Chapter 43 Cultivating a thinking surgeon
using a clinical thinking pathway as a learning and assessment process
We have, over the last 4 years, been developing in the UK a new approach to teaching and assessing clinical thinking and professional judgement for surgeons in particular and doctors in general (De Cossart & Fish 2005, 2006; Fish & De Cossart 2006, 2007). We began this work by conducting a detailed and robust analysis of the complexities of clinical practice, of the way senior clinicians conduct themselves in practice and of how they make difficult clinical decisions. Through this we came to see a huge range of invisible influences that shaped their success as clinicians in maximizing patient care in hospital settings.
We believe we form a unique combination of a widely experienced consultant surgeon working with a senior educator whose expertise is in the practice of teaching and with a long-term interest in the development of professional judgement (Fish & Coles 1998). This has, we believe, enabled us to explore and clarify our differing perspectives and harmonize them into an educational enterprise that enables doctors to uncover, explore, articulate and therefore develop those elements of their practice that are invisible. We have coined the term invisibles in respect of all this, because the focus of this work is on both the implicit elements of practice and those aspects of the tacit that can be identified. We do not use tacit, because some of the tacit is inevitably ineffable (see De Cossart & Fish 2005, Schön 1987) and also because the term apparently excludes the implicit.
Our newly developed suite of six ‘heuristics’ provides devices to prompt exploration and increase understanding of what drives visible behaviour and feeds observable behaviour (see Fish & De Cossart 2007). These focus on: the importance of the context of the decision making; the kind of person the doctor is; the drivers of the doctor’s professional practice; the forms of knowledge that are brought up in thinking about the patient; and the clinical thinking processes that lead to a specific professional judgement (see also De Cossart & Fish 2005, Fish & De Cossart 2007). We believe that in this we offer medicine a new language and framework in which to discuss, develop and assess the thinking processes which lead doctors to complex decisions.
In the past, surgeons spent many hours in their work environment reflecting on, analysing and developing their practice, mainly orally, in harness with a senior clinician and also with their peers. Such learning conversations, however, rarely led to robust written records of the development of the learner’s clinical thinking and professional judgement.
Today, two major changes (one in education and one in service requirements) have rendered this approach obsolete. In education, the introduction of more specific curricula for postgraduate medicine have highlighted the importance of recording the learner’s progress and the possible uses of this learning record over the doctor’s career. In service terms, the new ways of working in the UK, specifically because of the European Working Time Directive, have meant that doctors must learn faster and, given the current litigious climate, must focus more on being articulate about their professionalism, values, intentions, decision making and patient management (Royal College of Physicians 2005).
Indeed, by 2009 the hours of work for all UK doctors will be reduced to 48 per week. This virtually halves the time spent in practice and therefore the time available for postgraduate medical education, since doctors’ main learning opportunities occur entirely within their working hours. Interestingly, these issues are also beginning to emerge in the USA where in New York State the hours per week have recently been reduced to 80.
2 THE CHARACTER OF CURRENT TEACHING AND ASSESSMENT IN POSTGRADUATE MEDICINE, AS REQUIRED BY NEW GOVERNMENT INITIATIVES
The current elements that are required for assessment (and therefore for learning) in the new educational programmes for postgraduate doctors in the UK use methods (‘Tools of the Trade’) which attend mainly to the visible components of practice. These were aimed initially at the early years of postgraduate medicine but are already being pushed into more advanced training programmes. This is cause for concern, since they were unchallenging even for the most junior doctors in their simplistic characterization of real practice, and we believe that they are simply inappropriate for specialist doctors who are being developed to engage in the highly complex care of patients both in hospitals and in the community.
This foundation curriculum has come about because in the early 21st century the Department of Health (DoH), through the initiatives ‘Modernising Medical Careers’ and ‘A Firm Foundation’, set out to update and reform medical education and training and shorten the time between entry to medical school and acquisition of a Certificate of Completion of Training (CCT) (DoH 2002, 2003, 2004). As a result, newly graduated doctors are now required to undertake a compulsory 2 years of generic clinical work (Foundation Years 1 and 2 (F1 and F2)), designed to expose them to a wide range of clinical practice and ensure that they are able to recognize and initiate management of the acutely sick patient. This foundation programme is based upon the idea that all aspects of medical practice can be broken down into a series of competencies.
