Why are Junior Doctors no cleverer than I was?

Amongst doctors in training there seems to be little appreciation for the benefits of on-line learning. As a source of information (primarily via google and wikipedia) all but the most luddite seem to appreciate some of the benefits, although the benefits that are most often praised seem to be immediacy and accessibility. Accuracy less so, and not because most doctors know how accurate the information sources they're accessing are, thus give them less weight or learn how to assess, compare and cross reference relevant data - but because unfortunately many don't seem to care. That's fine when you need a two-line summary of a condition in a patient's medical history, but not good enough when on-line information is the backbone of your learning & referencing. Confession - I can't remember the last time I opened a traditional medical textbook to look something up.

The old-fashioned method of trusting a few reputable names (Davidson's, Harrison's, The Lancet, NEJM, Cochrane, the AHA, or even specialized online efforts such as Medscape or Up-to-date etc) isn't going to fly when there is such a huge amount of information available, going far beyond the scope of any of these august institutions. Frankly, appealing to authority rather than assessing sources, data and methodology yourself has never really been good enough either, even before the intertubes. Not to devalue these organs (all worthy in their own right, and still regularly form the backbone of my referencing) but their depth and breadth are already dwarfed by the rest of what's out there on the tubes.

So, we need to teach young doctors how to obtain, interpret, and evaluate data sources from more sources than can ever be pre-emptively approved. They also need to know how to integrate this new learning into their pre-existing knowledge to form new understanding and improve practice. That is, in order to learn and improve practice, they need to self-apply a constructive hierarchy of learning, from finding new information and understanding it, through using and evaluating that knowledge academically, and then applying it to their patients (creativity).


(Simplified version of the Revised Bloom's taxonomy (Anderson & Krathwohl, 2001))

I've talked before about how medical students are exposed to a huge volume of experience but seem to lack the skills or opportunity to assimilate it usefully. The same can be said of junior doctors, only substituting 'teaching' for 'experience'. When I was a junior doctor I got one hour of organized teaching a week at lunchtime, and the occasional attendace at grand round. I was often too busy to make either. Currently, the juniors in my hospital get an afternoon of teaching (An hour of Grand Round and 2.5-3h of specific F1/F2/CMT tutorials). It's bleep free and their wards are covered by on-call staff. So, 2-4x the amount of teaching, and they usually get to it. But knowledge and practice don't seem to be any better (and I am aware of the 'when I was a house officer' fallacy - I don't think they're any worse than I was). But why no better?

Often the methods used in hospital teaching programs try to jump over the intervening stages of learning, firing knowledge at the bemused faces of junior doctors via PowerPoint and expecting that to magically enhance their practice. I've even heard consultants bemoaning the fact that "They were taught this last week!". Not well enough, it would seem. Further, doing this kind of thing for 3 hours is utterly pointless. Even if they remember a few points from the first PowerPoint, they've forgotten them by the end of the third one, and are also apocalyptically bored.

The Plan

So, junior doctors have access to a huge amount of information, but don't know how to use it. They're also given a large amount of teaching time, a lot of which is wasted. I think there's an opportunity here, and I'm currently planning to change some of the junior doctor training at my next Manchester hospital placement to demonstrate it. Details a bit sketchy at the minute, but if things work out, I'll be setting up a (probably Wetpaint-based) VLE / Wiki to assist with the delivery of either the CMT or Foundation curriculum.

Face-to-face teaching will remain the backbone of the program, but with a 30 min introductory lecture rather than 3 hours of PPT-punishment. Then, case discussions (PBL style), followed by wiki-based knowledge sharing, evaluation and synthesis. I'm aware that contributions outside of class time are substantially lower than during, so I'd plan for them to do the majority of the work straight away. Also, since I'm a believer in evaluation-driven learning (but sceptical of how accurately exam scores reflect real skills) I'd expect to use their contributions as a marker of the learning process. So instead of just checking at an appraisal that the doctor has signed in to 70% of teaching sessions, I'd be able to give an indication of exactly how much the doctor has participated - this could even be used as a official learning objective by the educational supervisor.

So, that's the idea. I expect it will change, due to practical constraints, and also because I'm learning about the process of delivering this kind of connectivist program. But for me to be learning alongside those that I'm teaching is really exciting.