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The Art of True Learning - Approaching the Game Plan

Augmenting the acquisition of a CCT with career-enhancing depth

Written by: Andrew Vincent. Published: 2nd June 2010

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Few would disagree that working towards specialist qualification has changed radically in recent years and that doctors in training and consultants alike regularly express concern at the depth of experience being grown in today’s upcoming doctors. Although systemic factors adversely affecting learning, such as reducing junior doctor hours to comply with working time directives, are relatively straight forward to identify they are equally difficult to address as an individual. This article focuses on organising principles that re-assert the art of true learning.

The issue to consider
Whereas specialist training in the United Kingdom is well organised through PMETB, with ever increasing clarity on structure, process, curricula and requirements, less focus has been directed at the growing differential between obtaining a Certificate of Completion of Training and the breadth and depth of understanding necessary to excel as a consultant. If a trainee devoted their entire attention just to obtaining the necessary assessment that leads to qualification, they would possible pass with ease but be ill-equipped for the challenges they are likely to face as a responsible consultant, often in isolated circumstances with few places to turn for immediate support. Consequently, it is imperative that all doctors in training acknowledge the differences between obtaining their CCT and true learning to the depth necessary to succeed in life as a specialist consultant. The analogy is akin to the A-level student who swots their chemistry exam by intelligent application to the facts around the most likely questions, only to find that they flounder in university when the depth of knowledge determines their likely degree success.

There is a balance to be made. Failure to address the registration requirements is equally disastrous, leaving knowledgeable and clinically excellent doctors without
or with delayed qualification, adversely impacting their downstream career prospects by inadvertently creating the perception that they have ‘struggled’ when in fact they may be clinically superior to many of their post CCT colleagues. The approach we advocate is based on two key questions:

1. What do I need to know or be able to do to ensure that I gain my CCT?
2. What do I need to know or be able to do to excel in my desired post-CCT career path?

Trainees unclear of the answers in both questions are placing their future careers at risk. Although we are clearly advocating balance between the two questions,
arguably there isn’t a magic formula as to what that balance should be. Instead it is something of a zero-sum game that is very context dependent, meaning that
the answer is what the answer is for each question and subsequent failure to achieve the answer is damaging no matter which question you consider. A trainee intending to work in a broad-based capacity in a district general type hospital will have very different requirements in question 2 compared to someone who aspires to the highest
academic levels in a complex scientific area within an Academic Health Science Centre, although their question 1 answers may be identical. The concluding point is that you have to get both questions right, which means determining an appropriate game plan for each. The Deanery is extremely helpful in addressing question 1 but question 2 is very much up to you. It is vital that you do not confuse question 1 as giving you the answers to question 2, a lesson many have learned at their peril.

What’s the goal?
It is also important to consider the whole goal of progressing through a series of training posts, as this has bearing on how you answer the two key questions and also
gives rise to the unbalanced approach to training that can occur. If the goal is simply‘to get your CCT’ then naturally all effort should be devoted to question 1. However, we think that the goal needs to encompass 3 specific elements:

• Obtain your CCT
• Equip yourself with sufficient knowledge so as to be a safe, effective doctor in your chosen specialty
• Provide sufficient depth or specialisation so as to allow you to pursue your chosen career path

When all three elements are taken into account you can see the diversification of approaches necessary. Another way of breaking this down is to consider it in terms
of levels of depth or complexity. Failure to consider your true goal from a career perspective means that you can easily end up with a CCT but little or no chance of acquiring the type of post you actually want. That chalks this up as a rather vital consideration in our book.

What does ‘specialist’ mean in the modern health context?
It may not have slipped your notice that the Certificate of Specialist Training has become the Certificate of Completion of Training, inviting a question around where has ‘specialist’ gone? To answer this question we need to briefly consider the direction of travel for consultants in the modern healthcare environment. Under Lord Darzi’s models of care delivery institution there is considerable polarisation in the nature of work undertaken by consultants. Whereas major acute hospitals and specialist hospitals, especially those forming part of Academic Health Science Centres, will see an increase in the volume of complex work they undertake, the traditional DGH will likely see a reduction in complexity as fewer and fewer consultants hand on to specialist interests in non-specialist centres. This has significant implications for those currently in training. In effect, it means we need to train two distinct sorts of doctors and here the reality becomes a bit uncomfortable. The first sort is highly specialist, with knowledge and experience of complex cases and the most severely ill individuals, as well as having an interest in pushing forward knowledge by engaging in or organising research. The second sort is more akin to a ‘worker bee’ consultant, focused on delivery of more basic healthcare and generally without the specialist interest. We’re not proposing this so much as pointing out the implications of Lord Darzi’s stated nature of caseloads proposed in each institution type. If this is an area you are not clear about then we strongly advocate finding out, for instances using the Medicology Insights Programme (more information at www.medicology.co.uk/insights).

So, what we are dealing with is the fact that the term ‘specialist’ is coming to mean different things. At a basic level, specialist
means that you will be working within a specific specialty and therefore there is a minimum curriculum that you need to address that is already far beyond what
may get you your CCT. However, if your aspirations include working in a major acute hospital then specialist will mean being able to demonstrate a depth of knowledge and experience in complex disease, most likely in a specific area of your chosen specialty. This latter category requires a highly thought out game plan because competition for these posts will most likely be vigorous.

Having the right game plan
So, we have established that to pursue your career path of choice requires you to have a well thought out game plan that goes well beyond the basic curriculum addressed by the Deanery. That game plan can only be determined if you have a clear vision of your ideal future role. This is very much the starting point that allows us to break learning into distinct and manageable segments. Furthermore, rather than simply considering the type of role you wish to acquire, it is beneficial to go as far as thinking about the few services and locations that you would ideally like to work in. The more clarity you have, the easier it is to establish the right game plan.

