Leaders in Medical Education

Dr. Anthony Llewellyn, Medical Director of HETI

Osmosis Team
Published on Aug 27, 2015. Updated on Invalid date.

Dr. Anthony Llewellyn commenced as Medical Director of HETI in September 2012. Anthony’s background is as a Consultant Psychiatrist and Medical Manager with 15 years’ experience as a medical practitioner in public health services in a range of roles. He has established successful partnerships across medical administration and medical training groups to improve both educational and practical workforce outcomes. Anthony’s role in HETI is to lead and support excellence in postgraduate medical training in NSW public health services and organisations and specifically lead and support the Medical Portfolio of HETI.

Anthony is strongly committed to ensuring that the educational outcomes from medical training relate to service improvement and have a measurable outcome for patients and family. Anthony has a passion for improving on medical training in the particular areas of generalist skills and rural and remote health.

How did you first become interested in medicine and what led you towards psychiatry as a specialty?
That’s an interesting question. I suspect that my response is partly typical and partly atypical for someone of my generation. When I was still going to school in Tasmania in the 1980s most of us really only had one ambition after finishing which was to go to the local University of Tasmania. Going interstate to another university didn’t really occur as an idea.

Medicine was a pretty desirable course to get into (not much has changed) and I was pretty competitive by nature so that was definitely an influence. But the opportunity to mix up science and humanities was probably the biggest influence. I liked science at school, but I also liked subjects like english, history, legal studies and in particular a subject that was called social psychology (a mix of psychology and social sciences).

Even then, I was heavily attracted to human behavior as a field of study. So, my ambition going into medical school from the outset was to become a psychiatrist. Medical school for me was a process of experiencing all the other disciplines and eliminating them and reconfirming psychiatry as a career choice. I found this quite challenging, as my medical school was very traditional at the time, relied on a lot of rote learning, fundamental science and disconnected programs of learning. Luckily there was a fair bit of psychiatry related material weaved through the various years of the course to keep me interested.

One interesting observation that I would make about this period is that despite being clear about my intentions to my classmates it was interesting how often one of them would express surprise about my ultimate career choice. Comments like: “why would you want to do that?” or “I didn’t think you would want to be a psychiatrist!” were typical. I now understand that these comments were probably more about them and working through their own stigma issues than me.

As I say the main reason I think I chose psychiatry as a specialty at the time was (and still is) my interest in human behaviour, how people think, what motivates people and what makes people decide to choose one course of action over another etc… The second attraction was working in an area of stigmatization and inattention and working with patients who I felt a true empathy for.

Your education and experience covers health care from clinical, administrative, and educational perspectives. Can you share your background on how you got to where you are right now? Was there a specific catalyst that propelled you from the clinical side of medicine to becoming the Medical Director of Health Education and Training Institute NSW?
As I say I did my medical school at the University of Tasmania, in between final year medicine and internship (at the Canberra Hospital) I took a year away from medical studies to be the President of the Tasmania University Union Inc. I was the first medical student to ever get elected to this position and I learnt a lot of skills during this year such as: advocacy, negotiation, decision making, managing staff and organizations, governance, managing budgets. I learnt many skills during this time, which were invaluable when I went back to medicine.

When I finished my year as President there were more medical graduates than internships on offer in Tasmania so I decided to take up a position in Canberra where I managed to track down the only term in psychiatry. I didn’t really like living in Canberra and I met a few nice people from Newcastle whilst I was there so I decided to move there and spent the next 13 years or so initially working as a Resident then getting into the local psychiatry training scheme and undertaking my Fellowship and then ultimately taking on a Consultant Psychiatrist role in the service. I never regretted the decision to move to Newcastle it’s a great place to live, work and train.

