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Fostering 'horizontal' learning

Medical students and trainees move rapidly from one workplace to another and are expected to somehow identify and absorb the nuanced differences between one setting or team and another, and adapt their own behaviour to fit accordingly. For example, all doctors routinely take a history from their patients – but consider the differences between those taken in acute hospital settings from those in general practice. And all doctors establish professional relationships with patients – again think about the differences in relationship between doctors and patients in palliative care from those in paediatrics, obstetrics or psychiatry.

How do you help newcomers ‘see’ such differences and find ways of working with you, your team and your patients, that are appropriate and congruent? One way is to provide clear ‘joining’ instructions that outline preferred styles of dress, ways of addressing colleagues and patients, format for writing in notes or constructing letters, for example. Another is to invite newcomers to actively seek and articulate differences between observed practice in your workplace and those experienced elsewhere, and to discuss these where it would appear to be helpful. This is another situation where purposeful observation can be very powerful.

See ‘Teaching and learning through active observation’ in Explore around this topic.

Another important aspect of horizontal learning is around helping student/trainees to draw on their formal learning (gained in the classroom) to understand what they see in practice. One of the ways we can do this really effectively is through questioning, rather than telling. You might start with some Socratic questions, designed to explore what they know already, in order to make sense of what they see. For example, when they meet a patient for whom they are unable to come up with a differential diagnosis, you might start by asking them to identify observed signs and symptoms, then go on to explore what might be the cause and elaborate why they think it is or isn’t likely to be that. This might lead to another set of unanswered questions, which you might address through some heuristic-type questions, designed to help the trainee identify the ways in which they might develop their understanding or come up with the diagnosis. ‘Where might you go to find out more about this condition? What investigations might be relevant at this point in order to rule out X or Y?’

For more ideas, see the Supervision and Small group teaching modules in this series.

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