Learning at work

“The physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence.”

― P. Kalanithi, When Breath Becomes Air.

Paul Kalanithi was a gifted neurosurgical trainee and his memoir describes his own journey after a being diagnosed with metastatic lung cancer. During his career, he learnt that there is much more to being a brilliant doctor than merely knowing all the facts. But what exactly did he mean by this?

We experience two types of learning: firstly, incremental learning – we study a ton of new facts, medical knowledge, technical skills and learn how to get sh?t done as a Doctor in Training. Through incremental learning, individuals align habits with established norms, conform to ideals laid out by experts and reinforce existing power structures. Incremental learning involves the process of deliberate practice.

Mezirow introduced the concept of transformative learning. This is a deeper, developmental shift, where situations and dilemmas challenge our underlying assumptions and beliefs about the world. We grow through reflective engagement with our experiences as a clinician, the people we meet - particularly our patients - and by testing new mental models of how the world works. Transformative learning changes perspectives and relationships, laying the foundation for personal growth and innovation. It requires curiosity, attention, and courage.

Incremental learning is well known to us, but what practical steps can we take to encourage and inspire transformative learning for Doctors in Training? Here are a few examples:

1. An indigenous patient self-discharges from hospital against medical advice. The supervising consultant asks their Senior House Officer to spend time with the ward social worker and Indigenous Liaison Officer to understand more about this patient’s situation. They work with the patient to find a compromise to ensure ongoing care is provided within the individual’s context of holistic health.
2. A specialist has a relationship with a national patient organisation and involves their training registrar in the activities. During the year, the registrar orientates a patient advocate into a hospital working group, authors an article for patients about how to navigate the health care system and helps review information available online.
3. A team-building exercise is planned between midwives and obstetric registrars. They debate ‘Caesarean section on demand should be freely available in public hospitals.’ The midwives must present the affirmative argument and the obstetricians the negative.

Transformative learning more commonly comes from everyday activities too, but the key is to recognise the opportunity as it presents, to slow down and make space for it. Steps of transformative growth include 4 stages:

1. Note the experience. How did it make you feel? What happened when you reacted differently, or your prior beliefs were challenged?
2. Voice what happened. Discuss with others and see what their response is. What patterns do you notice? Reserve judgment and just describe it, keeping your mind curious.
3. Interpret the experience. Why did it go the way it did? Avoid usual thinking, e.g. ‘because we’ve always done it that way’ or traditional relationships and structures. What novel interpretations could explain it? What are the implications for future situations: both similar and dissimilar? What did you learn?
4. Own it. How does the experience fit with your own personal prior beliefs? Now bring the past and the future into the conversation. What does it mean for the relationships involved and the team culture? How can you build confidence in new ways?

As supervisors, it’s up to us to create the conditions for transformative learning. We must role model the reflective process, examine our own perspectives and consider where we might challenge our assumptions and beliefs. We need to encourage autonomous thinking, allow time for this reflection to take place as part of every day, on-the-job teaching.

Gradually, as we make room for deliberate practice and reflective engagement, our teams will master both ways of working and learning and see the benefits it brings for our relationships, workplace culture, and patient care.

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First published on The Medical Leader.

Table credit: MIT Sloan Management Review. 2019