SUPPORTIVE LEARNING ENVIRONMENT

How Role Models (Negative and Positive) Impact on Creating a Supportive Learning Environment within the Operating Theatre

Impact on Creating a Supportive Learning Environment

Doctors learn to become competent and to make good judgements through the experience of treating patients with appropriate levels of guidance and supervision. They also learn by consulting and studying textbooks, reference books and journals. Then thirdly they participate in formally organised teaching and discussion. All three can be found in clinical settings; studying and teaching also occur in other settings -- library, seminar, lecture room, and a range of workshops or laboratories.

This chapter focuses only on clinical settings, recognising that there is a continuum from treating patients under the watchful eye of more senior doctors, through engaging in discussions about those patients, to participating in discussions about patients one has not treated or being taught about the diagnosis and management of a patient in a mini-seminar or lecture soon after visiting that patient. The use of literature informs both the treatment itself and preparations for presentations and further discussions about that treatment.

Three modes of progression can be usefully distinguished;

Extending the range of cases one is competent to handle;

Increasing the complexity of those cases; and

Increasing the level of one's responsibility for the management of each type of case: from peripheral onlooker, to the acquisition of evidence from and about the patient, to provisional decision-maker, to treatment under supervision, to virtually total responsibility.

A well-conceived training programme will take all three modes into account. This involves the selection of clinical settings, the selection of patients for attention by the trainee, the trainees' level of responsibility for each type of patient at a given stage in their training, and the nature and amount of supervision or guidance or teaching given. Another critical factor is continuity of care: over what period of time does the trainee have contact with and/or responsibility for various types of patient; and is this sufficient for the proper development of competence? Lowdermilk and McGaghie (1991) report improvements in medical care as residents gain longer periods of contact with patients.

Although more formal attention is given to opportunities for clinical experience when selecting clinical settings, consideration may, indeed should be given to the wider clinical environment. The ethos and values of the workplace and the prominence of good role-models can have a major impact on the professional development of doctors. The role-model aspect is more formalised in the North American residency programmes through the evaluation of clinical teachers (see pp -). A related issue concerning individual teachers as well as training programmes concerns the quality of supervision. While most research has focussed on the supervision of house officers (Section 4.1) and trainee surgeons (Section 4.2), its disappointing findings may apply equally to registrars and trainee physicians. Supervision is not only central to the role of a clinical educator, but also an important extension of patient-centred values to conduct beyond a supervisor's direct personal contact with ...