The debate is interesting but it’s really about a non-question. To start from the beginning, we need to consider both training and education. Training fits people for today’s job, it will go out of date; education is for life and does not go out of date, educated people change themselves and, equally important, become change agents for those around them. Training enables people to follow a protocol, education enables them to know when not to follow a protocol. Training can be ‘delivered’ and sometimes ‘received’; education is something you can only do yourself, although it can certainly be facilitated or hampered by the environment.
Expertise comes from ‘deliberate practice’, lots of it. Some have said 10000 hours. It’s not enough to have the experience, there needs to be time to reflect on that experience. Reflection is personal but it can be aided by feedback by supervisors and colleagues but more importantly by feedback on the consequences of our actions with patients. There can be few encounters that are without educational potential. Every patient with a myocardial infarction is both the same and different from every other patient with myocardial infarction. The 101st (or 1001st) patient may require all the experience garnered from the earlier ones. This is education.
It follows that we cannot say someone is trained except in the narrow, but important, sense of technical competence. We cannot say that at some defined point a person becomes expert any more that we can say that they have become educated.
What are the implications? Debate about hours of training is largely sterile, education is a continuum. ‘Service load’ only becomes a problem when it prevents reflection, otherwise repeated experience promotes expertise. ‘Protected time for teaching’ (something on which I used to be keen) may be counterproductive as it isolates the learning from experience. The ability of doctors of all grades to follow up their patients over time is vital for developing and maintaining expertise. This has been lost in recent years and this is arguably far more damaging than any curtailment of hours. It is to be hoped that the initiative of the RCP, The Future Hospital may be able to address this.
Rapid Response:
The debate is interesting but it’s really about a non-question. To start from the beginning, we need to consider both training and education. Training fits people for today’s job, it will go out of date; education is for life and does not go out of date, educated people change themselves and, equally important, become change agents for those around them. Training enables people to follow a protocol, education enables them to know when not to follow a protocol. Training can be ‘delivered’ and sometimes ‘received’; education is something you can only do yourself, although it can certainly be facilitated or hampered by the environment.
Expertise comes from ‘deliberate practice’, lots of it. Some have said 10000 hours. It’s not enough to have the experience, there needs to be time to reflect on that experience. Reflection is personal but it can be aided by feedback by supervisors and colleagues but more importantly by feedback on the consequences of our actions with patients. There can be few encounters that are without educational potential. Every patient with a myocardial infarction is both the same and different from every other patient with myocardial infarction. The 101st (or 1001st) patient may require all the experience garnered from the earlier ones. This is education.
It follows that we cannot say someone is trained except in the narrow, but important, sense of technical competence. We cannot say that at some defined point a person becomes expert any more that we can say that they have become educated.
What are the implications? Debate about hours of training is largely sterile, education is a continuum. ‘Service load’ only becomes a problem when it prevents reflection, otherwise repeated experience promotes expertise. ‘Protected time for teaching’ (something on which I used to be keen) may be counterproductive as it isolates the learning from experience. The ability of doctors of all grades to follow up their patients over time is vital for developing and maintaining expertise. This has been lost in recent years and this is arguably far more damaging than any curtailment of hours. It is to be hoped that the initiative of the RCP, The Future Hospital may be able to address this.
Competing interests: No competing interests