Arch Dis Child 1999;81:531–534 531

PERSONAL VIEW

Education and personal development: a reflection

C Mark Taylor

The practice of medicine implies life long

learning, and the modern health service
expects career grade doctors to engage in a Question
programme of continuous professional devel-
opment.1 Doctors are a highly motivated
group, and so the expectation that they will
participate seems well founded. For those in ∆Knowledge Information
the training grades, professional development
is supervised and made explicit within post-
graduate medical education and training.2–4
Seniors have traditionally planned their profes-
sional development unassisted and in isolation. Assimilation
Most manage this with ease and confidence,
moved forward by the day to day challenges of
clinical practice, health service management, Figure 1 The education cycle (Ä represents change or
teaching, and research. However, a few do too confirmation of).
little in preparing for the changes of their
working lives, and as a result are resistant when
confronted with new ideas or novel ways of out of context is usually unmemorable. In step
doing things. 3, new information is assimilated, processed,
In responding to the needs of a patient, a and given a value, which in turn leads to a
doctor draws upon all of his or her wisdom and change in knowledge. Old concepts are either
life experiences. These resources far exceed the reinforced or altered, sometimes radically. It is
confines of medical knowledge or transferable a one way process. A well accepted or success-
clinical skills. For doctors, professional con- ful expansion of knowledge is likely to spark off
duct, core beliefs, and personal integrity are the next question, and so the cycle repeats. For
inextricably interwoven.5 This being the case, this reason the two dimensional image of
professional development is contained within learning is inadequate and many would prefer
personal development. Personal development to describe education as an expanding spiral,
is part of the process of life long learning and taking the learner through ever widening
follows basic educational principles. It shares horizons.8
with education a common philosophy, ethical Confirmation of a previously held view is a
frame work, and psychology, as well as practical valid end point of learning. Education, how-
components. This article reflects on the ever, has the power to change the perception
commonality between the two, with reference
and knowledge of the individual, and therefore
to the needs of senior doctors. The parallel
has an ethical dimension. In general, one
helps to make the learning processes of
personal and professional development more regards the process of learning as honourable
explicit, and allows us to see where compo- and empowering; knowledge is universally
nents such as reflection, mentoring, continu- thought of as a good thing. However, changed
ous medical education, and appraisal fit in. perception can be hard won, even painful.
Anybody at a particular time may find neutral,
unsolicited external information to be intrusive
The education cycle
or harmful. All teachers, including the educa-
Education begins by asking a question (fig 1).
This entry step into the cycle is crucial in a tors of apparently robust senior doctors, need
number of ways. First, learning is facilitated to work sensitively with the “crooked timber of
The Education Centre, when the process is initiated and owned by the humanity” (see appendix).9 Nevertheless, by
The Birmingham learner. This concept is at the heart of andrag- taking responsibility for the reflective, ques-
Children’s Hospital, tioning entry step into the cycle, the mature
Birmingham B4 6NH,
ogy, the theory of so called “adult” learning.6 7
Taking personal possession of an inquiry learner is better able to adapt to the changes
UK
C M Taylor demands that currently held knowledge is that will follow. In doing so, permission is given
re-examined and its boundaries and limitations to undertake the risk of change. This philo-
Correspondence to: defined. Internal reflection prepares for step 2, sophical educational point comes into sharp
Dr Taylor
email: cmtaylor@
the collection of external, objective infor- focus when applied to personal development
[Link] mation, and puts it into context. Information and the role of appraisal.
532 Taylor

