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Fiona Pathiraja: The ePortfolio and generation Y

25 Jul, 12 | by BMJ

Am I the only member of the ePortfolio fan club? If the recent vitriol on Twitter is anything to go by, one would be forgiven for thinking that the fan club comprises n=1. The most notable tweet about ePortfolio was from an anaesthetic trainee who said, “The portfolio is the medical profession’s equivalent of Mao’s cultural revolution—detainees given diaries to write down their own faults.”

Is it really this bad? I think much of the negative publicity around ePortfolio is unfair. Having returned to clinical practice after time working in the private sector and the civil service, I for one, find it useful. My experience of CPD and personal development outside medicine is a mixed bag. I found myself veering from high-quality leadership development courses to sub-optimal sessions on presentation skills. There is no formal “curriculum” in many non-medical jobs. No one holds your hand and asks if you have done a certain number of presentations to clients or says, “You don’t really have experience of skills in this area, how can we ensure your sub-speciality training is tailored to include this?” You are expected to learn on the job, attend in-house courses, be appraised, and seek out career development opportunities in your own time. The ultimate result of this is your standing in the annual promotion cycle and performance bonus.

Medics in training endlessly complain about the curriculum, ePortfolio, deanery teaching courses, Royal College fees etc. The truth is we just don’t realise how good we’ve got it. I wonder if we would be complaining as much if we had to compete for promotion to various registrar grades once already within a post-ST3 specialist training programme?

Of course, the ePortfolio is far from perfect. The end user is typically generation Y and expects technology to have the beautiful aesthetics and seamless functionality of their i-products.

Improving functionality e.g. linking curriculum items to assessments, and aesthetics is essential for an improved ePortfolio. Forced ePortfolio reflection is another bone of contention. True reflective practice is useful and the reality is that most of us reflect. Our tweets, blogs, and discussions in the mess are all reflection. Allowing ePortfolio to include free text reflection and links to social media might be a way of improving this.

Does the ePortfolio encourage a tick-box culture that drives mediocrity, rather than excellence? Furthermore, where is the evidence that a portfolio-based documentation and reflection produces good doctors?  Perhaps educationalists could work with the relevant educational bodies to elucidate the evidence behind the learning theory. And finally, what is the portfolio without the incessant workplace based assessments? Many supervisors need training and skills on how to do these appropriately.  It seems that an ePortfolio culture shift of increased transparency and trainee engagement is needed.

Many early career doctors could easily have taken the route of investment banking or management consultancy. They chose instead to work in the NHS. As a cohort of intelligent, motivated young people, we are able to take responsibility for adult learning, but need to be treated like adults in order to do so.  If the ePortfolio gods are listening—engage with us, take constructive feedback, and try to improve the portfolio to inspire the medical generation Y.

Fiona Pathiraja is a specialist registrar in radiology, based in London. She has previously worked as a healthcare management consultant and entrepreneur, and she spent two years seconded to the Department of Health, where she was clinical adviser to the NHS medical director. Follow her on Twitter @dr_fiona

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  • amcunningham

    Hello Fiona,

  • http://twitter.com/MedicalTeach Laura-Jane Smith

    These are excellent points, eloquently written. However I think it’s important to separate your enthusiasm for the concept of an ePortfolio and the structured nature of clinical training, from the points raised on Twitter about the functionality of the current version. Some of the tweets may have been over-zealously critical, but the frustration being voiced is a result of points you make yourself: Generation Y expects functionality and aesthetics in line with other applications we use. And we need to be inspired and engaged by being given the tools to act like the adult learners we are. I maintain a high degree of optimism that we can connect with developers and Royal Colleges and make life better for all of use: nhseportfoliorevolution.wordpress.com  <– please read and comment. 

  • amcunningham

    The more voices that join the discussion, the better. In some ways your comments echo many of the complaints about the use of portfolios to assess competenct that I have seen elsewhere. 

    For example, last year many trainees and others shared their experiences in comments on this blog post http://mededconnect.wordpress.com/2011/06/28/portfolios-and-competency/ .

    It would be really useful if you could write more about what it is you appreciate about the portfolio system. You don’t seem to be very happy about recording reflections or work-place based assessments. So which elements do you think do really work?

    Oh, and please share the NHS eportfolio revolution blog http://nhseportfoliorevolution.wordpress.com/ . It has been started by a junior doctor, and has had great support from the technical development team. In time I hope, like you, that we will see other stakeholders engage in discussions about portfolios and competency in these spaces.

  • Dr LJ

    Grrr, annoyingly has come up as wrong twitter name. Can you change to @_elljay:twitter ? Thanks. 

  • @Dr_Rhys

    Dr Pathiraja has asked me to
    expand on my acerbic 140 character rebuff of the ePortfolio system.

    At work I am a smiling, carefree
    nonchalant chap – albeit one who harbours a deep, dark secret. I resent the
    eportfolio; in fact I hate it.

