MRCGP & GP Training
First, a quick reminder...
A good learning log will:
Be written in a personal style, using the first person singular (I).
Analyse and comment, not just describe.
Focus on learning.
Make connections between ideas.
Show links between entries from day to day.
Show evidence of planning.
Show evidence of looking back.
Show evidence that you are reflecting on your progress.
A good learning log will show:
- Some evidence of critical thinking and analysis, describing your own thought processes;
- Some self-awareness demonstrating openness and honesty about performance along with some consideration of your own feelings;
- Some evidence of learning, appropriately describing what needs to be learned, why and how.
In a good learning log…
- You will be honest with yourself.
- You will learn something from it
- And you will have found the process of writing helpful
Learning cannot happen without reflection. And reflection is a skill that you can be taught and that you can build upon.
Ram's easy way of writing a Learning Log Entry...
Here’s the rationale behind the way I teach my GP trainees how to write a learning log entry. Basically, your learning log entries are there to (1) help you reflect and (2) help you provide evidence for the Professional Competencies. It is these 13 Professional Competences (PC) against which you are ultimately judged. At the end of your whole GP training period (once you’ve also got AKT & CSA under your belt), if there is good enough evidence for all 13, you get your CCT; if not – you don’t.
I feel that the old method of just asking you to ‘write and reflect’, even with the headings provided in the Log Entries section of the ePortfolio is prone to producing a large variation in the quality of reflection and learning amongst GP trainees. Why? Firstly, because GP trainees are not taught the skills of reflection very well during their undergraduate years. So they end up writing about anything – not knowing whether what they have written “meets the mark”. And secondly, asking a GP trainee to write freely does not get them to focus on particular Professional Competences. If they do cover any competences, again, there is likely to be a massive variation amongst trainees in terms of meaning and depth.
So, rather that just asking you to write freely and then reflect, (or follow the loose RCGP structure), my method is based on writing around the 13 Professional Competencies and being focused right from the start. The 13 Professional Competencies are meant to capture EVERYTHING any GP does in their GP job. Everything a GP does can be pigeon-holed into one or more of those 13 Professional Competencies. Therefore, it should also hold true that if we want to write about our experience, by focusing on those 13 Professional Competencies, we should be able to capture exactly what it is we want to write and reflect about and hopefully to enough depth and meaning.
Let’s start and see how this goes….
STEP 1. Think about the event/encounter/situation you want to write about
You don’t have to write anything at this stage. I just want you to think about it and on a piece of paper jot down some things that come to your mind that you might want to write about. Things you found interesting, difficult or inspiring! Keep your notes brief. If you start writing a lengthy thing at this stage, you will exhaust yourself. We want to save all that energy for the later bits – the bits that will really capture your thoughts and reflections.
STEP 2. Write a brief description about the event/encounter/situation
Keep this description short and concise. Again, we don’t want to tire brains and fingers too early! Keep it to say 2-5 sentences max. Keep clinical details brief – it’s okay to write “Chest examination – essentially normal”, unless of course, the detail is pertinent to your write up of the case. Remember, the first bit is the description and it’s purpose is to lay the context/foundation for the rest of your write up. So – make sure it is a description. Do not include any analysis of your thoughts or feelings – save that for later.
STEP 3. Quickly go through the 13 Professional Competencies (PC)
Now that you have thought about the case and written a little description of it, it is now time to focus on the meatier stuff – the areas you want to reflect on. These areas of reflection are simply the 13 Professional Competences. They are listed below for you.
- Only spend 3-5 seconds on each PC and ask yourself the question “Did this PC have particular relevance or meaning in this case?”.
If the answer is yes – put a tick next to it. Don’t think about it any more and move onto the next one.
If the answer is no – the again, don’t think about it any more and move onto the next one.
There will be some PCs that you did not initially intend to write about but after a little consideration, you get a “flash moment” where you realise it was of particular importance.