•Mentoring by teachers. Moreover, there is a hierarchy

•Buddy system within intrinsic motivation.12 The motivation of
•Computer system
loyalty to a colleague, or the sense of belonging
to an organisation, ranks below that of self
esteem. Higher again is “self actualisation”, the
Reflection need to know, understand, appreciate, or
(internal)
•CME
create. In practice, people are driven by various
Measurement •Appraisal internal and external pressures all at the same
∆Performance Objectivity
(external)
•Self-directed time. This analysis is well reviewed by Rogers13
learning
and is as relevant to personal development as it
is to education.5 Intrinsic, high level motivation
Assimilation
will be promoted if the individual finds that the
investment in learning or development is
personally rewarding, creating a positive feed-
Figure 2 The personal development cycle and its relations back loop.
(Ä represents change or confirmation of). Probably one of the greatest blocks to
personal development is that the crucial entry
Personal development step demands time for reflection; not a
Personal development too can be seen as a generously available commodity in today’s
cycle or spiral (fig 2). The similarity with edu- health service. Personal reflection therefore
cation is striking. Both are entered through a needs to be built into the time table of work.10
process of internal analysis, reflection, and It also needs to be structured so that there is a
questioning.10 In the same way that the learner comprehensive assessment of past progress on
uses this step to take responsibility for any which to consider future needs. Check lists are
change in knowledge base, in personal develop- available to assist with this process and some
ment the individual gives authority for the have been adapted to computer programmes
changes that will occur in performance and such as XXEN (3E Development Ltd, Cam-
attitude. Personal development can be encour- bridge, UK). Not everybody will follow the
aged and assisted, but because it has the same approach. Some will find the reflective
potential to alter self perception and outlook, process to be enhanced by maintaining a
those who would facilitate the process in others personal diary, portfolio, or a log.14 15 Some will
need to do so within ethical constraints. benefit from contact with a mentor, a senior
The second step in personal development colleague whose experience and wisdom ex-
deals with external information, just as it does tends beyond the person seeking guidance.16
in the education process. This includes infor- This relationship might be particularly valu-
mation sought out by the individual, such as able for newly appointed consultants. Others
critical reading, as well as formal, collective will find that their thinking is facilitated by dis-
activities, such as the rather didactic events of cussion with peers in the same speciality; a one
some present day continuous medical educa- to one “buddy” system or a small group meet-
tion, advanced practice, or management train- ing of equals. Having to voice one’s thoughts to
ing. Importantly, objective feedback on current another sympathetic and trusted colleague
performance and appraisal belong here. It is clarifies thinking and injects reality.
not the purpose of this article to comment in
detail on senior medical staV appraisal, but Measurements
illustrative points can be drawn from the Educators have agonised over the most appro-
education cycle analogy. The purpose of priate ways of measuring the educational
appraisal is to provide information that is valu- process. Whereas it is relatively easy to quantify
able to the person in terms of growth and teaching activity, assessing the extent of knowl-
maturity. It should not be confused with edge is complex. It is even harder to determine
assessment, which is a measure of performance the true output of the education process—that
against a standard. From time to time, is, reinforcement or change in knowledge base.
appraisal is bound to show up weakness in a The Royal Colleges set entrance examinations
person that he or she may find diYcult to deal for membership or fellowship, but after that they
with. If the initiative for appraisal remains with use easily quantifiable activities, such as time
the mature learner, to pursue the andragogic spent in recognised continuous medical educa-
analogy, these diYculties are more likely to be tion as a surrogate for measured progress. This
overcome, and appraisal seen as a productive misses the point. There is evidence that attend-
activity. ance at continuous medical education meetings
per se does little to change the performance of
Promoting personal development consultants, unless it is linked to practice
How can the important self directed entry into reinforcing strategies.17 18 Re-examining the
personal development be promoted? Within knowledge base of consultants at intervals would
education the necessary motivation has been be a huge and costly exercise that might define a
explored and described in terms of extrinsic standard, but not show whether they had
and intrinsic factors.11 Extrinsic factors—for progressed in their performance to match the
example, might come from cultural pressures demands placed upon them. Similar diYculties
within the health service: obligation or reward; occur in attempting to measure personal and
a mixture of sticks and carrots. Intrinsic factors professional development.
are generally more eVective and durable than Can changes in performance be measured in
extrinsic ones, and are thus rated more highly the personal development cycle? As far as the
Education and personal development 533

