Developing teaching to improve wellbeing of future vets
From anaesthesia to education
There are two questions that I commonly get asked about my current role: ‘What is it that you do?’ and ‘You could still go back to being a real vet, right?’.
Admittedly I have had a somewhat convoluted route to my present destination: I started in a busy university internship in the USA, entered an anaesthesia residency programme and spent 10 years working as a specialist in anaesthesia. Now I am part of the education group at the Royal Veterinary College, working in the Centre for Lifelong Independent Veterinary Education (LIVE).
When I joined the RVC in this role, I recognised a gulf in my own veterinary education, lying between the high-level knowledge and skills provided at university, and the skills required to be a vet.
As I said recently to a non-vet friend, my own education left me brilliantly equipped to provide top-level treatment, with the best possible clinical prognosis for my patients, but as soon as this patient management wasn't possible (because the client couldn't afford it, didn't want it, couldn't manage the logistics of it, or simply felt it ‘wasn't right’) I had nothing else to recommend.
Despite advances in frameworks of Day 1 competences, the biggest challenge to resolving this issue was that none of us in the team could define the set of knowledge, skills and personal attributes that ‘being a vet’ actually entailed. The frequently mentioned common sense element resonates for many, but how do we convert that to definable, teachable and assessable concepts, which we can apply in our teaching, and which support our students to be competent and confident Day 1 vets?
The most significant and exciting part of my role now involves researching the veterinary identity – searching for the answer to ‘What makes a vet a vet?’, and using this to inform the development of our vet students' professional studies teaching.
Defining an identity?
The evidence-based medicine movement has done much to diminish the influence of veterinary dogma, and ensure that there are good reasons for recommending the treatments we provide. However, for many, the message has been interpreted to suggest that only the most proven clinical approaches to diagnosis and treatment constitute gold standard care, and therefore everything else (by inference) is inferior.
In our research, we have identified that some vets define their identity by being able to apply available evidence in an individualised and context-dependent manner, tailoring their clinical decisions to fit the client's needs, the expertise and equipment available in the practice and the requirements of the veterinary business.
"What makes a vet? What is it that you do?"
To these vets, the concept of ‘gold standard’ care incorporates the client, colleagues and practice and is defined as the best possible course of action for all the stakeholders, not simply the action demonstrated to carry the best prognosis.
An alternative career identity is demonstrated when vets define their professional priorities more narrowly, perceiving a sense of achievement only when the client and other contextual influences allow them to provide textbook diagnostic reasoning and therapy.
It seems to be the case that the more broadly defined, context-dependent – as opposed to therapy-related – veterinary identity is associated with less career stress and dissatisfaction, and individuals who may demonstrate fewer markers of poor emotional health.
Professional identity programme
At the RVC, we have developed our teaching in response to these findings. Part of the veterinary curriculum is provided through the professional identity programme (Armitage-Chan and May, in press).
At the centre of this lies the formal curriculum teaching, which is built around professional reasoning (clinical, ethical, economic), communications skills and teamwork development and runs through the length of the veterinary degree. The students' progression in professional reasoning parallels their clinical reasoning development. As they learn the analytical framework and systems knowledge they need for clinical problem-solving, they simultaneously learn the framework and knowledge they need for resolving professional dilemmas and engaging with different stakeholders – the client, the business, the practice team and the profession.
Our approach to this element of veterinary education is not yet complete, and we are finding improved teaching and assessment methods each year. Embracing the notion of taking action in the face of uncertainty and following an untrodden path, we also learn from our mistakes!
As you can see, the answer to the first question (‘What is it that you do?’) requires quite a lengthy answer. However, as you might also appreciate, the answer to my second (‘You could still go back to being a real vet, right?’) is yes, I could, but why would I want to, when in my current role I can improve the confidence, competence and wellbeing of our future graduates?
Learning strategies: dealing with uncertainty
Lying parallel to the professional identity programme are strategies to develop the communication and teamwork skills necessary in practice to implement solutions to complex problems – those in which the solution impacts on several stakeholders, and for which there is no solution that will be perfect for all.
Students are encouraged to consider all the key affected parties, including:
members of the practice team;
the profession; and, perhaps most critically,
themselves, and whether they can draw a sense of satisfaction from the outcome.
Through assignments completed during EMS placements, students are encouraged to see this broader set of priorities role-modelled by the vets they see practice with.
This teaching has been created to develop confidence in action-taking in the face of uncertainty.
We know that veterinary students typically enter their veterinary education as high achievers. Many have never struggled in examinations and have consistently experienced the reassurance that their responses to academic questions are correct.
This mindset to knowledge can be reinforced in university education if questions are posed for which there is a specific correct answer. Students become trained in the notion that their goal is to find a single, correct solution and to be assured that they are correct by backing up their decisions with available evidence – citations from the scientific literature or clinical diagnostic results. An inability to act on incomplete clinical evidence has been identified as a consequence of this, with students becoming used to situations in which treatment decisions are only taken once the diagnosis is certain (May 2015). The natural tendency is therefore to continue to run diagnostic tests until they are convinced that their diagnosis is correct.
The disconnect between this approach to learning during clinical education and the realities of clinical decision-making in practice is becoming evident (Cooke and Lemay 2017).
There is therefore a need to use cases for teaching in which there are numerous acceptable solutions and an undefined diagnosis. In a series of set problems and simulated scenarios, students are asked to commit to a decision that may seem to be imperfect.
The goals of such teaching move away from finding the ‘correct’ diagnosis and treatment, and towards acknowledging the limitations of the chosen action, defending the decision and the process by which it was achieved, and planning for adverse consequences.
ARMITAGE CHAN, E. & MAY, S. A. (In press) Developing a professional studies curriculum to support veterinary professional identity formation. Journal of Veterinary Medical Education
COOKE, S. & LEMAY, J. F. (2017). Transforming Medical Assessment: Integrating Uncertainty Into the Evaluation of Clinical Reasoning in Medical Education. Academic Medicine, 92, 746–751
MAY, S. (2015) Towards a scholarship of primary health care. Veterinary Record, 176, 677–682
This article is based on the author's presentation at the annual meeting of the European Association of Establishments for Veterinary Education (EAEVE), which was held at the RVC in May 2017.