3. Dr Tim Fawns - an engaging approach to clinical education

And we can perhaps talk about that a bit more in terms of networking and how important it is. So Tim, can you tell us a little bit more about yourself, and what's important to you?

through each year and they are clinicians, and they're clinical educators. So they are teachers who teach other clinicians, and we educate them about education. So it's very sort of meta, if you like. But what's great about it is that we end up with a really large network of international educators, some of whom are quite influential, many of whom are very, very knowledgeable in various areas. So they bring a lot of knowledge to that programme. And I learned a lot through that, and my

colleagues do too. I also have a background in digital education. I was never a clinician, but I came through as a learning technologist working in the department of Clinical Psychology at the University of Edinburgh, before moving on to become a lecturer in clinical education with a kind of digital education background, I did a master's in digital education at Edinburgh. I also did a PhD in technology and education at

Edinburgh. So one of my big interests is in how technology relates to education, and then how all of that relates to clinical education. So I have a sort of interdisciplinary mix, to me.

to, and I guess it is quite similar, I work with the Darzi fellows with London Southbank University. So professor Becky Malby has got me involved using Whose Shoes with their coproduction module. And I meet clinicians from all sorts of different backgrounds. So I suppose in terms of how I see them learning, and I think you described, and perhaps you could talk a bit more in a minute, about your collegiate system of

learning. I see that as a big synergy, I think, in terms of how Professor Malby works with her students in terms of bringing all the expertise in the room, rather than just an expert imparting facts.

position that we can use to inform everything we do on the programme? And over the years, we've honed that into this, these principles, they are aspirational principles of hospitality, collegiality and advocacy. And these help us guide our decision making. So hospitality is the idea that you don't prejudge who it is that is going to turn up on your programme, who the students are going to be and you allow them to be who they are, and you try

to make space for them. So part of that is not being directive about what should be learned, not being too prescriptive, and trying to bring students into the discussions that happen at the time and where possible, to

contribute to the future design of the programme itself. And part of that is an emphasis on community building and relationship building, and I'll talk about that a bit later. Because there's a lot to say about how we go about building relationships with our students.

But we also have this principle of collegiality where we try to position - and I stress really, these are aspirations that we fall short of these aspirations, in many ways, a lot of the time, but we always hold those aspirations so that we can keep

going in that direction. So collegiality, we try to position the students as equal with the teachers rather than having this hierarchy, respecting the knowledge and expertise and experiences that they bring to our course, and learning from them as much as they learn from us. And then the final principle is advocacy, where we always try to position ourselves on the same side, the same team the same, well, hopefully, there are no

sides. But you know, being on the same team as the students, so that if anything goes wrong either with what we're doing or with what they're doing, that it isn't one side judging the other, but actually working together to try and make things better. So a good example is, we're a fully online programme, there are technical issues that

come up. And if we do a good job of being on the same team, as the students, then the students don't get annoyed with us for technical problems, but they just jump in and try to help us work through them collaboratively. So it's trying to create this collaborative atmosphere, where teachers and students all work together on this project of their education. And we learn from that too.

hiding who they are. But as soon as I say, I'm the chief executive, and remind me who you are, you get the hierarchy, you know, people will not speak openly and honestly. But if I'm Gill, and you're Tim, and everybody else has just got a name badge, and then it comes up naturally, as we've done, hopefully, who you are and a bit more about you and you get to know each other as people, then you're creating that level playing field. And I think that's what you're doing with your students, which is

brilliant. And the other thing I heard was that being on the same team, so it's the same kind of idea, but a different sort of slant on it. And one of the most powerful cards that we've had really one of the most powerful scenarios in Whose Shoes has been around 'us and them' and

who is your 'us and them'. And perhaps some of the work that we've done with care homes, it might be that the catering staff or the care staff, they both want the best for the people, but the practicality of running a kitchen and ordering staff against the personalization of people having choice and perhaps the farmer who always got up and had his breakfast at 5 in the morning or the woman with dementia who might want to wander into the kitchen and peel

carrots all day ... You know, I'm just coming up with some quick examples. But I think as soon as people suddenly kind of almost pop the balloon and realise that we're all on the same team, and all trying to do the best but just coming at it from different perspectives, which is of course where Whose Shoes comes in. So very, very interesting.

