The clinical environment is a learning environment
Dear Editor
The paper by Moonesinghe et al raised a number of important issues.
In the UK the European working time directive has caused a detrimental
impact to the exposure of juniors, probably more so than our American
counterparts whose working hours are still comparatively long.
In the setting of a stretched NHS, consultants are under increasing
pressure to give preference to patient provision and 'productivity'
targets over educational supervision.1 This together with shortening of
training programmes, reduction of working hours, ethical imperatives to
protect patients from harm, and the fact that opportunities for training
within a clinical setting are unpredictable, have a profound effect upon
traditional approaches to training.2 In the UK there has been a move to
focus upon the quality of training experiences and the use of work placed
based assessments and reflective practice. This may produce acceptable
outcomes in some specialties, but in skill based e.g. surgery, the
reduction in hours will undoubtedly lead to less clinical exposure.
Consequently this can lead to a mismatch between the expectations about
what educational objectives can be achieved and what the actual clinical
teaching environment can provide,3 meaning juniors have the potential to
be short changed in their training. However the current situation offers
an opportunity to modernise and focus training programs through
optimisation of learning environments.
Emphasis needs to be placed on changing attitudes to that of
promoting teaching at all times in the clinical setting. Trusts need to be
mindful of this rapidly changing environment and the responsibility they
have to their junior doctors.4 It is essential for the future of the NHS
that consultants can facilitate trainees to be interactive, work
collaboratively and learn through exploration. This may require steps such
as devising job plans to ensure that adequate supporting professional
activities (SPAs) are designated to medical education and allowing shorter
procedural and outpatients lists to ensure more training time. This is
again an opportunity to empower trainees to have personal responsibility
for focusing their training opportunities to what they feel is their
deficiencies, which would undoubtedly stand them in good stead in their
continuing professional development.
Failure to recognise the clinical area as the learning environment
will give rise to two problems. Firstly there will be an increased
reliance on non clinical learning environments, such as the use of
simulation, which can undermine the development of 'real life' and
interpersonal skills.5 Secondly future consultants may not be of the same
standard as their predecessors, whose training was more extensive and not
subject to restrictions, which ultimately may have a detrimental impact on
the quality of patients' care.
1. O'Neill PA, Owen CA, McArdle PJ, Duffy KA. Views, behaviours and
perceived staff development needs of doctors and surgeons regarding
learners in outpatient clinics. Medical Education. 2006;40:348-354.
2. Kneebone R, Nestel D, Wetzel C, Black S. The Human Face of Simulation:
Patient-Focused Simulation Training. Academic Medicine. 2006;81(10):919-
924.
3. Jolly B, Harris D, Peyton R. Teaching with Patients. In:Peyton RJ.
Teaching & Learning in medical practice. Guildford: Manticore; 1998.
4. Lesky LG. The Ever-Widening Training-Practice Gap. Academic Medicine.
2007;82(3):219-221.
5. Hanna M, Fins JJ. Viewpoint: Power and Communication: Why Simulation
Training Ought to Be Complemented by Experiential and Humanist Learning.
Academic Medicine. 2006;81(3):265-270.
Rapid Response:
The clinical environment is a learning environment
Dear Editor
The paper by Moonesinghe et al raised a number of important issues.
In the UK the European working time directive has caused a detrimental
impact to the exposure of juniors, probably more so than our American
counterparts whose working hours are still comparatively long.
In the setting of a stretched NHS, consultants are under increasing
pressure to give preference to patient provision and 'productivity'
targets over educational supervision.1 This together with shortening of
training programmes, reduction of working hours, ethical imperatives to
protect patients from harm, and the fact that opportunities for training
within a clinical setting are unpredictable, have a profound effect upon
traditional approaches to training.2 In the UK there has been a move to
focus upon the quality of training experiences and the use of work placed
based assessments and reflective practice. This may produce acceptable
outcomes in some specialties, but in skill based e.g. surgery, the
reduction in hours will undoubtedly lead to less clinical exposure.
Consequently this can lead to a mismatch between the expectations about
what educational objectives can be achieved and what the actual clinical
teaching environment can provide,3 meaning juniors have the potential to
be short changed in their training. However the current situation offers
an opportunity to modernise and focus training programs through
optimisation of learning environments.
Emphasis needs to be placed on changing attitudes to that of
promoting teaching at all times in the clinical setting. Trusts need to be
mindful of this rapidly changing environment and the responsibility they
have to their junior doctors.4 It is essential for the future of the NHS
that consultants can facilitate trainees to be interactive, work
collaboratively and learn through exploration. This may require steps such
as devising job plans to ensure that adequate supporting professional
activities (SPAs) are designated to medical education and allowing shorter
procedural and outpatients lists to ensure more training time. This is
again an opportunity to empower trainees to have personal responsibility
for focusing their training opportunities to what they feel is their
deficiencies, which would undoubtedly stand them in good stead in their
continuing professional development.
Failure to recognise the clinical area as the learning environment
will give rise to two problems. Firstly there will be an increased
reliance on non clinical learning environments, such as the use of
simulation, which can undermine the development of 'real life' and
interpersonal skills.5 Secondly future consultants may not be of the same
standard as their predecessors, whose training was more extensive and not
subject to restrictions, which ultimately may have a detrimental impact on
the quality of patients' care.
1. O'Neill PA, Owen CA, McArdle PJ, Duffy KA. Views, behaviours and
perceived staff development needs of doctors and surgeons regarding
learners in outpatient clinics. Medical Education. 2006;40:348-354.
2. Kneebone R, Nestel D, Wetzel C, Black S. The Human Face of Simulation:
Patient-Focused Simulation Training. Academic Medicine. 2006;81(10):919-
924.
3. Jolly B, Harris D, Peyton R. Teaching with Patients. In:Peyton RJ.
Teaching & Learning in medical practice. Guildford: Manticore; 1998.
4. Lesky LG. The Ever-Widening Training-Practice Gap. Academic Medicine.
2007;82(3):219-221.
5. Hanna M, Fins JJ. Viewpoint: Power and Communication: Why Simulation
Training Ought to Be Complemented by Experiential and Humanist Learning.
Academic Medicine. 2006;81(3):265-270.
Competing interests: No competing interests