Teaching & Learning

Half Day Release (HDR)

IDEAS FOR HDR SESSIONS

Click on items in blue for free resources to use at HDR

CLINICAL TOPICS

  • Please click the “CLINICAL AREAS” section in the navigation menu above – lots of free resources!
  • Also, look at the RCGP’s GP curriculum
  • Some ideas…
      • Dermatology quiz
      • End of Life Matters &  prescribing
      • Mental Health: sectioning
      • MSK ISCEEs/OSCE stations
      • Palliative Care & symptom management 
      • Safeguarding – child, adult, domestic violence
      • Sexual Health – taking a good sexual history, overcoming embarassment.
      • Women’s Health PBL
      • Prescribing
      • Referrals

COMMUNICATION SKILLS

Little Tip for Programme Directors

A HDR session is typically something like 4 hours.  That’s along time for mental focus.  So, try and break it up and use different methods for different sections to help bring HDR alive.  For instance, rather than doing a whole 4 hours of say Balint or a clinical Lecture, how about doing something in the second half that is different to the first.   You don’t have to change topic – just a different educational method.  For example…

  • 2-3pm: session 1
  • 3-3.30: refreshments, break, socialising
  • 3.30-4.30: session 2
  • 4.30-5pm: plenary, evaluation & close.

TPDs, Trainers & Trainees – please help Bradford VTS make this an even better resource for you.   Let’s work collectively.  If you have documents and presentations that you think might be helpful to others (no matter how rough or ready), please email them to me so I can share through hosting on here.   Even if you’re not sure, just email them xxx
                                  
[email protected]

What is Half Day Release?

All GP training schemes offer a half or day release programme in the UK.   This is where one half day a week (or one whole day every two weeks), GP trainees get together for some structured learning in a collaborative, contextual and constructive way.  

HDR sessions cover a wide range of things.  There’s the obvious clinical stuff, but also things which cannot be easily learnt from books but invaluable for the rest of your working life.  For instance, medical ethics, person-centred care, managing your workload, MRCGP, the arts in medicine and so on.  

The HDR programme is devised by the Training Programme Directors (often in collaboration with the trainee cohort) for the next 6 months.    Sometimes, the HDR programme can take a little while to construct if the TPDs are keen on a programme that is tailored to their trainees’ learning needs.  All trainees are expected to attend 80 percent of the sessions.   

The sessions are usually held in a central point like the Postgraduate Centre at the local hospital or they can be at alternative educational facilities. 

The sessions themselves might be delivered by 

  1. the Training Programme Directors, 
  2. the GP Trainer,
  3. the Trainees or 
  4. a combination of the above.

Do I have to go?

Absolutely.  No ifs and buts… all GP trainees (i.e. GP and hospital based) ARE EXPECTED TO ATTEND for the whole afternoon at least 80% of the time. Hospital consultants will have been asked to release those of you in hospital posts as this is a compulsory part of your training ….and remember to sign the register!

When there is no HDR, do I have to work at the Surgery?​

Should the trainee be working at the practice instead?    It depends on why there is no Half-Day Release.

  • If there is no HDR because that HDR session falls on a national holiday (like Christmas Day or a Bank Holiday) – then obviously, the practice cannot make trainees work at the practice instead (the practice will be closed anyway).
  • However, if there is no Half Day Release  because it is near to a national holiday (but not actually on it – e.g. HDR on Tues, but Christmas Day on Wednesday or Thurs of Fri), then yes, you should be working at the surgery instead.    You may see some trainees being “let off” by being given the half day off, but what your practice does with you is up to them.  At the end of the day, you are being paid for the half day, so practices are well within their rights to ask you to work it.    So, the norm should be that if there is no HDR, trainees should be at the practice instead; this is what most GP training schemes tell their GP training practices.
  • If there is no Half Day Release because it has been cancelled, again, you should be working at the practice.   Remember, if no HDR then go back to work at the practice (unless it is a bank holiday).
  • Of course, what the practice wants trainees to do when they are at the practice is up to them.  It might be a surgery.  The trainee might help with on-call, catch up with their admin time or do a project.   Discuss it with both your Practice Manager and GP Trainer.

The educational philosophy behind HDR...

As we said early, HDR is a place where GP trainees get together for some structured learning in a collaborative, contextual and constructive way.  

  • Collaborative 
    Every trainee brings with them a wealth of different experiences.  So we call all learn from each other.   In fact, an ST3 can learn invaluable life changing lessons from the experiences of an ST1 (and vice versa of course).
  • Contextual
    HDR provides an opportunity for you to bring up topics that you find difficult or need help with.  The Training Programme Directors can then formulate a learning plan for the next 6 months that is relevant to you right now.
  • Constructive
    HDR session are often small-group based.   As learners share with each other what they know or how they feel, this enables each of you to build on what you already know.   In other words, you construct new knowledge on old knowledge.