approaching them. So we have many conversations about assessment. Postgraduate is quite different from undergraduate. And so we can have these conversations about what the value of having a mark is, what it means. To us not really that much, because nobody will ask a postgraduate student on our programme, what mark they

got after the fact. You get a qualification. That's good. And what's more important to us, and too I think most of our students is what they learn. So the importance of the mark disappears a bit or fades into the background. And we can have these open conversations about what what does the mark even mean? Is it like just a snapshot of what happened right now. And actually, we'll get on to I'm sure the pandemic but this throws a whole different light

on everything. Because the mark you've got during a pandemic is probably even less representative of you than it ever was before, than marks ever were before. So I think that the light that the pandemic has shone on education is really interesting. But yes, so certain structures can make it harder to have this collegiality in this sort of flattened hierarchy. But we just continuously work on that in discussion with students.

equal. So perhaps if a student, you might have a brilliant student, but then they're not well, we're in a pandemic, so she's even worse at the moment, they might have a young family, how to be fair in terms of requirements and flexibility of the course? And do you think that's changing as modern programmes evolve?

and inclusivity. Assessment is one of them, again, because you end up kind of funnelling people through a certain lens, in some ways, when you assess summatively, you have criteria, and everyone needs to meet those and you have designs of assessment that everyone needs to conform to, that may or may not suit the particular individuals. But what we do as a team is we, we try to use our

discretion where we can to kind of erode some of the hard lines here, you know, we try to treat each situation on its own merits, rather than assuming that because a student was late handing something in or, or whatever that that everyone has to be treated the same. We want to find out a little bit about why that was and tried to be lenient. So we would try to err on the sort of the side of lenient and flexibility. But we might sometimes be acting against institutional policy

that is the opposite. And, you know, let's see who ends up coming out on top. And, I mean, there's a, there's a conversation that I saw happening, I think it was on Twitter, recently about, to what extent might students be using the current situation to create excuses for handing in work late or getting special circumstances? And what do we do about that, and this might be contentious. But my view is, we really just need to the default position for me has to be believing people. People really

do have a lot going on. People's mental health has been stretched very far over the last 18 months and already before that. So the greater risk to me is that you

don't believe someone, than that you do believe someone and they might take advantage, you know, discuss but that that's the view that we take, because I think we need to trust our students, and we need to trust them by default. And that trust is then the basis for building relationships with them where we can get to know them and work

with them. And if it turns out that we discover that they were kind of stretching the truth or whatever, if we ever did discover that, then we would want to know the reason for that as well, we wouldn't assume that they did that out of callousness or whatever. So the trust is the basis for the relationship and the relationship then allows you to understand what's actually going on, and then that allows you to do something about that.

initially. And it reminds me, before I set up Whose Shoes, I was working in social care, that's my background. And I was around at the time when they first started introducing personal budgets. And personal budgets can be the most amazing

thing. So for example, I remember a mother of a young man with learning disabilities and how they'd been used to having ridiculous numbers of carers that they didn't know coming in and out of their house as if it was their house and just so impersonal and how they've managed to use a personal budget to employ people that actually related to their son and got him

doing the things that were important to him. But the issue that came up was trust. And surely these people will go off and spend their budgets on cigarettes and drugs and alcohol and, and it didn't happen because people are responsible and they have got, they come into a situation and certainly being a student and the cost of things these days. They don't come lightly they come because they really want to or need to

learn that course. And again, it was interesting to me because I've got a friend who would make the most amazing clinician in her particular field that she's applied for. She's actually given up a very serious job to go into this field that she's passionate about, but is struggling with young children. is struggling with that lack of flexibility. And sometimes that can even be that you've prepared to do one thing and you've got everything lined up in your

personal life. And then something arbitrarily changes, and perhaps for other students without responsibilities that might just be annoying, or doesn't matter. But for other people, it could be a showstopper. So I love the way that you're recognising all those different factors. And I think I can see why Katie says you're very forward thinking. That's nice.

