Learning from clinical practice

 When designing a programme of assessment, medicine arguably faces particular challenges because of the need for regulators to reassure the public that their doctors are competent. Doctors are usually comfortable with the psychometric method as the predominant paradigm, which has been valued in medical research, typically favours a quantitative and positivistic approach. Although the importance of context specificity in medical assessment has been recognised for many years, the sociocultural assessment paradigm remains unfamiliar to most doctors. However, the practice of medicine is frequently recognised to be an art as much as a science. This is perhaps most apparent in the specialty of general practice, where the sociocultural context is seen as crucial. Elsewhere, the strength of intuitive beliefs about assessment paradigms was demonstrated and some suggestions as to how these may be challenged were considered. 

Another potential way forward is by making the proposed new paradigm feel less unfamiliar. One method of achieving this is by drawing analogies to a context with which clinician-educators are very familiar with, namely healthcare. The lessons that can be learned from healthcare, especially from the field of general practice or family medicine, will now be explored. 

The importance of patients’ beliefs in the daily ‘bread and butter’ of general practice cannot be overstated. Often the beliefs may be naïve and misguided, but they are firmly held. They come from patients’ prior experience of healthcare, for themselves or their family members. If explored carefully, a belief that seems implausible often has very rational and understandable origins; for example, a family member previously presented with atypical symptoms, which meant that a rare illness was not recognised. A skilful general practitioner (GP) doesn’t just ignore the beliefs, as that is neither productive nor efficient and neglects the all-important doctor-patient relationship.44 Instead, a good GP seeks to negotiate a treatment that is both compatible with the patient’s beliefs and attuned with the scientific and medical evidence of what is needed in this case. Normally a compromise can be reached. At the same time, some beliefs need to be gently challenged if they are not compatible with a safe clinical outcome. Are there lessons to be learnt for medical education? Beliefs in the benefits of summative assessment may seem naïve to those fully conversant with the developing literature, but they are firmly held and, if carefully explored, it is clear that they too have a rational basis. There is a desire for rigour and upholding of standards to enter the medical profession and there is a perception that newer forms of workplace assessment lack objectivity. Skilful designers of assessment programmes should therefore try to acknowledge and accommodate those beliefs where possible. When the beliefs are not compatible with ensuring fairness for students and ultimately a good clinical outcome for patients, then a dialogue is needed to challenge these beliefs, within an attitude of mutual respect.

As others have pointed out, there are other potential similarities between the promotion of formative assessment and good clinical care, especially in general practice.

Mentoring seems very beneficial in helping learners to interpret feedback but appears hard to implement in practice; this is very similar to continuity of care which is much valued by patients although practices find it hard to deliver with limited resources. However, a key benefit is that GPs also value continuity of care as it makes the job more meaningful and satisfying; educators may well find long-term mentoring similarly rewarding.

There are also arguments that it is more efficient as resources can be saved be avoiding unnecessary or redundant investigations and referrals. Mentoring in medical education might also ultimately save resources by intervening earlier in a learner’s career with targeted remediation, rather than waiting for failure in end-of-year assessments followed by costly resits; the old English proverb, ‘a stitch in time saves nine’ has long highlighted the benefits of avoiding procrastination. If the students become ‘trained’ at being receptive to feedback, interpreting it and then changing their behaviour, it is at least plausible that this will help them in their career to avoid expensive and dangerous clinical mistakes. 

Just as compromises in achieving continuity in clinical practice have been proposed, there could be other ways of achieving some of the aims of mentoring, perhaps by a using a small team of mentors communicating closely with each other. 

Emotions can be a potent barrier to patients being open to receive information in consultations, especially those that involve the reception of bad news. However, once the intensity of emotions has settled, patients are often extremely interested in receiving more information to help them understand their condition and plans for more treatment. So emotions in themselves should not be an insuperable barrier to prevent students being receptive to feedback information. 

However, the crucial difference in education is that the ‘diagnosis’ in summative assessment terms is pass or fail. If the diagnosis is ‘pass’, then there is no incentive for students to need more ‘treatment’. If the diagnosis is ‘fail’, then they do have an incentive to engage, and there is some evidence from the first study in this thesis that many failing students will engage with feedback. 

We therefore need to find a way in which the diagnosis is not simply a pass but a more nuanced description of strengths and weaknesses so that students have an incentive to seek more information to help them plan their ‘treatment’.

 It may therefore be possible for assessment programme designers to employ some of these insights from the clinical perspective while trying to change the assessment culture to one that is more supportive to students receiving feedback in a meaningful way. Time should be taken to explore beliefs in a way that fosters mutual respect, in order to try to reach compromises which are reasonably acceptable to all stakeholders. While accepting that the challenges of implementing long-term mentoring are very significant, there is great potential that clinicians and students would subsequently find the assessment system more rewarding in the end, with beneficial effects on intrinsic motivation. 

To explore other options, please click below.