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Helping student to ‘talk’ their way into workplace-based learning

One of the challenges of learning in the workplace is that much of the complexity of practice goes unseen. Many aspects of medical practice take place in the minds of practitioners, who engage in an internal dialogue based around differential diagnosis, clinical reasoning, management planning and exploring prognosis. A key challenge for the clinical teacher is to find ways to make this thinking accessible to the trainee and to find ways to access the trainee’s ‘thinking’ as a way of ensuring they are ‘on track’.

Some of the ways in which you can do this include the following.

‘Thinking aloud’ – providing a narrative as we teach a skill or procedure is commonplace in clinical teaching. Providing a narrative along the lines of ‘What I am considering with this patient because…’ or ‘What I am struggling with here is…’ or ‘I am weighing up the options of X versus Y because…’ are equally powerful.

Purposeful observation – by priming a trainee to observe purposefully, we are making explicit the ways in which we look at patients or situations. For example, rather than asking a trainee to just observe a consultation with a distressed patient, you might ask them to note aspects of the patient’s verbal or non-verbal behaviour that indicate distress. Alternatively, you might ask them to note down specific strategies you use to calm the patient and to address fears or anxieties. 

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

‘Talk the talk’ – many clinical teachers have ‘set ways’ they like trainees to present patients. These set ways often reflect the ways in which practitioners organise their thoughts about patients, as a way of ensuring a systematic approach to diagnosis, etc. By being clear with trainees that this talking prompts a way of thinking, you are labelling it as a teaching strategy rather than a personal ‘quirk’. These ways of talking about patients are often the ways in which particular ‘cultural practices’ are made evident. For example, the way a patient is presented in surgery is different from medicine, which is different from psychiatry, etc. By being explicit about this, trainees again gain insight into the ways in which medicine is practised in that context.

Use case-based discussion – this is another example of the ways in which workplace-based assessment tools can be powerful workplace-based learning tools. Case-based discussion is designed to explore the thinking behind practice, for example to consider why the trainee made a particular diagnostic or management decision. It provides an opportunity for the trainee to make their thinking explicit and to develop their ideas. Clinical teachers can make the most of these opportunities by changing the types of question that check out the knowledge base (e.g. what are the diagnostic indicators for…) to those that require the trainee to provide a rationale for decisions made or not made. For example, ‘You made the decision to admit this patient, can you tell me more about the factors that you took into account… how might you justify sending this same patient home… who else in the team did you involve/could you involve in that decision-making process’, etc.

See also the Workplace-based assessment module in this series.

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