (Knowles, 1980). It is therefore imperative that we create the right environment. Too often, as teachers, we are concerned about ourselves, the information we want to deliver, and how we intend to do this. But to create the optimal environment for adult learning, we must shift our focus and become more "learner centred" (Newman and Peile, 2002).
Tough (1979)Â suggested that adults are motivated by goals that they already have in mind and which they bring to the educational experience. They make decisions about how much effort to give, how hard to work, in part due to their perceived likelihood of success (Bandura, 1986). It is therefore important to set clear goals and expectations. Adults are also more likely to view their teachers as facilitators who can help them meet their own goals (ARMC, 2009). Facilitating therefore requires the ability to challenge and make students aware of their own styles and assumptions (Brookfield, 1996). A raised awareness of an individual's goals and a collaborative approach is more likely to create a learning experience that will meet the learner's needs (Cohen, 1995).
David Kolb's model of experiential learning (Kolb, 1984; Figure 2) is a useful paradigm; which is based on research in social, educational and cognitive psychology (Kaufman and Mann, 2007).
Figure2. Kolb Learning Cycle
For Kolb's model to be effective it is imperative that learners progress through each step as described (Figure 2). If trainees are hurried it can lead them to skip the essential processes of reflective observation and abstract conceptualization, leading to a sub-optimal experience. If these components are missed learners will likely fluctuate between concrete experience and active experimentation, and as a result enter a "trial and error" type learning experience which will inevitably be chaotic and unrewarding for those involved. As trainers we should aim to facilitate the reflective process and ensure trainees have adequate time to complete all steps in the cycle.
The importance of this type of active reflection is highlighted by Schon (1987). He argues that formal theories inherent to training a professional do not apply to the messy reality of practice. Learners reflect in these messy moments to compare or contrast theory and practice "reflection in action". Learners also reflect after the fact to determine how to "do better" next time "reflection on action". Through this reflection, learners develop "wisdom" and experience that enhances their performance. As trainers we need to intentionally create opportunities for reflection as we teach adult learners. Reflection can be promoted by challenging views and opinions, debriefing after learning experiences and having opportunities to practice what they have learned in a safe environment where they can get feedback on their progress.
Feedback is a very important step for enabling reflection (Pitts, 2007) and one that most of us often neglect. Learners have wonderful opportunities for reflection when they meet with a trainer to get feedback on their progress, their strengths, and their areas for improvement. If the learner has a chance to reflect on his or her own needs, then this triggers internal motivation that is essential (Schon, 1987). With this type of approach the learner feels more in control and will be more likely to invest in the learning and accept joint responsibility for it.
Section 3: Assessing the validity and reliability of the workplace-based assessment
The Royal College of General Practitioners recently introduced a new curriculum, which focuses on the knowledge, skills and competencies that are required in general practice (RCGP, 2007). The introduction of this has been influenced by a perceived need for educational reform (Scheele et al 2006) as well as political, social and workforce pressures (Ebrahim, 1999; DoH, 2006; MMC, 2010). A new assessment process was also introduced of which the workplace-based assessment (WPBA) is a major component (Swanwick, 2005). As the name suggests it can be simply defined as an "assessment of what doctors actually do in practice" (Swanwick and Chana, 2009). It assesses doctors throughout their vocational training and has multiple components. It has been argued that observing trainees in a range of different situations, over a period of time is superior to one off 'exit style' examinations (van der Vleuten, 2000).
The introduction of the WPBA can be linked to educational theory. Miller's pyramid of competence (Miller, 1990; Figure 3) can be used to map the different types of assessment against different levels of competence.
The work-place based assessment (WPBA) sits at the top of the pyramid and therefore potentially gives a better indication of how a doctor will perform in a real-life setting. This is in contrast to controlled traditional assessment methods which focus on the lower tiers and correlate poorly with professional competence (RethansÂ et al, 2002).Â
The WPBA in General Practice constitutes several different educational methods (Appendix 2), in an attempt to cover many of the competencies required for independent practice (RCGP, 2007). The formative nature of individual assessments enhances the opportunity for the assessor to observe the trainee in their day-to-day practice and give feedback on performance (Carr, 2006). An overview of the many component parts helps build up a picture of a trainee's performance so a summative judgement can be made (Swanswick, 2005)
As an assessment modality the WPBA raises many challenges. Van der Vleutin (2006) introduced a framework to help define the usefulness of any assessment. It looks at the utility, or usefulness, as a product of its reliability, validity, cost-effectiveness, acceptability and educational impact (van der Vleuten, 1996). For the purposes of this assignment the author has examined some of these components in more detail with respect to the WPBA.
A reliable assessment is one that yields the same result, if repeated under identical conditions (van der Vleuten, 2000). It is therefore imperative that there is a high degree of consistency and reproducibility. The WPBA should aim to reduce the amount of distortion due to random and systematic errors so that scores consistently reflect student performance. Three major factors affect reliability: the number of encounters observed, the number of assessors, and the aspect of performance being evaluated (Norcini, 2001).