But, if you are “umming” and “aaahhhhing” for too long, then the answer is probably no. Move onto the next PC.
- And important rule of thumb – do not make something out of nothing.
For example, let’s say you know you need more evidence for Community Orientation, the DO NOT force this event to become a Community Orientation entry if it is not obvious from the start.
- Go through all 13 PCs QUICKLY and by the end of 1 minute, you should have a set of PCs that you want to write about.
The 13 PCs
- Communication/Consultation Skills (CS)
Communication with patients, and the use of recognised consultation techniques
- Practising Holistically (PH)
Operating in physical, psychological, socioeconomic and cultural dimensions, taking into account feelings as well as thoughts
- Data Gathering & Interpretation (DG)
For clinical judgement, choice of physical examination and investigations and their interpretation
- Making a Diagnosis and Making Decisions (MD)
A conscious, structured approach to decision making
- Clinical Management (CM)
Recognition and management of common medical conditions in primary care
- Managing Medical Complexity & Promoting Health (MMC)
Aspects of care beyond managing straightforward problems, including management of co-morbidity, uncertainty, risk and focusing on health rather than just illness
- Organisation, Information Management & Leadership (OML)
An understanding of the use of computer systems to augment the GP consultation and primary care at individual and systems levels, the management of change, and the development of organisational and clinical leadership skills
- Working with Colleagues & in Teams (WWC)
Working effectively with other professionals to ensure good patent care, including sharing information with colleagues
- Community Orientation (CO)
Management of the health and social care of the practice population and local community
- Maintaining Performance, Learning & Teaching (PLT)
Maintaining performance and effective CPD for oneself and others
- Maintaining an Ethical Approach to Practice (Eth)
Practising ethically, with integrity and a respect for diversity
- Fitness to Practise (FTP)
The doctor’s awareness of when his/her own performance, conduct or health, or that of others, might put patients at risk, and taking action to protect patients
- Clinical examination & procedural skills (CEPS)
Competent physical examination of the patient with accurate interpretation of physical signs and the safe practice of procedural skills
STEP 4. Start writing about each of the selected PCs one by one
So far, you have written a brief description (2-3 mins) and gone through the Professional Competency list to determine which ones are relevant (1 min). So, up til now, you will have spend about 4 minutes. You can now spend the rest of the time writing about what matters – the Professional Competences – and thus get the “validation” marks! This is where you need to spend you brain and energy.
More rules of thumb when writing about each Professional Competency
- First of all, SIGNPOST which PC you are writing about. This will help focus you and help the reader. Use the Professional Competency heading as your subheading. eg “PRACTISING HOLISTICALLY”
- Then start the body of the text for that competency perhaps by exploring your feelings. If there was an emotion evoked within you – that may help you with SELF-AWARENESS – and this can help you with the next bit – critical analysis. So write about What you felt and what made you feel that way. Keep it concise. However, not all competencies will be associated with a feeling or emotion.
- Then do a CRITICAL ANALYSIS & REFLECTION in each competency you write about. What was good? What was not so good? What could you or others have done differently? How could we prevent something the next time? What did you learn? (see table right).
4. Then summarise with some CONCLUDING COMMENTS by GENERALISING AWAY FROM THE SPECIFIC. What I mean by this is to use the specific situation you are writing about to try and formulate a generic solution/learning point that could be generally applied to all patients. For example, you might have thought that a patient got angry with you because you only grasped what she was fully after towards the end of the consultation and that perhaps it would have gone better if you had given her space and time and explored it at the start. So, in this case, the generalisation might go something like this… “From this i learnt that the patient -dr relationship is enhanced if one explores the patient’s agenda from the start. This of course helps with other parts of the consultation like shared management too.
5. Sometimes, it is difficult to write about one competency in isolation. You may need to write about two together. In this case, use COMBINED HEADERS like “PRACTISING ETHICALLY/FITNESS TO PRACTISE” and then write the body of your piece.