To examine the construction of a game plan, let’s consider Bob, whose career aspirations include becoming a respected specialist in complex Crohn’s Disease in a tertiary centre ideally in the North of England. What is clear is that Bob is going to need more knowledge and experience than can be naturally acquired from just obtaining his CCT.

Bob’s vision is already quite clear because he knows what sub-specialty interest he wants to develop and where he wishes to work. However, it can be improved further by considering what type of work he will be engaged in, or what his ideal job plan may look like. Bob considers this and establishes the following. Besides his clinical case load, Bob envisions being involved in policy and framework development, regularly speaking at national and international congresses on complex Crohn’s disease and being recognised for improving the practical application of current Crohn’s research. Having clarified this vision, Bob constructs a learning game plan that looks a little like this:

The game plan should clearly identify distinct learning goals delineated by rotations or intended roles, so that Bob knows exactly what knowledge and skills he needs to acquire at what point and the value these deliver for him in his chosen career path. This means that he is better positioned to gain exactly the knowledge and skills from each component of his developmental pathway and is less likely to end up at CCT time with career-limiting holes. Implementing the right game plan Knowing what you want out of a job or rotation is fundamental but you need to get off on the right foot too. On entering a job, we advocate sitting down with your supervising consultant and addressing the following: Your longer term • career aspirations (the vision) What learning you’d like to gain from this rotation What learning they feel you need to acquire for CCT progression What additional learning they feel you would benefit from, given your desired career path Any barriers or problems that need overcoming, including developing a strategy for them This implementation should be backed up by regular review at time points that allow you to take alternative action if you are not meeting your milestones. Ideally this means the earliest possible goal-setting session with your consultant, an early review 3-4 weeks later to see if there are any implementation problems and then 1 – 2 interim reviews to ensure that knowledge and skills are actually being developed according to plan.

Factors influencing learning quality
Having a game plan and a clear set of intentions is one thing but when you come to implement it you are now subject to the vagaries of workload fluctuation, other people’s sickness and absence, your consultant’s continually eroding time and the quality of learning you are having delivered to you. Broadly, the factors influencing your learning, besides yourself, can be split into two distinct categories:

• Things that get in the way of your learning
• Things that affect the quality of your learning

The commonest overarching factor is service delivery. Your Trust is subject to a series of targets with penalties for breaching them, as well as ever growing restrictions on working hours, as well as being mindful that completed episodes lead to income under payment by results. Whereas the more service delivery (the daily clinical load) you engage in, the more experience you are gaining, it is also easy for this service delivery to obstruct the acquisition of assessments and specifically hamper your attempts to get specific bits of learning that are important to you. If you find yourself in this situation it is important that this is raised as early as possible, whilst there is still catch up time and hence the need for regular and early reviews. It is pointless to pass through a job, not gain the learning you need, feel justified in concluding that your employer didn’t deliver for you when in fact it is your career at stake. It’s your career and so you need to take every active measure to ensure you gain the learning you need.

It is important to remember that organised learning sessions will be focused on the generalist and not the specialist. This may not deliver the depth of learning that
you require and so it is vital that you have identified where depth is required and developed your own self-directed learning programme to ensure that you amass
knowledge in this area.

Quality of learning is primarily affected by you. If you are out on the razzle the night before important learning sessions then your knowledge retention is going to be impaired. We’re not saying you have to become a saint but we do advocate choosing the razzle nights a bit more
strategically! If you are working nights, it is difficult to subsequently follow up on what happened to a patient because you are generally not permitted to be there the following day and the patient has often moved on by the time you are back. In these situations, it is important to make a diary note to review what happened in those patients that are important to your learning journey. Finally, the quality of your learning can be enhanced substantially by engaging in reflection. This technique involves asking yourself a series of short questions after each relevant patient episode, including:

• What did I learn from that episode?
• Did I consider all angles or possibilities?
• Was there anything else I should have done or considered?
• With hindsight, what would have constituted optimal care?
• What were the most important factors in the episode and how did I address these?
• Where were the risks in the episode and was I mindful of them or just lucky?

Essentially, the clinical arena is awash with learning opportunities if you take the trouble to stand back and acquire the learning. We do appreciate that in the drive for results and the frenetic working environment it is easy to simply forget that you are there to learn as much as there to do.

Ensuring success in your post-CCT career
What we have described in this extensive article is an approach to structuring your learning so that your learning goals are firmly tied to your career aspirations. Nobody else knows your aspirations quite like you and so this is not a job that someone can do for you. Successful doctors, whether by accident or by design, have taken it upon themselves to acquire the depth of knowledge and skills necessary to be placed top of the pile when it comes to gaining just the post they want. In the modern era there will be increasing numbers of ‘ordinary’ jobs and far fewer ‘special’ ones, meaning you’ll have to compete harder and demonstrate why you are the perfect candidate. Doctors leaving that until CCT is within sight have placed themselves at a considerable disadvantage
because a consultant interview is the summation of a long learning journey as well as the start of a new challenge. Perhaps the best analogy is that of Hermione in
Harry Potter. She consistently goes above and beyond the ‘curriculum’ in the areas she feels will contribute to her future success and so when faced with a seemingly insurmountable challenge she pulls just the right spell out of her knowledge bank and saves the day. A strategic approach to your learning journey will leave you in the same shape when the learning gets put to the test – when the perfect post for you looms on the horizon.