Psychiatry is an area where there are generally not enough doctors and Newcastle was no different at the time. A few of the other Registrars (trainees) decided that there was an issue with this and we eventually got a bit political about it. Ultimately it became a situation of the management saying: “well if you don’t like the roster and the job gaps what are your suggestions?” This led to me taking on a part-time role as a trainee doing some Medical Administration jobs. Initially I was just spending time recruiting more doctors to fill positions in the service and I got quite good at that. Everyone was pretty happy because all of a sudden we were filling the positions and the overtime roster was less of a burden.

The General Manager of the Mental Health Service decided to invest in sending me to a one-week Management training course where I did my first 360 review and learnt about the Situational Leadership model. Both tools and approaches I still use today.

This new knowledge led me to getting involved in more management roles so that when I completed my Fellowship I was already doing the Manager of Medical Administration role and was doing clinical psychiatry part-time. Eventually I moved into other full time Medical Manager roles and with a few other colleagues set up a combined Medical Administration / Medical Education unit for my service that has been a model for other services.

I find I like to work on the big picture and make strategic links so the transition from clinical medicine into the management world made sense for me. Eventually the opportunities to take on bigger roles in my local health service got a bit limiting and the HETI job popped up. Having only been really indirectly involved in medical education up until that point I wasn’t really sure that I was going to be successful in the role but the job description was as much about managing and improving the strategic outputs of programs as being a medical education expert so I decided to apply and luckily I got the job, which I am really glad that I did as it given me a new challenge to work on and re-ignited my passion for improving health care systems.

You have been involved in developing onthewards.org, an educational platform aimed at improving the availability of resources for generalist junior doctors. How do you see dynamic online platforms like Osmosis and onthewards being integrated with medical education now and in the future?

(*note correct spelling of onthewards)

onthewards came about from a chance discussion that I had with another colleague, James Edwards, that I met during my work at HETI. Its one of the many good things about the HETI job, lots of people come to you with ideas that they have related to medical education. I’ve being making websites as a bit of a hobby for a while and James, who is founder of onthewards, as well as Evangelie Polyzos, COO, wanted some advice about getting a company to develop a site for them to put up a whole lot of really good quality podcasts they had made about junior doctor issues onthewards.

It seemed like something I could probably set up for them and we weren’t sure whether it would take off, so we decided to go down the now well-worn #FOAM pathway because an attractive part of the model is the low infrastructure cost. Our unique value proposition was that we were providing Free Open Access Medical Education to ward-based doctors whereas most of the other #FOAM sites are more aimed at the trainee or Consultant level.

We’ve been amazed at how well-received our site is. Its only been going for less than a year but we now get thousands of hits per month and I keep running into interns and medical students who tell me about this fantastic site called onthewards. I think the secret is that its providing learning that’s relevant and unique and very accessible to the learner (we now have an app where you can even download the podcasts and listen to them disconnected from the internet when you want), we have plans to get a bit more dynamic and interactive and even potentially social. The site is probably not for every junior doctor or medical student but no learning modality ever will be.

The ongoing challenge will be keeping it fresh and relevant and getting more feedback about what’s useful and what’s not so useful.

I think dynamic learning platforms will inevitably become more and more integrated with medical training into the future because they are learner driven and learners are prepared to support them with either donations (in the case of #FOAM sites like onthewards) or subscriptions (in the case of platforms like Osmosis), if learners find them useful and they support outcomes like passing relevant or keeping up to date then the learning institutions will have to adapt to them being used and many already are.

You’ve noted a research interest in “Personalized Learning Environments”. Can you briefly expand on this concept and its potential to alter the course of medical education delivery?
One of the risks of online learning is that it becomes all about individual learning. I’ve had a look at Osmosis and clearly your team has recognized this as a problem and done some clever things to mitigate against this.

There are many theories about what’s the best way to deliver medical education. One theory is about how knowledge is imparted and constructed. I believe that we construct our own knowledge as a medical professional within what’s sometimes referred to as a “community-of-practice”, i.e. what we come to accept as true in medicine is partly based on what our trusted colleagues also believe to be true.