     

    Time consuming

    The benefits of an electronic
    portfolio are that it is systematic, generic and permanent. Therein lies the
    eportfolio’s flaws – in that it is time-consuming, inflexible and not dynamic. I
    begrudge the cost of this static form; paying over seven hundred pounds for
    something which does not specifically reflect me or my training needs.

    The eportfolio system is a thief
    of time – stealing hours from anxious, overworked juniors when morale is
    already at a low ebb. Each ‘doctor hour’ spent on creating ‘a personal
    development plan’ or on forced ‘reflection’ can be multiplied across the
    nation. Taken as a whole these are tens of thousands of valuable ‘doctor hours’
    lost – creating prose that is never read; this theft is criminal.

    The phenomena of the ‘rush’ to
    have noddy Likert forms completed by jaded and busy seniors every spring/summer
    is matched by their glacial paced apathy in replying. The specific number of
    ever changing hurdles that need to be jumped each year is arbitrary. How can
    this stiff system be equally correct to appraise an academic trainee and an
    acute medic?

     

    Adequacy

    The appraisal process is designed
    to demonstrate adequacy and highlight areas of failure. Doctors tend to be
    hugely competent over achievers who intensely dislike being told that they’re ‘satisfactory’
    – always hoping that an appraisal may be a time where they may receive.. err..
    praise. It doesn’t improve the quality of teaching I receive. It doesn’t remove
    the burden laid at my feet to ensure I have fulfilled the curriculum. It doesn’t
    prompt me with clever ways that other trainees have overcome similar problems
    or fulfilled ‘competencies’ (urgh.. shiver.. I hate this word).

     

    Not evidence based

    Reflective trainees may be safer
    than those who have no self-doubt, self-criticism but there is no evidence that
    asking someone to type their thoughts ensures that they become a  safe physician. Forced reflection is public flagellation-
    it is phoney repentance for the cameras. I resent the reliance on faddy
    educational gimmicks such as reflective learning. Introspection may produce
    wiser decision makers – but the process of sharing isolated pockets of this cannot
    be proven to ‘improve’ the quality of doctors nor identify those who are
    failing.

     

    Evolution

    I am not afraid of change – I am ‘of
    the new system’ – a pilot F2 and a ST trainee. I resent the evalngelism for the
    current electronic portfolio because it is inferior to my paper based
    portfolio. My papers, thank-you cards and hand written notes are awkaward to
    integrate with the eportfolio system. Certificates, handouts and handwritten
    notes made my traditional portfolio ‘live’ and better reflect me. My paper
    portfolio grew over the years as I worked through medicine and into neurology –
    and now it is ‘lost’ and instead I have an empty emotionless electronic form to
    fill. Scanning my paper portfolio is an option – but an unappetising one. And
    let’s be honest – nobody but me was ever interested in my portfolio anyway. It
    was loved but unread, a living thriving accurate diary but as secret as a tomb.

     

    The failing doctor

    ARCP and the eportfolio will be
    used as the tools to ‘identify’ the failing doctors – but said tools are so
    blunt that they will not be identifying any more flaky physicians or dud Docs
    than the previous system of covert surveillance and nous could spot. If it is
    designed to identify those doctors who will be arrogant, reckless, or cut-corners
    – well the system cannot spot borderline psychopathic tendencies – I predict
    they will do equally well under the new system.

     

    The alternative?

    A trainee would have three
    questions asked of them and completed by three Consultants who feel they know
    the junior well enough to answer them anonymously; Are they currently up to scratch?
    Are they a good egg? Would you want them as a Consultant colleague? If the
    answer to any of those three is not a resounding ‘yes’ then they are put on
    probation (and by all means this probation may that start off looking like the
    current system). You must also report all complaints made against you. You must
    complete a truly anonymous 360 degree survey yearly.

     

    Babies and bathwater

    I do like the concept of 360
    degree feedback (albeit I would make it so that you could not choose who
    completes this for you. The ability to cherry-pick those with a similar world
    view undermines the potential of the survey). I am aware that there is no room
    for negotiation here and that only by financing this industry can I become a
    consultant. I have to agree that they can share my data – which includes all my
    personal data – as an essential part of enrolment. At least I can opt out of
    the ever prying Facebook; and that the social media behemoth doesn’t require
    regular penitent reflection.

  • ben

    The e-portoflio is illustrative of broader problems in post graduate medical education, in particular:

    1) The fact that the e-portfolio is designed merely to capture the incidence of learning experiences but not to help clinicians access training and education opportunities. When it merely records educational activities that would be happening anyway (and does so in an intrusive and time consuming way), quite naturally clinicians see it as a waste of time with little added value.

    2) Reductionist approach to competencies. The aim of the game here is to reach the threshold for adequacy, not aspire to excellence. Indeed, there is no mechanism in the post graduate medical education system to recognise when clinicians are doing a fantastic job rather than the bare minimum of what is deemed necessary. Revalidation is based on similar principals and I can’t quite wondering this is all inspiring a culture of mediocrity

    Keep praying to the e-portfolio gods but I very much suspect that we are stuck with it

  • http://twitter.com/dr_fiona Dr Fiona Pathiraja

    Hi Ben,
    Many thanks for the comment and hope you are well.

