First do no harm: education deals with the application of general principles in uncertain situations

‘First Do No Harm’ is a series of 12 brief monthly articles with internet footnotes about harming and healing in general practice. Each instalment is based on one of the 12 RCGP competency domains, this month’s being:

10. Maintaining performance, learning, and teaching: maintaining the performance and effective continuing professional development of oneself and others.¹

‘We should start not by asking what we can learn from research-based knowledge but by asking what we can learn from a careful examination of artistry, that is, the competence by which practitioners actually handle indeterminate zones of practice — however that competence may relate to technical rationality.’²

INTRODUCTION

Good decision-makers not only make the right decision but make it the right way so they can repeat success, learn from mistakes, and teach. Learners commonly retrospectively misrepresent their thought processes and actions so they fail to benefit from experience.³ A broad education addresses knowledge, clinical expertise, reflection, emotional intelligence, self-awareness, and the ability to form relationships, using role-modelling and a combination of genuineness, acceptance, and understanding.⁴ The scientific method, like everyday common sense, involves being sceptical, seeking corroboration, checking for bias, and often accepting achievable verification in the absence of unachievable falsifiability.⁵ Becoming a better consulter is a process of maturation beginning with rigid use of simple models and moving towards eclecticism.⁶

HARMING

Concentrating exclusively on practising or preaching, training, or education,⁷ learner-centredness or didacticism,⁸ teaching or assessment,⁹ patient-centred consulting or evidence-based medicine, curricula that are formal and assessed, or curricula that are informal and hidden.^4,10 Being concerned only with disease-oriented evidence.¹¹ Requiring problems to match routinely available solutions.¹²

HEALING

Objectively evaluating clinical and teaching performance.¹ Engaging in clinical governance¹ and continuing professional development.¹³ Taking part in mutual appraisal,¹⁴ seeking feedback from colleagues and patients, and being responsive and adaptable.^4,15 Being concerned with patient-oriented evidence that matters.^1,4,11 Using an interpretive approach to define the unique problem and its unique solution.¹²

ATTITUDE

Abandoning protective layers in favour of the loony dook or skinny-dip, recognising that the expanding girth of our growing body of knowledge increases our exposure to unfamiliar waters.

KNOWLEDGE

Training is the process of skill and knowledge acquisition; education incorporates this and more; initiation into professional values and development of emotional and cognitive intelligence. Training is based on rules and certainties; education goes beyond this to deal with the application of general principles in unfamiliar and uncertain situations.⁷ GPs when among their peers and on away-days should be foxes (knowing many things drawn from a variety of traditions); when consulting with patients and supervising juniors they should be hedgehogs (providing clear solutions to ill-defined problems). Experts should be credited only within their area of expertise, not by virtue of status.³

SKILLS

When training: noting where the learner is, identifying where they need to be, and testing progress.⁹ When educating: talking less than listening. When learning: reacting less than reflecting.⁴ When moving between practices: using NHSmail to get confidential information about the consequences of one’s actions.¹⁶

Supplementary information

The internet footnotes accompanying this article can be found at: http://www.darmipc.net/first-do-no-harm-footnotes.html