Social Learning – the missing link in Medical Education?

Thank you for inviting me to talk this afternoon. I would like to acknowledge the traditional owners and custodians of this land on which I speak, their elders past and present (the Ngunnawal people)

My name is Ewen McPhee. I am a GP Obstetrician from Emerald in Central Queensland. I moved to Emerald 25 years ago in my fourth post graduate year, and haven’t yet found a reason to leave. Like most country practice life is busy, but the challenges of being a GP and a Generalist Obstetrician are always exciting and different.

In recent times my role has changed. I am more involved in GP supervision and mentoring Rural Generalist Registrars, a unique Queensland Health program that is repopulating the Bush with young keen clinicians.

Today I wish to talk about what I think of as the missing link in Medical Education, Social learning. I will talk about Knowledge, Information abundance and how we could use social media to meet the needs of our patients.

Preparation for this talk started just a few days ago. I was sitting with a GP registrar newly moved to my town and we were talking about exam preparation, a topic dear to many registrars and medical students in this room today I would imagine.

The Registrar had had some time away, in paediatric practice, and had decided that specialist medicine wasn’t for her. On returning she had found the transition to Generalist practice challenging and was concerned that perhaps she should reduce her hours so that she could hit the books. She was finding that the gap between her knowledge and the needs of her patients was significant and she was worried that this would be a concern for the upcoming KFP and AKT.

She was anxious about her knowledge gaps and worried about the best way to address them.

There are many skills that a GP must have, key amongst them is a broad knowledge, an ability to synthesize information quickly, formulate a management plan and to ensure that is communicated effectively. We must build rapport with our patients, learn of their history and that of their family. As GPs we must embed ourselves within community and often take a leadership role in medical, social and political areas.

In our meeting I suggested that background knowledge was important, but knowledge in such a practical and dynamic field as general practice cannot just be found in books, with due respect to Professor Murtagh. Knowledge gained by evidence is critical to safe and quality care but there is more to the toolkit of a GP than Up-to-date or Therapeutic Guidelines.

Let’s reflect more broadly on our digital world, with access to rapidly expanding databases of information, new studies, case reports and non-systematic narratives. Anabelle Bentley said, in the BMJ in 2010 that the secret to effortless professional development is to just read 75 trials and 11 systematic reviews each day. Even then the quality of the data, its completeness and relevance to general practice is inconsistent.

Archie Cochrane’s database was going to help us sort out the Information abundant world we live in, but even the Cochrane database has been unable to keep half its reviews up to date.

Information Overload is a fact, there is more information every day than we can ever hope to absorb. The Gap between knowing what we should do and actually doing it is widening.

Often we cling to an island in the river, an island of information that we know, were comfortable with and interested in.

Often we are passive recipients of knowledge from learned specialists with their fingers on the latest data, or Drug companies with their own slant on medicalised management.

Clay Shirky a Web 2.0 advocate calls this information abundance. He points out that it is nothing new. Information has been increasingly more available since the Gutenberg printing press became widely available in the 15th century. When talking about information abundance he points out that it isn’t too much information, but Filter Failure, that creates anxiety for people faced with gaining knowledge.

There is no doubt the signal to noise ratio for quality information is high, but to be better doctors we need to deal with it.

General practice is a profession where tacit knowledge (gained by understanding what others do, through modelling, case discussion, critical review and analysis) creates the flexibility of critical appraisal that we need to see an undifferentiated clinical problem.

General practice is also largely an individual art, where the learner is responsible for their own education. It is a profession where experience counts, where our best teacher is our patients, their families and the community in which we live.

So what should I say to my Registrar? Why does she feel this way? Should we cut her hours and reduce her clinical load? Is there a way to encourage my Registrar to keep seeing and learning from her patients while improving her efficiency in recognizing her knowledge gaps and retrieving relevant information?

In an information rich world how can we manage the flow, how do we filter out that information that fills the gaps in our knowledge and makes us more complete clinicians?

Setting up good habits for lifelong learning is critical to a satisfying career.

Dr Richard Eve a GP Tutor from West Somerset developed a simple tool to identify our knowledge gaps called PUNS & DENS. This is the first and most important filter in social learning. Patients Unmet Needs (PUNS) simply put is the habit of asking ourselves, at the end of the consultation “What could I have done better?”

Unmet needs may be knowledge based (Clinical or non-clinical), Skill based or Attitudinal. Some of the needs might require system change, practice or partner discussions. Over time though a series of PUNS will identify the Doctors Educational Needs. Eve notes that the more consultations a Doctor does, the greater the ability to identify educational needs with clarity. Focussing us on what we need.

Having identified these needs the challenge is to find relevant information. Quality evidence based knowledge delivered through traditional journals, online databases and aggregated information portals still forms the foundation of our information needs. However the cost in time and money can be prohibitive and a disincentive.

There is a concept called the 3 Levels of Pull . This is a proposition around information management, applied to social media, which can take us to the next level in helping learners and patients. As a clinician faced with a unique problem we must be able to pull that data towards us when we need it. This is where Social Medial and Social Learning can provide rapid access to validated, digestible, easily retrievable information.

The first level is Access, finding things when and where you need them, the ability to have at your fingertips a resource for those unexpected occurrences.

We can turn to the internet for up to date information through databases such as PubMed, but often we have a problem that is beyond the evidence base, that requires experience or tacit knowledge that you may not have. There are new Databases evolving that use complex syntax and AI to make answers to clinical questions easier to find. SearchMedica, Hakia Pubmed Symantic Searches, GoPubMed

Social Media has created a virtual space where we can find and chat about problems with people we have identified as knowledgeable on a subject or an innovator. Twitter is my virtual tea room. Within the boundaries of professional conduct and patient confidentiality a quick clinical question can see a rapid response within seconds from someone with expert knowledge or a link to information that will assist me.

To do that I have followed thought leaders, innovators, medical educators and even students with a passion for their topics. Posing a clinical question in 140 characters can really focus your mind on what’s important too.

YouTube provides us with yet another opportunity for targeted learning, with an explosion in procedural videos, and more recently an Australian innovation JAMIT instant tutorial from ACRRM

The second level of Pull is Attraction. How do we attract people and resources to us that allow us to learn new things that we never knew existed? Deloitte talk about harnessing serendipity. Increasing the probability that chance encounters will lead to quality outcomes is based on the choices about where and with who you spend your time. Developing a robust social network of like-minded people, following leaders, and carefully selecting blogs & podcasts creates a stimulating learning environment.

Social media has tools that can allow you to monitor the conversation for useful tips and information. Feed aggregators such as Feedly can pull stuff that interests you into a platform that you can view on your PC or your mobile device. There are many other apps that allow you to set up filters around your needs

The third Pull is Achieve or taking Access and Attraction to the next level.

One of the key leaders in the field of Social Learning is Mike Cadogan known widely for his Blog Life in the Fast Lane. He and his Emergency Physician Colleagues first created a new concept in Social Learning called FOAMed. As the story goes it was found in glass of Guinness but anything is possible with ED Doctors I guess.

Free Open Access Meducation describes that aggregation of Blogs, Podcasts, Tweets, Google searches and many more Digital and Social Media streams as a font of tacit knowledge, opinion and experience available to be disseminated, debated and dissected in a free and open manner. New Search engines GoogleFOAM makes this even more accessible for instantaneous retrieval. The GMEP Project provides a portal through which we can share our own knowledge and expertise, create clinical questions and learn.

By becoming part of a greater group through the power of Social Media Tools we can draw together all our knowledge needs identified through working with our patients, our colleagues and the wider medical community…


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