just reflect the student? Or does it sometimes also reflect the context that this is all happening in, maybe they did need some more flexibility because they have children or they have caring responsibilities. And often I

think, we don't try to find that out, we just say, "Well, this is the rule. And they knew that when they signed up for it" so one of the things we try never to do is to say they knew what they were getting into when they signed up for this programme. And hopefully, the pandemic has highlighted why that's

problematic. Nobody can predict the future to the extent that they always know what they signed up for, or how it's going to play out or what support they're going to need, or what circumstances will change during the course of their study that they then need to be able to deal with. And it's really the teachers and the students and the administrators and the institution and the wider context and culture that are contributing to this educational

activity that's happening. And sometimes you need to address more than just one of those things, in order to create a better future.

as an admin in hospitals. And it's fascinating, and sometimes the administrator, you can have a fantastic person or perhaps a receptionist, and people are coming to them asking questions, and they're being set up to fail, because they don't know the answers to those questions. But they're expected to know the answers. And if you kind of dig behind it a bit, and find out what's going on in the wider system, and perhaps how things could be improved by ... It's working together, isn't it, all

of this? So rather than having the 'us and thems' with admin, and lecturers and students, and never the twain, three of them should meet?

want to break down all these partitions and silos. And we are very fortunate to have the greatest administrator in the world, Debbie Spence on our programme. She'll be very embarrassed if she ever hears that.

the relationship building. And what we do is as soon as somebody indicates that they might be interested in applying for our programme, so this is as early as possible, Debbie will be in touch with them. And she will start building a relationship with that person just by being herself and being very helpful and informative. And she will then if they apply, she will help them through the

application process. Not everybody does this, you know, most people I think are left to themselves to fight through the system. And then they already have this relationship with

Debbie before they start. And then she's part of the induction that happens and then the rest of the programme team come in to the induction and get to know these students, but they already know Debbie, so we've got this kind of running start, if you like on the community aspect that's done through Debbie just being brilliant at administration, but the the sort of human side of administration where actually helping people navigate systems is important.

It isn't just a chore and it makes a significant difference if you can smooth things out for people. But she's such a integrated part of the team that it makes it easier for her to help people. Because she knows all about the programme. And she knows what we do and how we think about things. So she contributes to our governance and our leadership and our decision making. And we all sort of work together. So it's, again, it's this kind of everyone working on this educational project together.

cleaner'. We find that everybody has got their wisdom to offer. And sometimes ... we've got a poem actually around a hospital porter. And basically, he can see what's going wrong, but nobody thinks to ask him, because he's having those conversations with people and building those relationships in everything that he does. Or she does, you know. So, I mean, it applies across the board doesn't it that to value people and build team working, and everybody's an equal member of

that team. And within that team, you're going to get some people who, they're going above and beyond, aren't they? And that's adding so much value to your course, that people have got that relationship. Another thing that sort of comes to mind is, in maternity, they talk a lot, there's a big national programme around continuity of carer, but it's continuity of relationships, really. And Debbie is your 'continuity of carer' in a way for your students.

tension in education, I'm sure in clinical practice between standardisation and local discretion if you like, and, and how much can you improvise? And how much do you have to conform to the system because the systems ... there needs to be a balance, or there needs to be a sort of combination of both. You do need some standardisation. And you need some consistency and people understanding how the

wider thing works. But if you lock everything down too tightly, then people can't operate according to the expertise that they've developed or the values that they've developed. And so there's constant negotiation of the balance of structure and agency, if you like or standardisation and discretion.

