A theoretical framework was used to ground the curriculum and syllabus template development. An understanding of the relevant theories is necessary to ensure the development of appropriate instructional strategies within the GP context and environment of learning.4
There is no single theory that explains how aspiring health professionals engage in learning.5 Each provides a different lens. The curriculum and syllabus draws from both humanistic and sociocultural learning theories. These include the humanistic theories of adult learning, transformative learning, experiential learning and reflective learning; and the sociocultural learning theories of communities of practice and work-based learning.
Promote self-motivation and self-directed learning
Humanistic learning theories pose that adults plan, manage, and assess their own learning to accomplish self-actualisation and self-fulfilment. They are self-motivated, driven by their own values and goals, and seek independence in their learning. The RACGP recognises that competent GPs are self-aware and can identify and address their learning development needs to ensure patient safety.6,7 Supervisors and medical educators are seen as facilitators of learning.5 Sociocultural theories support the role of supervisors, noting that learners develop their values, beliefs and problem-solving strategies through collaborative dialogue with a range of senior colleagues in the context of a working community.
Self-directed learning is a central theme of the RACGP curriculum and syllabus. Learners are diverse, with different experiences, understandings, strengths and weaknesses. A one-size-fits all approach will not suffice. The 42 units of the curriculum and syllabus enable learners to self-identify their priority areas of learning in accordance with their unique experiences, personal needs, and the needs of patients and the community that they work in. Supervisors support learners through facilitation, discussion and guidance.8
Support supervisors to provide scaffolding, enabling contextual and situational learning
In real-life medical practice, clinical situations are rarely neat, typical or standard. GPs are frequently faced with situations that are complex and poorly defined. Understanding and working within this ‘messiness’ of professional practice is at the heart of professional expertise.9 Being able to learn in this messy environment is crucial to being able to practise within it.
Dornan et al. noted that clinical teaching for the 21st century is not about teaching, it is about supporting students to learn from real patients within clinical practice.10 Learning and knowledge construction are facilitated through interaction with an authentic environment.4 Situativity theory proposes that knowledge, thinking and learning are situated in experience.11
In line with sociocultural and work-based learning theories, general practice training provides opportunities for learners to learn from their clinical patients through a supported apprenticeship model. GP learners are ‘workers’ within a practice community. They are situated within the culture of their learning environment and need to construct meaning with other participants in the environment. Using real patients for learning allows learners to link prior learning to memorable patients to reinforce, consolidate and contextualise what has been learnt.10 Positioning learners as meaning makers and constructors of knowledge within their environment is central to promoting how learning through clinical practice might best progress.12
Development of expertise in clinical medicine requires more than a collection of knowledge and skills.13 It could be argued that a modern general practice expert is someone who knows how to access knowledge efficiently and can form conceptual links between seemingly unrelated areas. Learning how things are interconnected is often more useful than learning about the separate pieces. This expertise is best gained from experiencing the complex interplay between the physical and social contexts in the real-life clinical setting.14 Expert performance is a complex integration of knowledge and skills that are appropriate to the unique situation that learners face.13
The curriculum and syllabus uses common case scenarios and learning strategies to maximise contextual learning. Case scenarios focus on presentations, not diagnoses, and consider all aspects of general practice. In using case-based learning, the syllabus presents cases that are authentic (based on real patient stories), involve common scenarios, tell a story, are aligned with defined learning outcomes, have educational value, stimulate interest, create empathy with the characters, promote decision-making and have general applicability.15 The curriculum and syllabus also uses ‘what if the patient was x or y’ questions to prompt learners to consider the broader context in which the cases apply.
Contextually relevant learning for general practice cannot be achieved without learners crossing the ‘threshold’ of learning within the general practice environment, which is complex and often uncertain. As learners enter general practice, they might feel a sense of discomfort, as they do not understand the context of the new situation they find themselves in.16 To be able to enter this complex environment and develop new contextual knowledge requires scaffolding. Scaffolding refers to guiding learners through the volume and complexity of knowledge required.5 Supervisors are able to guide learners, introduce new ideas and language, and provide perspective to the context. The curriculum and syllabus supports supervisors by identifying learning outcomes and suggesting activities or questions to consider to assist with scaffolding. In this way, learners will be able to step over the ‘threshold’ into the new learning of the general practice environment and, with the help of supervisors, take their place in the community of practice.5
Promote a deeper approach to learning through reflection and development of evaluative judgement
General practice training provides repeated exposure to the complexities of clinical practice. However, experience alone is not sufficient for learning to occur. Formal theoretical knowledge and experiences must be critically applied, interpreted and integrated into existing knowledge structures to become new or expanded knowledge. Reflection and discussion are crucial for this active process of learning.17 Furthermore, reflecting on experiences of participation helps learners understand the scope and complexity of illness and disease and link theory with practice.10
Transformative learning theory explores how critical reflection can be used to challenge and change – or transform – a learner’s beliefs and assumptions through the process of problem-solving.5 It is proposed to have three stages: (1) reflecting on previous perspectives about a clinical issue or event, (2) engaging in critical evaluation and self-reflection on the experience, and (3) taking action about the issues, which leads to a transformation of meaning, context and longstanding propositions.4,5
Critical reflection is not necessarily a natural or intuitive ability; it needs to be developed.18 The curriculum and syllabus supports guided reflection to maximise the learning opportunities from this exposure through examining or auditing previous professional experiences to avoid repeating past errors, identification of learning needs or areas for improvement, identification of alternative methods of approaching complex situations, the use of small group and supervisor discussion and the collection of evidence of new learning.
