Luminary Learning Gastrointestinal Disorder- Issue 1

58  • LUMINARY LEARNING: GASTROINTESTINAL DISORDERS as nursing staff, and creating spaces where concerns can be voiced (Edmondson, 2012). Being able to speak up is related to the climate of learning environments (Boor, Van Der Vleuten, Teunissen, Scherpbier, and Scheele, 2011) and the approachability of clinical supervisors (Boor et al., 2008), which influence willingness to seek support when help is needed (Kennedy, Regehr, Baker, and Lingard, 2009) and ask for feedback (Bok et al., 2013; Teunissen et al., 2009). When viewed through a lens of ‘feeling safe to speak up’, the harassment and intimidation that is regarded as legitimate and of educational value in surgery (Musselman et al., 2005), ‘pimping’ by clinical supervisors (Brancati, 1989; Kost and Chen, 2015), ‘tense’ communication in ORs (Lingard, Reznick, Espin, et al., 2002), and witnessing rude behavior (Flin, 2010; Porath and Erez, 2009) are threats to learning and safe practice because they inhibit a workplace culture of speaking up. These factors influence the internal tension providers face when faced with choosing ‘voice’ over ‘silence’ (Eppich, 2015). As an example of how social milieus contribute to communication breakdowns, we explore some factors that impacted the activation of rapid response teams (RRTs) in four Australian hospitals (Kitto, Marshall, et al., 2014). RRTs are comprised of physicians and nurses who provide expert support to colleagues when a patient’s clinical status deteriorates. In one-third of patients whose clinical status warranted RRT activation, issues of hierarchy between treating physicians and nurses, discrepant perceptions about who makes ultimate decisions, and barri- ers to interprofessional communication prevented RRTs from being called (Kitto, Marshall, et al., 2014). The opposite also occurred: nurses activated RRTs as ‘work arounds’ to compensate for breakdowns in collaboration with doctors. Together, those two types of shortcomings repre- sent collective incompetence (Kitto, Marshall, et al., 2014). Unfortunately, however, the domi- nant discourse of competence is an individualistic one, which deflects attention from relational issues like power dynamics or inability to adapt collaborative strategies to new or changing situations (Lingard, 2012). To summarise, this section shows that learning to become a doctor is more than just acquir- ing knowledge. Learning and doing are part of the same process (Teunissen, 2015), and participat- ing in authentic patient care within the social context of healthcare teams is essential for learning. Shared activities in these social contexts are structured through verbal and non-verbal commu- nication (Lingard, Reznick, DeVito, and Espin, 2002) enacted during work activities. Thus, talk is the vehicle to co-construct the meaning of shared experiences and is central to learning from practice. Now that we have explored the role of talk in learning, we turn our attention to the current state of continuing professional development. Section II: The Current State of Continuing Professional Development After completing residency and subspecialty training, doctors become independent licensed prac- titioners alongside nurses and other health professionals. Doctors must, however, participate in educational programs for the rest of their careers. Continuing professional development (CPD) helps them acquire and maintain specialty-specific knowledge and skills, which meet the needs of their patients (Peck, McCall, McLaren, and Rotem, 2000). Participation in approved programs of CPD allows them to remain licensed (Sole et al., 2014), maintain their specialty certification