Most GP training schemes see general practice as a partnership between you, the enthusiastic doctor, willing to learn and wanting to be a high quality General Practitioner and the GP educators.   The Programme Directors who seek to provide a training scheme that is flexible and centred around your needs,  The Trainers in general practice who pride themselves on their commitment to training and to giving you a wide range of experience in their practices, and the Consultants in specialities who wish to prepare you to face the breadth of clinical situations that General Practice will give you.

As a team they are concerned about their trainees’ personal and professional development through all the posts they will be in and in all the learning opportunities they provide.  All GP training schemes aims to facilitate the development of doctors who are  reflective practitioners. At the end of the three years all GP training schemes would hope  that their trainees will (i) have a sound, practical knowledge of clinical medicine, (ii) understand the basic principles of health and health care for populations and (iii) have a broad and balanced understanding of medical ethics.   Now, doesn’t that sound good?

Oh and one other thing…  HDR is generally there to create a safe space in which difficult or uncomfortable issues can be discussed by GP trainees.  We hope you will see the HDR group as your “extended educational family”.   No doubt, you will create some life long friends. 

How does HDR work?

This is the rough format for most schemes up, down and across the UK.

  • All GP trainees are to attend for a collaborative educational experience.  This helps trainees
  • However, if there is no Half Day Release  because it is near to a national holiday (but not actually on it – e.g. HDR on Tues, but Christmas Day on Wednesday or Thurs of Fri), then yes, you should be working at the surgery instead.    You may see some trainees being “let off” by being given the half day off, but what your practice does with you is up to them.  At the end of the day, you are being paid for the half day, so practices are well within their rights to ask you to work it.    So, the norm should be that if there is no HDR, trainees should be at the practice instead; this is what most GP training schemes tell their GP training practices.
  • If there is no Half Day Release because it has been cancelled, again, you should be working at the practice.   Remember, if no HDR then go back to work at the practice (unless it is a bank holiday).
  • Of course, what the practice wants trainees to do when they are at the practice is up to them.  It might be a surgery.  The trainee might help with on-call, catch up with their admin time or do a project.   Discuss it with both your Practice Manager and GP Trainer.

Structure of HDR sessions

There are several types of session frequently used in the Half Day Release course.   Some styles are chosen because they are sometimes the most optimal way of learning something.   For example, how many of you love lectures?   Did you know that you only learn about 10-20% from a lecture? What’s worse is that 3 months down the line, this falls to 15-10%.  So, why do we like lectures so much?   It’s simply because we are used to them!   In contrast, in small-group learning, things might be slower to learn, but you retain them for a lot longer.   You are likely to retain 40-60% of what you learn 3 months after a small-group learning session.  Isn’t that impressive?     We are not saying lectures are rubbish and everything should be small-group based.  Lectures do indeed have their place – especially if you want to disseminate large quantities of vital information in a short space of time to a large number of people.   All we are saying is that there are other methods than just lectures and getting “expert” speakers in.  And some of the methods that have been chose for HDR sessions has been chosen by your Training Programme Directors because they are educationalists – in other words, people who understand how teaching and learning really works and what is optimal and suboptimal for a particular topic or context.   Trust them!