One nice consequence of this model is a freedom to understand that there are very few, if any, incontrovertible facts or truths in medicine, a way of dealing with ambiguity if you like. Which I think makes a lot sense when you think about evidence based medicine being about bringing “the facts” as they are currently understood to the individual needs and situation of the patient.

Personalized Learning Environments (PLEs) are a relatively new concept in education and there are many definitions of them. The idea has obviously come about because of some of the new emerging digital education and social technologies so many of these definitions are about the technology side. The ones I like are more about how the concept sits within a framework of social learning.

What is a PLE? Its really just a way of looking at the tools and resources that the learner has constructed for themselves to aid their learning. As an example one trainee might rely on a Harrison’s textbook for deep knowledge about disease mechanisms, whereas another might use Wikipedia. The same trainees might use a physical notebook versus Evernote for tracking their summaries and one might go to the library to review old exam questions whereas the other goes online to a site like Osmosis to test their learning retention. One trainee might use twitter to keep up with their social network (community of practice) another might prefer facebook.

PLEs offer the opportunity to make us more efficient in our learning if done well. But here’s the trick, learners don’t always necessarily understand the best approach or best bang for buck in learning. So informing learners about which tools are useful for what is going to be really important into the future and encouraging them to also link their PLEs into a good community of practice will help to ensure that what they are learning is consistent with what others are learning.

Psychiatry can be a difficult specialty to recruit into for some countries. What do you see as the biggest barrier for recruiting junior doctors into psychiatry? What do you see as the most promising strategy to overcoming this barrier?
In one word: “stigma”. This issue is surprisingly well researched and a lot of papers point to this being a key problem. I mentioned this earlier. Its seems weird initially that many intelligent medical students and doctors can hold such illogical and incorrect ideas about mental illness but that’s what the research shows and when you understand that stigma is more about unconscious than conscious thinking it starts to make sense.

What can we do to counter this? Actually quite a lot. The research shows that you won’t change the views of those already set in their ways but depending on what study you look at there are about 5-10% of medical students or doctors who are “open-minded” to psychiatry. Basically if we talent manage this group, by giving them enough exposure to good learning experiences in psychiatry we can eventually get the right amount of doctors to train in this area. There’s a group at the University of Maryland that have been doing this for decades. We basically replicated their approach about ten years ago in the HNET (Hunter New England in Psychiatry) program and it works.

What are some changes you would like to see in the current Australian medical education system and healthcare system?
The big topic in medical education in Australia currently is internships. We are partway through a national review and I’m hopeful that a lot of good things will come out of this.

The main opportunity I see here is a possibility to better integrate the medical training continuum in Australia by bringing those in the medical school space, prevocational training space and college training space closer together around the intern space.

On the ground this makes a lot of sense because its often the same people who are teaching the medical students, who are also supervising interns and supervising registrars (trainees).

In relation to the overall Australian healthcare system, I think it’s important to recognize that we have one of the best healthcare systems in the world. I do not necessarily think we need to make major changes to it. Coming back to medical education it would be good to see higher value placed on the clinical supervisor and clinical teacher role in our system than we currently have. At the present the overall system tends to reward the good clinicians and a small group of doctors doing research at the elite level and teachers, supervisors and others doing research are below this.

Do you have any final thoughts regarding the medical profession as a whole?
I think it is always important to remember why we are here in the first place and how we get things done. Its amazing how many conflicts about issues going on in health services are resolved when we have a meeting and pause to ask the question “is this the best way of caring for patients” and “are we truly working as a team.”

As doctors we remain privileged within the system. With privileges comes responsibility. As I see this a couple of these responsibilities are: 1. to remain connected and responsive to advocating for our patients, not just on an individual case basis, but as part of a system that is continually asking whether we are patient (or consumer) focused. And, 2. to be respectful in our role in the teams we work in and to understand how our behaviour is sometimes received by other members of our team, very often we communicate with each other as doctors using a style of language and communication that challenges ideas and concepts, this style is often seen by other professional groups as aggressive and disrespectful.