Hot Tip for Trainers
Many trainers say to me that they often can recognise that a Trainee’s learning log entry isn’t quite good enough – but they can’t pin point why. If this happens to you, the first thing I would say is STOP, EXPLORE and DON’T MOVE ON. Then ANALYSE the log entry in more detail and compare it to the 4 ISCE levels of Reflection as outline in the table above. It’s going to be a deficiency in one or more of these four things that lets the Learning Log Entry down. It’s usually not the first once (Information Provided is generally good enough in most log entries, if not a bit too excessive). It’s more likely to be a lack of SELF-AWARENESS OR a lack of CRITICAL ANALYSIS & REFLECTION and thus not generalising away from the specific (see point 4 above). So, use the ISCE criteria to help give educate the trainee on how to write more meaningfully.
STEP 5. Consider Evidence for Future Learning
And the last bit, which again, does not need to be lengthy – is a brief outline if there is anything you feel you need to spend sometime learning to help make you and your performance better. For example, an e-module, sitting in on a specialist clinic, spending some time with the Health Visitor, doing a course on Women’s Health etc.
When writing about future learning, please be very specific what you plan to do or what you have done. Do not write “I plan to read around the subject”. This is not good enough because it doesn’t actually provide any convincing evidence that you will do this. In fact, if it was allowed, you could write this generically about anything! So, be specific. Say something line “I have booked onto the Leeds Women’s Health Course for GP on 2nd July” or “I have found a BMJ e-module on how to handle difficult patients – i will do this”. Or even better “I did some online searching around the subject and found www.abc.com really helpful because it suggested that the 3 major features requiring admission are…”. I hope you get the idea.
A little variation... write the "description" of the case last!
Some GP Trainers advise trainees to write about the educational bits FIRST and the description of the event last. This is a great method especially for those trainees who write reams and reams of waffle in the description – which, by the way, does not “score many competency points”. It’s also great for them because those trainees spend so much time and energy in writing the description that by the time it comes to writing about the competencies/learning/reflection, they are a bit exhausted and write only a line or two for the section that matters the most!
Writing about the reflection/learning/competencies FIRST, encourages the trainee to spend their brain power where it is needed the most – on the educational bits of the writing rather than the descriptive bits. It makes sense!
If you are a trainee who writes a lot in your description but little in your reflection, try this tweak. Also try it if you’re the type of trainee who often thinks “I can’t wait till this entry is over” – you’re energy is probably being zapped by the bits that don’t really matter at the expense of the bits that do.
I have used this method so many times and have even managed to get GP trainees who are struggling to impress the ARCP panels. For those of you who are Educational Supervisors or GP Trainers reading this – why not get a trainee who has just started with you to write an ePortfolio log entry about a patient encounter in ANY WAY THAT THEY WANT TO. And then, in the next tutorial, USE THAT LOG ENTRY and demonstrate to them “live” how they can make it better by using this method. And at the end – ask, if the second write up was more meaningful for them?
Some of you may be wondering whether this method is simply “playing” or “gaming” the system and not true learning. I beg to differ. Allow me to explain. This method provides simply a structure just like other structures out there on how to write a learning log entry and how to reflect. This is a framework – nothing more. The “meat” that goes on this skeleton is provided by the trainee and if what they provide is rubbish – the the entry will remain rubbish no matter what framework is used.
I also like this method I’ve outlined because it starts making the GP trainee think of their work in terms of the Professional Competences and by doing so, they truly understand the nature and philosophy behind their work. It transforms the “chit chat” that they have with their own minds into something that more of a “challenge and discussion”. I do believe that all the things we do as qualified General Practitioners can be captured by this 13 Professional Competences. So, it’s good to talk about these 13 dimensions of our work. In doing so, we explore these 13 areas deeply and meaningfully with some sense of direction. Without it would be like aimlessly wondering in the Amazon.