There is now a requirement that these competencies are tested at frequent intervals by four devices known collectively as Tools of the Trade. These tools are: the personal assessment tool (MINI PAT); the clinical examination tool (Mini CEX), which focuses on the processes related to the clinical examination of patients; the DOPS (which is concerned with the doctor’s ability to complete clinical procedures correctly); and Case-based Discussion tool (CbD), which tests seven competencies of the doctor’s consideration of the patient case, each of which is given a very broad definition (e.g. ‘professionalism’) and is assigned one tick box. All these tools are designed to be optically read by computer, and record most of their details in tick boxes. The specialty programmes currently being developed to follow the foundation programme are likely to include a core and a specialty element. They too, worryingly, enshrine these four limited tools.
Each of these Tools of the Trade is based upon some research (which seems to give them credibility beyond previous assessment processes). But most of this research was conducted in cultures other than the UK and largely in undergraduate contexts. In fact there is no sound evidence that these tools are appropriate either for the selection or for the in-programme assessment of postgraduate doctors in Britain. Neither do they support the development and the detailed assessment of professionalism, clinical thinking or professional judgement. Indeed, they depend heavily upon only what is observable in the clinical setting and make no demands on trainees to reach beyond the basics on which they are repeatedly tested. For this reason we see them as necessary but not sufficient in the foundation years, and as needing to be replaced in the specialty years with something that does more justice to the nature of real clinical practice.
We believe that Tools of the Trade encourage a reductionist approach to clinical practice in doctors of the future which not only minimizes the importance of professional judgement but also ignores previous work on decision making in medicine. A review of this literature shows three broad approaches. Statistical models (for example those based on the Bayes theorem) have supported decision making in medicine and the way it is taught by some since the 1960s (see White & Stancombe 2003); illness scripts have been favoured by some (Schmidt et al 1992); and pattern recognition by others (Patel & Groen 1986). None of these seems to have been developed beyond the original concepts, and we do not see evidence that they attend adequately to clinical practice in its more complex forms. However, it is our contention that the dimensions of decision making they attend to and a critical exploration of their ideas (based on what happens in real practice) ought to have informed the content of Tools of the Trade.
Our critique of these approaches is that they have traditionally focused postgraduate learners on diagnosis and on their underlying factual (propositional) knowledge, driving postgraduate learning in medicine more and more in the direction of learning clinical factual knowledge. All of this has emphasized a formulaic approach to teaching and assessment, which does not attend to the complexities of clinical practice, the need for doctors to develop wide-ranging exploration of the patient case and to provide for individual patients a carefully constructed management plan which takes account of all the human factors as well as the scientific ones and which is the mark of a wise professional. Indeed, in the more recent literature we have found reference by both clinical and lay writers (Demar et al 2006, Eraut & Du Bouley 2000, Montgomery 2005, White & Stancombe 2003) to the inappropriateness of the tyranny of algorithms and protocols and their dangerous exclusion of doctors’ discretion to move outside them.
It is true that more recently there have been broader approaches to medical decision making in the work of Atkinson (1995), Cox (1999), Dowie & Elstein (1988), Downie & Macnaughton (2000) and White & Stancombe (2003). While we applaud this trend towards drawing on science together with the humanities and arts to understand and illuminate the thinking processes involved, we believe that even here the basic conception of medical decision making to which these new approaches are directed has been too narrow.
It is our contention then that much work on medical decision making is flawed because often the ideas have been developed from theory to practice, overlooking the complexities of real clinical practice and highlighting only the easily definable aspects of it. We see evidence that this approach is creating doctors who are fearful of stepping beyond clearly defined boundaries learned in the classroom (at medical school and hospital induction programmes). We find it deeply disturbing that doctors are being restricted by such systems and becoming fearful and unable to use their discretion safely for the benefit of the patient.