2.6 Workplace context
2.6.2 Workplace teaching as a competency
Miller (1990, p.s63) described a four stage pyramidal model for assessing: ‘…the professional
services delivered by a successful physician (doctor).’ These four stages are knows about,
knows how, shows how and does. Teaching is one of the professional services that doctors need to deliver competently. What are the implications of viewing teaching in the workplace in the same light as a practical skill? Before explore teaching as a competency, I consider how
clinical teachers guide trainees to gain medical competencies when measured against Miller’s pyramid.
Knows about At this level, the clinical teacher guides their learner through being in the OR
so that they get an overview and knows about the environment. This can vary from a learner’s first experience in the OR such as a nurse or a medical student observing anaesthesia or surgery. On the other hand, an experienced anaesthetist may be seeing a new specialty such as cardiac anaesthesia or obstetric anaesthesia for the first time. This experience may be so different to their previous experiences that they are effectively newcomers. In this
circumstance, the clinical teacher takes responsibility for ensuring the learner is safe, that they cause no harm to the patient and that they abide by local protocols, such as not breaking sterile practice.
Knows how The learner has completed the knows about stage and is now ready to gain a
deeper understanding. At this level, the learner should be able to describe or explain the event or procedure. As part of this stage there will be some explanation from the teacher to the learner of what is going on. This sets the scene for the learner becoming competent and contributing to patient care. The learner is still only observing. For example, when considering central line insertion, a medical student would get to observe, and receive an explanation of the procedure and reasons behind its use. This paves the way for the next stage.
Shows how This is the stage when the learner starts to do things to or with the patient. This
might be simple such as holding an airway or inserting a peripheral venous cannula. They would already have observed and explained the procedure. At this level, the teacher supervises the learner’s actions and corrects or intervenes as necessary. The learner might have practiced the procedure in a simulated environment such as the clinical skills laboratory.
Does When they reach this level, the learner actually does what they have learnt and
practices the skills until they are ready to move to the level of independent performance. At this stage the clinical teacher begins to stand back as the learner’s competence and confidence grow.
I would argue that throughout a teaching session in the OR the learner is likely to be learning at more than one level. For example, a medical student might be practicing intravenous cannulation, learning to manage an airway, while visiting a new OR and seeing
gynaecological surgery for the first time. As discussed above under experiential learning, a task of the teacher is to guide the learner to identify which of their many experiences are currently in focus.
Can OR teaching be a competency? How does teaching as a competency match to Miller’s hierarchy?
If we consider the development of doctors as teachers, it can be argued that as doctors, they are already expert learners and are well aware of what teaching, as a practical skill, looks like. Furthermore, they have experienced a lot of teaching and will already teach. Thus, they also
know how. One purpose of TTT courses may be to reinforce these two levels of learning the practical skills of teaching. At a higher level some of the courses give the opportunity to teach within the safety of the classroom, shows how. The area that is not so well covered and much more challenging is how to move from shows how to does. The implication in the word does is that this is for real and is about actual performance.
How do we manage the transition from shows how in the classroom setting to does within the clinical workplace? This is particularly important when dealing with patients in the clinical setting because their life may be at stake. At the simple end with a clinic consultation, a wrong diagnosis might be made. At the more acute end, a mistake by an anaesthetist might
kill or permanently maim a patient in less than three minutes. If this happens while a trainee is learning, it will clearly be the responsibility of the supervisor and this will affect their own medical career.
If we are to equip our trainers of the future with the skills to manage the learning of doctors for the future then we need to address this transition from classroom to workplace. The theory can be learnt and the learners’ understanding can be assessed in the classroom. The
psychomotor skills can be learnt in clinical skills laboratories and simulators. In some simulators, it is now possible to conduct full anaesthetics on manikins. However, at some stage the learners have to make the transition to anaesthetise a real patient for a real operation. While there have been descriptions of how to manage this is in the literature there is little empirical evidence for the recommendations other than they have stood the test of time. Even less well researched is how we teach these doctors to teach within this environment. As was discussed earlier many of the doctor teachers are still trainees. Then they take on the
responsibilities for the learners and the patients while others learn.