    I agree that there is a problem with the wider landscape of medical education. I feel it is a shame that those who are keen to teach and are good at teaching are sidelined as they aren’t necessarily ‘educationalists’. Whilst credentialising teaching activities is important, I feel that we should maintain the body of those keen to teach who don’t necessarily want to gain higher degrees to prove that they can.

    With regards to the eportfolio, I think in an age of transparency and documentation, we need something to record our learning. Asking a consultant if a trainee ‘is a good egg’ probably won’t cut it any more. As you say, we are probably stuck with it. However, that probably doesn’t mean that we should be happy to take it at face value and should lobby the AORMC and NES to improve it.

    Fiona.

  • http://twitter.com/dr_fiona Dr Fiona Pathiraja

    Hi Rhys,
    Many thanks for the very lengthy and detailed comment!!
    I particularly like the paragraph on evolution. I agree with you that the portfolio needs to be personalised in order to have most value. Hope that the AOMRC will take this aspect up and develop it in order to improve the ePortfolio for new generations of trainees.
    FP

  • http://twitter.com/dr_fiona Dr Fiona Pathiraja

    Hi Anne-Marie,
    Thanks for your comment. Perhaps it didn’t come across in the blog but I do reflect on the portfolio. I think that we need to improve the way we are able to reflect e.g. if I write a blog, why can’t I just link to that? Surely our social media reflections are just as valuable as other reflections? The ePortfolio needs to include free text comments and the ability to link to social media to improve the value of reflective practice.
    FP

  • http://twitter.com/dr_fiona Dr Fiona Pathiraja

    Thanks Laura-Jane. I agree that there is a lot to be done with the portfolio, mainly improvements with functionality and aesthetics as I mentioned in the blog. I am hopeful that the AOMRC will hear the message and will seek to develop the portfolio in line with the needs of trainees. As it is now a fundamental part of a trainee’s postgrad education, it deserves investment and high quality development.
    FP

  • http://twitter.com/mgacsm Clare Morris

    I would share many of the sentiments about the value of an e-portfolio for capturing, mapping and therefore making explicit the learning arising from working. I agree too, that the limitations described (in terms of connections to assessment data, or authentic, in the moment reflections) limit the e-portfolio value. For me, a key point lies in your observations about the nature of reflection, the recording of reflections and the ‘evidence’ that a reflective doctor is an effective doctor. Conceptions of reflection arise from the work of John Dewy and Donald Schon, the latter being perhaps more familiar within the medical education world. (Schon was intact a PhD student of Dewey). Schon originally used the term reflection-in-action to describe the professional artistry of expert practitioners who experience something that does not go ‘by the book’ and in the moment itself think through, experiment and come up with a new form of action that deals with the problem arising. This seems to me far removed from the compulsory, instrumental approach to reflection embedded in many professional portfolios these days. Here more novice practitioners are asked to evidence their thinking about things that ‘went wrong’ with their practice, rather than conundrums, puzzles, anomalies, complexities arising within practice. In so doing, the word reflection is diluted into something quite different and used as a proxy measure for a thinking doctor.
    Clare

  • http://www.drlj.wordpress.com/ Dr LJ

    I agree that the “reductionist approach to competencies” is currently the biggest threat to medical education and therefore the future of medicine. Training structures and assessment instruments need to recognise and inspire excellence. Many trainees do amazing things, but this is despite the system, rather than because of it. This is urgent, and I am confident the powers that be will recognise the need for change. LJ

  • amcunningham

    That sounds like something that can be easily achieved in the future, and I’m very surprised that it is not possible to insert hyperlinks already.

    With regards to work-place based assessments I’m dleighted that Clare Morris has started this blog.
    http://medicaleducationmatters.blogspot.co.uk/2012/07/why-arent-wpba-working.html

    It tackles some of the deeper issues which upset trainees when they express anger about ‘eportfolio’ I think.

    Thanks
    AM

  • Ben Hall

    Dear Fiona,

    thanks for your blog entry. I agree that we are fortunate to have an onus professionally to reflect. However this has been cumbersome in its current form rather than enjoyable and constructive. I believe the data we put in is lost and hence largely useless other than as a “ticking box exercise”. I have spent the last day turning over in my head what I want from my eportfolio and I want something that is: flexible, searchable, shareable, beautiful, collectable, evolutionary and above all a tool for improvement. I can safely say that I am a reflector but I have NEVER looked back at my eportfolio entries. They are largely introspective, hidden and non-collaborative.
    What I would like is a blend of twitter, a blog, google + and google docs. I could work on my own on this. If people other than my appraiser were interested they could read, search and comment. Communities could develop for example a department, practice or speciality training scheme. Sharing of ideas, comments, collaboration and goals could emanate from such a sharing of information. We could even share mistakes god forbid! Of course all it would need then is a counter for all those boxes to tick and link. Perhaps a friend could programme this. Open source of course.

    Generation Y can keep their clunky apparatus. And I’ll keep my subs fees.

    Ben.
    GP trainee.

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