Specialisation of doctors goes on in the daily grind, in the clinical work in each department. Good specialist training requires a working situation that facilitates master-apprentice learning
Photo: Einar Nilsen
«Now just turn the child over and listen over the lungs,» the senior consultant said when we were halfway through the neonate examination. It sounded so simple, and I knew how to handle the stethoscope, but as a rookie specialty registrar with no children of my own and very limited experience in handling people weighing less than five kg, I quickly realised that I did not have the slightest clue how to move this little body in a reasonably professional manner. «Oh, well – just hold her here and lift her up a little, and then turn her over like this.» And presto, the child lay sleeping on her tummy and I had taken my first step on the road to becoming a specialist in paediatrics.
What specialities we should have, what the specialist training should include and how long it should take are among the topics of the discussion surrounding the development of a new speciality structure, which has been ongoing in the Norwegian Medical Association and the Directorate of Health in parallel over the last few years (1). The proposal from the Directorate of Health, which has recently had a hearing round (2), includes some major changes in the current specialities structure, including in terms of the actual training. The foundation period will be included as Part 1 of the specialisation, and the training process will be more structured and module-based. The opportunity to accumulate merit from research or other disciplines has been removed. The directorate estimates that in total, the formal specialisation period can be cut by approximately eighteen months, and it wants the training to become more streamlined and efficient. However, to ensure that we train skilled specialists we also need to look at their working conditions in the hospitals.
This is where the doctor becomes a specialist. Specialist training involves more than just acquiring theoretical knowledge. The evidence base for diagnostics and treatment is constantly changing, and what was deemed best practice when the specialist completed his or her training ten years ago will often be outdated today. The specialist nevertheless remains a specialist – as of today, only specialists in general practice are required to renew their specialty. One is therefore a specialist not only on the basis of possessing a theoretical overview of the discipline at any given time. Becoming a specialist involves a process of maturation. Through their work, specialty registrars accumulate experience that will add up to a solid frame of reference with which to encounter patients or problems within the limits of the discipline. This constantly expanding frame of reference will enable the doctor to make increasingly independent assessments that comply with the professional standard of the discipline in question. The specialty registrar must learn the craft that enables her to benefit from theoretical knowledge. She must learn how to use the tools, both concrete and more abstract, that are necessary to make the correct diagnosis and provide appropriate treatment to each individual patient. This may involve such basics as the technique used to turn a baby over, which cannot be learned from reading a book. A craft must be learned through practical experience.
The key learning arena for specialty registrars is in clinical – or practical – service. This is where the patients and their problems are found, and this is where experience is accumulated. For this experience to be correctly placed within the frame of reference, it is essential to have an opportunity for ongoing supervision and feedback from doctors who are more knowledgeable, have encountered the problem previously and know the discipline from the inside. Structured supervision, training courses and other educational platforms are important supplements, but will never be able to replace good, old-fashioned master-apprentice learning.
A specialisation will thus never be better than what is facilitated by the conditions for learning in each department. Working conditions that will ensure high quality specialisation require sufficient resources and staffing to permit experienced and less experienced doctors to collaborate, on the same patient and on the same task. The requirements for «production» must not be at the cost of the time devoted to professional development. We often hear that the doctors’ working day is devoured by administrative activities. Perhaps we should also be concerned that the time for «doctor-oriented» activities is disappearing. Morning meetings, x-ray meetings, internal training activities or simply a good exchange of professional views at lunchtime are easily disregarded in favour of production efficiency. This only serves to enhance their importance as arenas for knowledge transfer. It is time to plead for the everyday doctor-to-doctor interaction!
As for ourselves, we can take some small steps to facilitate ongoing supervision by ensuring physical proximity in time and space between experienced and less experienced doctors. Are the offices and workstations of senior consultants and specialty registrars located close to each other? Does the call schedule ensure that they are on duty in the same outpatient clinic at the same time? And do we have a culture that encourages constructive feedback, irrespective of who is the formal supervisor of whom? Employers who place a clearer emphasis on the teaching duties of their staff members will also gain the added benefit that more experienced doctors receive a further incentive to maintain their skills and craftsmanship.
Swearing the Hippocratic oath remains a ritual in some countries. A full section of the oath is devoted to the duty to teach one’s craft to others – «to teach them this art», as the Norwegian translation says (3). An equivalent formulation has been incorporated in the Norwegian Code of Medical Ethics: «According to his/her competence, a doctor should help in developing and disseminating medical knowledge» (4). This requires that the working day includes space to transfer such knowledge, to give and receive feedback, and to discuss the subject area and professional decisions wherever they may arise. This is how we train – and maintain – skilled specialists.