Elstein et al (1978) showed that doctor's performance varied considerably depending on the clinical context, and therefore there was little correlation between an individual's attainments in one clinical case to the next. This highlights the need to observe trainees over several patient contacts before passing judgement. Similarly it has been shown that assessors can have quite contrasting opinions about performance, when observing the same case (Noel et al, 1992). Over the duration of the training programme the various components of the WBPA are carried out by many different people and hence any biases are theoretically minimised. Also, by using a multitude of different assessment methods, in different situations it is more likely to reflect a trainee's level of competence. This process known as triangulation ensures a holistic view of the trainee, as well as a reliable method of assessment (Swanwick, 2005).
It can be argued that focusing too heavily on reliability and control of variables could potentially compromise validity (de Kare-Silver, 2010); which refers to the degree of confidence we have that an assessment measures what it is intended to measure (van der Vleuten, 2000). As discussed previously, the WPBA is linked to the higher tiers of Millers Pyramid (1990). It assesses performance in a real life clinical situation, i.e. the ability of a trainee to perform the role that is expected of them as a GP, and therefore has a high degree of validity. In its nature the WPBA lacks an inherent reliability. Whereas knowledge based assessments can be standardised to improve reliability, applying these principles to WPBA would be detrimental to its purpose.
Rather than aiming for a single comprehensive assessment, the solution is to have a range of assessment methods which each have a focus on different modalities within Millers Pyramid and therefore give a more holistic representation of achievement (Swanwick, 2005). This is reflected in the RCGP multi-component examination. The other components needed to achieve status of membership to the Royal College are; the Applied Knowledge Test (AKT) which as the name suggests assesses the lower levels of the pyramid, and the Clinical Skills Assessment (CSA) which is a structured clinical examination using standardised patients' to assess competence. All three components are therefore more indicative of a trainee's level of competence and performance.
The WPBA has been implemented throughout various medical specialities and its acceptability has been open to criticism from several corners. It is seen by trainees and educators as a 'tick-box' exercise which fails to assess the complexities of professional behaviour (Sabey and Harris, 2012). Concerns have also been raised about the standards, methods and goals of individual assessment methods (ARMC, 2009).
WPBA is a component of the summative process but also has great potential as a learning development tool (Swanwick, 2005). In view of the inherent role of feedback in the WPBA one could deduce that its implementation will invariably have a positive impact on learning and performance. In reality however, there is little information in the medical education literature to support this claim (Sanders, 2010). The expectation is that through observation of practice, a supervisor can potentially detect and inform the development needs of a trainee (Veloski et al, 2006). However advantageous this 'dual role' may seem, in reality it is seen as a source of tension for both trainees and trainers. It has been shown that there is a tendency for doctors to give colleagues the benefit of the doubt, and reluctance to give negative feedback in formative assessments (Coletti, 2000).
For WPBAs to be reliable and valid they require a large number of clinicians to be involved in assessment. This has cost and time implications as ideally any individual involved in the assessment process should have adequate training. Ultimately all attempts to assess standards for medical practice will involve making a judgement and the value of the assessment methods used lies in the defensibility of that judgment (Southgate et al, 2001)
Assessment drives learning (Brown et al, 1997) and assessments should therefore focus on encouraging the development of desirable skills and behaviours. WPBAs are a relatively new feature in medical education, and there is limited experience of their use (Sandars, 2010). The process of WPBA is intended to be trainee-led with facilitation from clinical supervisors (Jubraj, 2009). Trainers often find that their role as an educator conflicts with their role as evaluator (ARMC, 2009). The relationship between trainee and supervisor should be balanced, establishing early on the expectations and responsibilities of both.
Despite their inconsistencies and poor evidence base, learning theories have a role to play in education (Romanelli et al, 2009). For the author, reviewing his own learning methods has been an empowering process. A greater self-awareness and understanding has encouraged the development of a more balanced approach. A review of strengths and weaknesses allows one to exercise more control over learning and aids reflection. Overall, development of a broader range of learning techniques and teaching strategies will provide a more diverse experience for all.
The traditional assumption underlying many teaching styles is that students are "empty vessels" waiting to be filled with knowledge (Montgomery and Groat, 1998). Students however are becoming increasingly diverse. As teachers we should recognise this diversity and aim to introduce activities which expand the learning styles of our students in the same way that learning styles of our students should bring flexibility and adaptability to our teaching styles. Matching teaching styles to learning styles will not solve the problems as there are many other factors which influence the learning environment. We should aim to facilitate learning in an environment which is challenging to all learners and learning styles.
Assessment is inseparable from learning, and therefore needs to be considered when planning education. It should not be viewed as a seprate component and needs to be integrated with teaching and learning as part of a holistic educational programme. At the heart of it is the relationship between the trainer and trainee. It is this relationship that must be fostered and encouraged. The primary purpose of WPBA must be to promote learning and inform this relationship. If designed and implemented well WPBA can ultimately help us acquire General Practitioners with the skills and attitudes we and the public desire.