individual is concerned the answer is “yes”. generic form, could be developed for specific
Each cycle re-engages the process of reflection groups of colleagues to assist in both reflection
and self analysis (fig 2). There is an examina- and the documentation of their development
tion of the progress made and an acknowledge- plans.
ment of any failures. By keeping a written These are radical proposals and they deserve
record of one’s personal development, and widespread and critical debate. Ideally, they
therefore not trusting to fickle memory, a clear should be adopted only after careful evaluation
picture emerges. Most people will be far more and with supportive evidence. The immediate
judgmental about themselves than would an political pressure to do something now to dem-
external agency. onstrate consultant performance is a stimulus,
In the present political climate, clinical but must not be used as an excuse for omitting
practice is under scrutiny, and an assurance of the necessary research. Any enforcement of
quality is demanded. Self regulation of the unconsidered or valueless regulatory schemes
medical profession and the measurement of is likely to damage the very self motivation on
consultant performance have become conten- which professional development depends.
tious issues. Counting continuous medical edu-
cation activity might placate those who demand Conclusion
tighter regulation, but not for long. Self man- Personal and professional development operate
aged records of personal development are in a similar way to education, have similar end
appropriate and potentially far reaching meas- points, and are encompassed by the same ethi-
ures, dealing with real end points of the process cal framework. This insight illustrates where
and preserving motivation. Although some of mentoring, formal continuous medical educa-
this information is private and would not be dis- tion, and appraisal belong. The individual doc-
closed, a component dealing with professional tor maintains motivation and responsibility for
matters might become a valuable public meas- the process by engaging the cycle through
ure of the good standing of a doctor. Will the reflection and self analysis, the essential entry
medical profession adopt this approach? If so, step. The Royal Colleges have a vital role in
can it be done, researched, and tested in time to researching, advising on, and promoting per-
assuage those who think that regulation belongs sonal and professional development on behalf
outside the profession altogether? of their members. Self maintained records of
personal development might be the best way to
Where do we go from here? facilitate and demonstrate the professional
Professional development is an integral respon- advancement of career grade doctors. Al-
sibility for doctors at all levels of seniority, and though the immediate benefit will be to the
safeguards the quality of health care. Much can doctors who undertake it, personal develop-
be done to make the process explicit and attrac- ment can only support quality assurance. This
tive. It is helpful to see it primarily as an may be the way for the medical profession to be
educational process, and part of the holistic regulated.
development of the doctor. The analogy with the
principles of adult learning emphasises the Appendix
importance of the individual’s motivation and In his essays on the history of Western thought, Isaiah
the need for reflection. However, this needs to be Berlin draws out the plurality of two world views. One,
supported at many levels, by clinical directors, the academic approach, is based on the idea of a single
external verifiable truth, sought out and applied by
trusts, and by the postgraduate deans. The experts. This is in continuous tension with personally
Royal Colleges have a vital role. For example, held internal truths, based on the unique experiences of
within the academic board of the Royal College the individual, from which derive idiosyncratic powers
of Paediatrics and Child Health, the subcom- of originality and creativity. Modern society and its citi-
mittee for continuous medical education has zens live within this tension. Here lies the debate about
now been renamed the subcommittee for how much doctors should be assessed and controlled, or
operate with clinical freedom.
continuous professional development. The
change in title is important, indicating that its
Although a personal view, this article is submitted on behalf of
remit has moved on. The bean counting exercise the members of the Royal College of Paediatrics and Child
recording hours of teaching can be seen as Health subcommittee for continuous professional development,
who provided valuable criticism both in discussion and at the
politically necessary but a temporising solution. draft stage. They are Professors I Booth and M Weindling, and
The Colleges have much higher responsibilities Drs M Little, J Sheild, G Soulby, and A Thomson. The author
is also grateful to Dr D Wall, Mr D Morley, and Dr MH Taylor
to their fellows. They are in the business of pro- for useful suggestions. Special thanks are accorded to Dr Z-J
moting what one might call evidence-based Playdon for her good counsel in matters of education and
professional growth.
education—that is, educational methods that are
confirmed in their ability to improve the 1 Good medical practice. London: General Medical Council,
outcome of learning. Giving positive feedback— 1998.
for example, is a well tested way to motivate and 2 The new doctor. London: General Medical Council, 1997.
3 The early years. London: General Medical Council, 1999.
to change the learning outcome in an adult.19 20 4 A guide to specialist registrar training. The orange guide.
London: Department of Health, 1996.
How this, and other components of appraisal, 5 Fox RD, Mazmanian PE, Putnam RW, eds. Change and
can be developed alongside clinical practice are learning in the lives of physicians. New York: Praegar, 1989.
6 Knowles M. The modern practice of adult education. Andragogy
important considerations for those leading the versus pedagogy. Chicago: Follett, 1980.
profession at this time. Mentors could be trained 7 Brookfield SD. Understanding and facilitating adult education.
Milton Keynes, UK: Open University Press, 1986.
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systems researched. Methods and skills in self medical curriculum: a whole that is greater than the sum of
its parts. Med Educ 1997;31:264–71
analysis can be taught or written about. 9 Berlin I. The crooked timber of humanity. London: Fontana,
Computer programmes, already in existence in 1991.
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10 Continuing professional development for doctors and 16 Oxley J, ed. An enquiry into mentoring. Supporting doctors and
dentists. A working paper of the standing committee on dentists at work. Standing committee on postgraduate medi-
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CORRECTION

