Learning as a GP trainee does not only happen while you are seeing patients or in formal teaching situations. You can learn a lot from informal conversations with colleagues during breaks or over coffee.
This article discusses what trainees can learn from ‘coffee room chats’ and how this can be captured in the e-portfolio. An example of a chat transcript is provided, followed by the log entry it generated.
By the end of this article, the trainee should be able to identify what they learnt in conversations with colleagues; reflect on what they learnt; be capable of drawing up 'mindlines'; and sum up how their learning could affect their practice.
What are mindlines?
Mindlines have been defined by Gabbay and le May as ‘guidelines-in-the-head’, knowledge acquired from a wide range of sources, mixed with experience and continual learning to inform medical practice.1
Greenhalgh and Wieringa explain it in this way: ‘Medicine is a practice – .... The question facing every practitioner, every time they encounter a case, is: "What is it best to do, for this individual, at this time, given these particular circumstances?" The skilled practice of medicine is not merely about knowing a set of abstracted rules and recommendations but about deciding which of many competing rules is most relevant.’2
An example of a chat
Dr A (trainee): I saw that little girl you sent into hospital last week. Turned out she had appendicitis. From the way she presented, I'm so amazed you made the diagnosis. She presented rather oddly.
Dr B: Yeah. You were at VTS when we discussed it last week. The GP she saw at boarding school thought, with good reason, that she had whooping cough and sent her home on clarithromycin, but mum called saying she had an awful night. When I saw her, she looked really unwell; temperature of 39.5C.
She said her tummy was sore from the coughing, so I just put a hand on her tummyand she had right iliac fossa tenderness and guarding.
Dr C (senior partner): Good old fashioned examination wins the day. Did you follow the new sepsis guidance then? Was she a red or an amber?
Dr A: Well Dr B wrote up the notes really well, with all the bits from the sepsis guidelines. I was very impressed.
Dr B: I created a computer short-cut with the sepsis headings so at the press of a few buttons, it auto-populates the headings. You know, CVS, Resp, Behaviour....
Dr C: Computer short cuts didn't save that girl; old fashioned medicine did.
Dr B: But I did record everything and generated an impressive letter so the hospital couldn't give me grief. I even recorded the oxygen sats!
Dr C: Your MDO will be so proud.
The log entry
Subject title: Sepsis Guidelines
What were the circumstances of the conversation? (who, when, where): I was in the coffee room with 2 GPs (Drs B and C) and we discussed a recent case, a young girl with appendicitis, diagnosed by Dr B, who I saw post-operatively.
Why were you having this conversation?: I read Dr B's notes and I was impressed that he made the diagnosis, which could so easily have been missed if the signs and symptoms were all just put down to the original diagnosis of whooping cough. I may have been tempted to advise the mum to wait a bit for the antibiotics for whooping cough to kick in, but if I had followed the sepsis guidelines, I may have sent her in because she did actually score highly.
I'm not sure if I would have watched and waited, which amounts to dealing with uncertainty and safety netting, or blindly following guidance and admitting her. The sepsis guidelines are being criticised because GPs applying the guidance are sending too many patients into hospital.
What did you learn?: I learnt that it is important to pick up cues (tummy pain) and follow through with an appropriate examination, which is what Dr B did. Dr B is IT-savvy and I need to find out how he created his short-cut to record his clinical findings.
Dr C, who is a really experienced, seemed to think less of doctors who practice defensive medicine. As this stage of my training, my notes are a lot more comprehensive than his and in a recent tutorial, he advised me to write less to improve my timekeeping. I think Dr C may think less of me for following guidelines and writing long notes.
What will you do differently in future?: I will be alert to cues. When the patient is not responding as expected, I should re-open the investigation and consider whether the original diagnosis was correct.
What further learning needs did you identify?: I need to learn how to create the computer short-cut.
How and when will you address these?: I will arrange a short tutorial with Dr B, or ask the office manager who has good IT skills how Dr B created his template. I should do this in the next two weeks.
Shared?: Yes
Conclusion
From reading the above entry, we can see that the GPs in the coffee room revealed how they had acquired their knowledge from a variety of sources and from experience. Dr B's decision to admit was not based on just following the sepsis guidance; it was based on a willingness to reconsider the original diagnosis and pick up cues.
Dr B wrote good notes and had developed IT aids to reduce the time taken to write these notes. The trainee learnt that it is possible to do both and was intending to learn these IT skills. The trainee also learnt, from Dr C's comments, that what we do in particular situations is influenced by values, rituals, professional expectations, legal frameworks and economics.
The trainee shows awareness of conflicting 'guidelines', namely: sepsis guidance versus watchful waiting with good safety netting; and writing comprehensive notes versus running to time.
By reflecting on these conflicts, he comes to a new understanding of what he could do, and how he could do it, that is, he has constructed a 'mindline'.
- Dr Naidoo is a GP trainer in Oxford. She has written three books on how to pass the CSA. The latest book CSA Practice Cases for the MRCGP Paperback was published in January 2016.
References
- Gabby J, le May A. Mindlines: making sense of evidence in practice. Br J Gen Pract 2016; 66 : 402-403
- Greenhalgh T, Wieringa S. Is it time to drop the ‘knowledge translation’ metaphor? A critical literature review. J R Soc Med 2011: 104; 501-9