So, HDR sessions may involve the following types of educational sessions…

  • The classic is lectures– where an expert comes in to talk about a topic.   But it might be a GP trainer or a trainee, or a combination of.
  • But it may involve a group of individuals who construct a presentation to deliver to others.    For example, a group of 6-8 trainees who explore a topic/theme by looking at the literature, visiting community based projects or NHS services, contacting local experts etc. They then give a presentation to the whole group. The great thing about these sessions is that you develop presentation skills as well as exploring topics in new and interesting ways.   The preparation is possibly more important for your learning than the final delivery!
  • And then there is something called fish-bowling.  Where a small group of people (minimum 2), do something in the middle – like role play something.   And all the learners around the outside make comments or start off a discussion.    The central stage “actors” can then try new approaches based on what was said by the group on the outside.  This is a powerful learning technique especially for things like consultation skills. 
  • This is where the large group is split into groupettes of 6-8.   Research shows that members of small-groups are more likely to share and voice their honest opinions compared to the scariness of the large group.    This is why small-group learning is so incredibly powerful.   Again, sometimes you may think “Why couldn’t they have just said that rather than go around the houses and have a discussion about it?”.  It’s a fair question but again, the research shows that you learn more deeply if there is a discussion first, and because of that discussion, you are more likely to EFFORTLESSLY learn new things and be able to recall them months after.   So, it seem SLOWER is a MORE EFFICIENT way to learning things.   Here are some examples of small-group based learning methods.
  • Problem Based Learning (PBL) – where the small group is presented with a case to consider over several weeks or days.    The trajectory of the case is staged on several pages.  Each stage (or page) is considered on different days.   So, you start off on the first page which may pose questions for the group to consider.    Through discussions, the group might then identify new learning needs which are then shared out to the members of the group to research and answer when the group next meets.   At the next meeting, the group reviews the learning needs and what was found before considering the next page in the PBL case.    The process then continues with the second page and so on until the case is completed.  
  • Balint sessions – The Balint group method is a way to discuss cases or situations arising in practice, which have aroused feelings in the trainees. The small group focuses on relationships and feelings (and NOT problem-solving or clinical management).  These sessions focus on the doctor-patient relationship.   Someone is asked to present a case that they found interesting or difficult.    They simply present matters of fact and then what went on.    They then sit of out the group whilst the remaining small group considers the doctor-patient relationship or dynamics.    The idea is to stay away from clinical problem solving because a lot of difficult doctor-patient situations are a result of the doctor-patient relationship, not the clinical conundrum!   These sessions will help you recognise difficulties in the doctor-patient relationship when you consult with your patients.
  • ISCEEs – ISCEEs is a term invented by Bradford.   It stands for Intensive Structured Collaborative Educational Experience.  It’s a bit like an OSCE where you go around stations.  The difference being, rather than one person going around each station, you go around in little groupettes of 4-8.   In this way, you learn from each other as well as the station expert!  The focus is more on the learning than on grilling you!   Questions are posed to stimulate your thinking rather than trying to make you feel like you are being examined.  ISCEEs, unlike OSCEs, are relaxed and informal.
  • Open Group Sessions

    In ‘open group sessions’, the groups are free to set their own agenda. Some advance planning will be necessary, and it may be helpful to set aside 5 minutes from the previous week’s HDR session to decide what you want to do and who is going to bring or do what. This could be case-based, for example…

        • Interesting cases from hospital or GP work
        • Cases which raised problems
        • ‘Critical incidents’ in which something went wrong or nearly wrong
        • Ethical dilemmas
        • Videos (although sessions are planned into the course for further analysis of consulting skills).
        • Material can also be topic-based, for example…
              • Medico-political developments such as National Service Frameworks, new funding schemes etc
              • Ethical issues in the news eg the lady who wants to have another baby using her dead husband’s sperm, the Siamese twins that will undergo separation despite parental condemnation
              • Jargon terms which you may think everyone but you understands, so you’ve never dared to ask (eg Clinical Governance, Nurse Practitioner, Revalidation, Appraisal, Mentoring etc)
        • Anyone bringing a topic for discussion should do a little preparation beforehand, perhaps bringing a journal or newspaper article.  Group members may also be asked to choose aspects to go away and research, and bring their findings back the following week. 
  • Mock stations – may schemes do mock CSA sessions.   There are stations just like the real exam except each trainee goes around and is given 1-1 feedback on their performance. 
  • OSCEs – schemes may also devise OSCE stations like you had as a medical student.  Each station focusing on something different.  Again, as you did as a medical student, you go around the stations individually as you are quizzed and given feedback. 

HDR sessions may involve the following resources…

This may be prepared videos or videos your educators ask you to bring in.      This is a valuable way of getting feedback on how to perform even better.    You might at first feel reluctant and shy at showing yours – but everyone does!   Be brave and overcome this “video allergy”.   Don’t worry, the educator will ensure your feedback is balanced and not painful.  And prepare to be surprised how how much you get from such sessions.   Please make sure your video actually works and set it to the right point that you want to watch it from.  It saves a lot of faffing on the day.

This may be a case that someone has written up or someone from the group presents.  The great thing about cases is that it is learning based on REAL LIFE experience.   We call this experiential learning.  It is one of the most powerful ways to learn and remember things.   

Feelings are important.  The way we feel about things often determine our behaviour.    And sometimes, the key to doing the right thing is examining our feelings and working on those.   For example, a trainee in the practice once presented a patient with knee pain who he thought was wasting doctor’s time because he just wanted a sick note.   But on further enquiry, he hadn’t really taken a good MSK history.   The patient had actually twisted his knee 6 months prior, and it swelled immediately but did not seek medical advice.   He presented now as it was interfering with walking and it still remained swollen.   An MRI showed a meniscal tear.   Why had the trainee missed this and jumped to the “wanting a sick note” conclusions?  He said he knew that twisting injuries had a high rate of internal knee damage.  We explored this, and the trainee was honest.  He saw the patient as unemployed and this made him conclude that this patient does not contribute to society and therefore was a fair bit against the patient right from the start.  Because he made early conclusions about the patient’s work ethic without really asking him, he ended up doing a bad clinical job.   In other words, his attitudes and feelings on this occasion affected his clinical performance.  And it could not be rectified without tackling this first. 