Patterns of care and survival for children with acute lymphoblastic leukaemia
diagnosed between 1980 and 1994

Stiller CA, Eatock EM. Arch Dis Child 1999;81:202–8.

There were some data points missing from table 4 under the column headed “O” (After 2 years). The corrected table
is printed in full below.
The error is regretted.

Table 4 Survival of treated children categorised by age, sex, white blood cell count, immunophenotype, and Down’s syndrome status

5 year % All children First 3 months 3 months to 2 years After 2 years

survival
(SE) O E p Value O E p Value O E p Value O E p Value

Age at diagnosis (years)

0 37 (3.8) 107 61.6 < 0.0001 24 11.6 < 0.0001 58 32.8 < 0.0001 25 17.4 < 0.0001
1–4 81 (0.8) 584 738.9 75 80.2 163 231.1 346 427.5
5–9 74 (1.2) 433 422.7 36 50.5 162 160.6 235 211.6
10–14 61 (1.7) 363 263.8 47 39.7 156 114.6 160 109.5
Sex
Male 73 (0.9) 919 837.6 < 0.0001 94 105.8 0.064 323 313.8 0.40 502 418.5 < 0.0001
Female 77 (0.9) 568 649.4 88 76.2 216 225.2 264 347.5
White blood cell count (×109/l)
0–49 80 (0.7) 928 1068.7 < 0.0001 102 116.0 < 0.0001 267 339.9 < 0.0001 559 611.3 < 0.0001
50+ 57 (1.5) 518 377.7 72 59.4 260 183.5 186 134.3
NR 70 (4.2) 41 41.6 8 6.6 12 15.6 21 20.4
Immunophenotype
Common (incl. 81 (0.7) 847 971.6 < 0.0001 80 109.0 < 0.0001 213 315.1 < 0.0001 554 547.4 0.44
pre-B)
T cell 51 (2.1) 286 214.7 42 27.2 173 106.9 71 80.7
B cell 51 (5.9) 38 18.8 13 3.3 20 6.6 5 8.8
Null 56 (3.2) 120 107.4 17 19.2 63 51.6 40 36.7
NR 71 (1.9) 196 174.5 30 23.3 70 58.8 96 92.4
Down’s syndrome
Yes 57 (5.7) 39 15.6 < 0.0001 9 2.2 < 0.0001 15 4.8 < 0.0001 15 8.6 0.041
No 75 (0.6) 1448 1471.4 173 179.8 524 534.2 751 757.4

The expected numbers of deaths and log rank tests for each variable were based on a stratified analysis allowing for all four other variables.
O, observed deaths; E, expected deaths; P, two sided p value from log rank test; NR, not recorded.