Reflection can occur in response to new or complex problems; reflection can also be used when anticipating challenging situations.19 The curriculum and syllabus offers potential questions or challenging situations that learners might face in their clinical practice to encourage reflection on these situations, even prior to them occurring. Reflection is often not fully realised without the support of another person, either a supervisor, colleague or peer.17 Supervisors and peers play a role in helping learners make sense of their experience, through key counselling and mentoring skills, such as non-judgemental questioning and acceptance of differences.17 The curriculum and syllabus provides reflective questions that can help guide this interaction.
It is hoped that deeper learning and reflection can build evaluative judgement capability in learners. Evaluative judgement is the capability to make decisions about the quality of one’s work and that of others.20 Clinicians use evaluative judgement to determine what quality practice is, if their practice is at the necessary standard and whether they need to invest in further learning. It is a key part, therefore, of the self-monitoring required for working without supervision.21 Strategies that are considered to improve learners’ evaluative judgement include giving learners opportunities to discuss standards of care, the integration of peer feedback, how work does or does not meet standards of care, feedback on clinical skills, questions to guide reflection and the opportunity to witness exemplary behaviour.20 These strategies have been incorporated into the curriculum and syllabus.
Promote social learning from and within communities of practice
Humanistic learning theories focus on the individual, rather than the influence of culture and social structures on learning.5,22 The curriculum and syllabus supports independent self-directed learning; collaborative learning with supervisors, colleagues and peers; and sociocultural learning, with the learner becoming part of a community of practice.23
GPs and doctors on their journey to RACGP Fellowship work within communities of practice.11 In progressing to become a Fellow, doctors participate within communities of practice, undertaking the work of caring for patients. As they progress, they take on greater autonomy under the direction of one or more mentors or supervisors. Adopting a community identity in order to become a part of the community is an important step.11 The importance of belonging to this community of practice should not be underestimated,23 and the curriculum and syllabus supports the development of this social connectedness by encouraging learning with the support of supervisors, other practice staff and peers.
Promote all the expectations, values and principles required of an Australian GP
The RACGP has identified five domains of general practice that highlight the breadth of competencies required of a GP.6 To ensure that the curriculum and syllabus is comprehensive, all five domains of general practice have been integrated throughout. For example, effective communication is essential for improving patient health outcomes.24 Communication and the patient–doctor relationship is Domain 1 of the RACGP curriculum and syllabus. Strategies to support teaching and learning of communication skills have, therefore, been interwoven throughout the curriculum and syllabus. Similarly, ethical, professional and legal behaviours have also been integrated into the curriculum and syllabus. These competencies are best consolidated within the clinical environment, not separate to it. Asking trainees to record, role-play and discuss incidents that have ethical and professional implications is crucial to the development of this skill.5 This is reflected within the curriculum and syllabus.
Provide a framework to support coaching of learners
Supervisors and educators are a key part of general practice training. However, being a skilled clinician does not automatically make one a skilled educator. Supporting, guiding and teaching learners can be challenging, especially when this is competing with the demands of clinical practice. The curriculum and syllabus aims to support supervisors and educators in their teaching role.
Learners change their approach to learning as they develop expertise, shifting from expecting their teacher to provide information, to seeking support in translating knowledge into practice with an understanding of the context. This change in focus is important for developing confidence in coping with uncertainty.25 The syllabus uses guided questions, suggestions for feedback, words of wisdom and learning strategies that aim to use the supervisors’ expertise and understanding to help trainees apply their knowledge and deal with challenging and uncertain situations, rather than expecting supervisors to be the transmitters of knowledge.
The capacity to coach is now understood to be an essential skill of a teacher.26 Coaching is more than mentoring, in that it includes responsibility for the learner’s progression. This involves active feedback, both corrective and affirming, with the aim of enabling the learner to achieve their full potential.26 There is no one right way to coach a learner. It is both learner and coach dependant.27 The curriculum and syllabus supports this individual, tailored coaching, allowing the supervisor and educator to work with the learner to focus on the questions, strategies and areas that align with the learner’s learning needs.
Inform the assessment of learning
The curriculum and syllabus, along with the Progressive Capability Profile of the General Practitioner, provides the competencies and their indicators for blueprinting the RACGP assessments from entry to general practice Fellowship pathways, including selection, through progressive and workplace-based assessments, to Fellowship exams. The curriculum and syllabus provides comprehensive detail and rationale for the topic areas and content that will be assessed. It offers approaches to learning, and curated resources relevant to the content to assist learning. The case consultation examples within the curriculum and syllabus have been designed to demonstrate how the RACGP clinical exam assessment areas can be applied to a clinical scenario. The curriculum and syllabus has been developed and extensively reviewed by those involved across the full scope of Australian general practice, and is the basis for the development, writing and delivery of all RACGP assessments.