Where actors are trained to play a particular patient role enabling you to practice your skills with them.  This is great for fine tuning your skills and making mistakes rather than subjecting that on patients.

Real patients might be bought in not only to show you clinical signs but for their experience of the disease on their lives (= the illness).  Where patients come in to tell you first hand about their experiences so that you truly understand how diseases affect people’s lives.     The effect of the dis-ease on the patient’s life is called “the illness”.  Being a GP is all about understanding the illness, which is often not covered in clinical textbooks because every patient’s experience in unique and individual.    If we are to help with alleviating suffering, one needs to understand the illness and not just the clinical features of something.  Understanding the illness is powerful stuff!   (And a massive thing in the CSA)   

Can you give me some tips on giving feedback in group sessions to lessen the chance of me upsetting someone?

  1. Try not to expression your opinion as the “right” and “only” way.   
    Bad: “Well, you did that bit wrong.  The way you should have done it is…”
    Better: “You know that bit where you said xxxx.  I have a suggestion for you that might help.   How about yyyy.   What do you think?”
  2. Use the words “I wonder if”.  Tentatives are better accepted than definitives!
    Bad: “The right way to do that is xxxx”
    Better: “I wonder if yyyyy might have worked better.   What do you think?”
  3. Don’t criticise if you don’t have an alternative suggestion.
    Bad: “I think you jumped in with closed questions and it sounded like an interrogation”
    Better: “I wonder if at the beginning if you had given the patient a golden minute to speak, whether that would have made the consultaton go better?  What do you think?”
  4. Own your statements using the “I” word.   In other word, don’t present your views as “the national standard”.
    Bad: “One should ask about xxxx when a patient says yyyy.  That should have been a big hint to you.”
    Better: “Whenever a patient says yyyy to me, I often ask xxx.   Do you think that might have helped here?”
  5. Be specific and descriptive.  Don;t be vague.
    Bad: “Oh, things just didn’t go right from the start did they.    If you had focussed on a better start, perhaps it would have been better.”
    Better: “I wonder if things fell apart because of what happened at the beginning of the consultation.    You came in with a lot of clinical questions right from the start and I wonder if you asked the patient just to tell their story in their own words for a minute or two might have build the relationship?  What do you think?”
  6. Say what you saw and heard rather than your judgements.   People can easily react to judgements and disagree with you.  But it is difficult to disagree with the observed facts of what was seen or heard.
    Bad: “I don’t think you built enough rapport at the start.    That’s why things went sour later on”
    Better: “At the beginning did you notice the patients face when you said “Okay, you’ve only got ten minutes, so please tell me quickly what’s up with you”?  I’m just thinking in terms of rapport and hence the rest of the consultation.  What did you make of that?”
  7. Make sure the feedback is balanced. 
    The aim is not to destroy the person with lots of negative feedback.   So, if you find yourself saying a lot of negative stuff, please give say some nice things too and be genuine about it. I like to think of feedback like an emotional bank balance.   Do not make negative withdrawals without putting some positive stuff in.   Maintain a health emotional bank balance.

Emotionally charged sessions

in some HDR session, trainees may furnish the small group with things that really distressed them significantly at a personal level.  We need to remember that HDR is a safe place and we need to protect the trainee from their distress.   That is why giving feedback in such a sensitive way is crucial.    Both the Pendelton’s and Gibbs’ methods outline below might help structure an emotionally charged session to help the it go more smoothly with some good educational outcomes for everybody.  But always remember: look after the trainee.  Training Programme Directors will often do this throughout, and at the end of the session where necessary.  However, trainees should be mindful of doing this too.  It is everyone’s responsibility to make our fellow colleagues feels safe, respected and valued.

PENDLETON’S RULES FOR GIVING FEEDBACK

  1. Find out what kind of help the presenter wants
  2. Ask the presenter to say what they feel they did well
  3. Ask the group to say what they feel the presenter did well
  4. Ask the presenter to say what they feel they could have done differently
  5. Ask the group to say what they feel the presenter could have done differently
  6. Discuss the broader issues which the case raises
  7. Ensure any uncomfortable issues have been dealt with before moving on

GIBBS’ REFLECTIVE CYCLE

Gibbs Reflective Cycle

Please leave a comment if you have a tip, spot an error, spot something missing or have a suggestion for a web resource.
And of course, if you have developed a resource of your own, please email it to me to share with others.

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