around mental health. So it's breaking taboos as well that, if you're working in a mental health trust, do the staff have permission to show vulnerability and bring their own issues? You know, it's that whole thing about clinicians and professionalism, and boundaries ... and so that's the sort of thing I find really fascinating. And I don't know the answers, but I love it when people are pushing the boundariesand being a bit more forward thinking.

that you want. So of novice to expert or beginner to master or, you know, from not knowing to knowing. But in reality, things don't work out the way that we plan. So our designs are never perfect, actually. But also, they're always reinterpreted by

the learners, they always are kind of modified by the conditions that they happen in, there's always some kind of subversion going on as well. You can't predict to the level of precision that you would need to perfectly design a learning experience, you can only really design tasks and configure conditions, and then it sort of plays out in this messy reality a little bit differently from how you'd intended. And the pandemic, again, has really

shown that. So, what I think we need is, rather than pretending that it was all fine, we achieved all the learning outcomes that we said we were going to, and now we can move on. We want honesty and openness about what were the limitations of this educational experience, such that the learners have a good understanding of what they still need to go on and learn after the course. And then they can have a discussion about how they might go and learn that.

And I know in medicine in particular, sometimes it's difficult to admit, when you don't know something due to kind of the cultural history of the profession. And that can filter into teaching where teachers feel like they need to present themselves as confident and

knowing a lot of stuff. But actually, my preference would be that teachers were really open and honest about their own limitations, not pretending to know more than they did and working with the students there and saying, how could we find out, how can we learn more? What is it that we would still need to do after this point in order to to get to where everyone needs to be to do their future practice and developing principles for ongoing learning after the end of the course?

today? And one of my Darzi friends, a wonderful paediatrician, who's now Associate Professor at the Health Systems Innovation Lab at London, South Bank University Dr. Tom Holliday would like to ask you a question. Is that OK?

prepares trainees for the complex reality that they will be faced with when they qualify? And if not, where do you think the gaps are? And how could they be addressed?

so much as you know, graduates are ready. But really, the undergraduate is just a step in the bigger process of becoming a clinician who really knows what they need to know or is ready. And you could even argue, are we ever really ready, given the uncertainty that we will be practising? So if you think of undergraduate as just one step, and the postgraduate is another step and And beyond that, as another step, we need to just

keep going forward. But I think that there's an issue in terms of dealing with uncertainty and complexity, that we could do better. And then again, this issue that I brought up about imperfection and honesty, I think is really crucial here that we shouldn't pretend for one thing that when someone has done their undergraduate training, they are fully fledged, because we know really, that that's not the case. And it's not the fault of the graduates. And it's not really

the fault of the teachers. It's just that it isn't really possible in that structure, in that space of time to get people ... most professions, anybody that I am aware of, as far as they need to be, especially if they're not really embedded in practice in a way that they're actively participating. So I think there is always more to be done in allowing students to participate actively in practice settings as part of teams. And again, I would bring that relationship building and trust

and things in there. We need somehow to be able to trust students to participate at a safe level, in practice, and in a way where they are part, they feel like part of the team and everybody knows who they are. And you actually have these personal connections between more senior members of the team and more junior members of the team. And in order to do that, we probably need to think a little bit differently about the relationship between patient care and education, which we

tend to separate. And you'll have noticed a theme of mine is like, worrying about these separations and trying to break them down. Does education have to be separated from patient care, because if it is separated, then it will always be marginalised, it will never have priority over patient care. But if we can think of them as stuff that happened together, education as part of the practice of healthcare, then I think we have more scope for

building it into practice. But there's a real cultural change that would need to happen, cultural perspective. And I don't know if we have space to discuss all of that right now. But it comes down for me to trust and relationship building, openness, vulnerability, and a valuing of education and educational expertise, as part of this negotiation of like, practice and education at the same time.

evolving. I would love. So, OK, well, we have come to what we thought would be a good kind of time so that Tom and others can listen on his commute on the train. So thank you so much, Tim, for being an early guest in this podcast series and believing in what we're trying to do here. It's been fascinating to talk to you, and thank you.