Monthly Archives: October 2016

Teaching Multimorbidity – part one

About a week ago I read an interesting article in the August Journal of Comorbidity entitled: Training doctors to manage patients with multimorbidity: a systematic review http://jcomorbidity.com/index.php/test/article/view/87/308 Only two studies satisfied their criteria for inclusion and these were about Multimorbidity workshops.  One of the studies appeared to favour workshops over online modules but both studies were judged to be at risk of bias because of methodology so it is hard to draw conclusions apart from that more research is needed (noting the paucity of research in this area generally).  It is certainly challenging to conduct research and evaluation in this post-graduate context.

Multimorbidity is a clinical area of interest for me and one where I introduced teaching for GP registrars a while ago so I was motivated to look at this again. I thought that this blog should not just raise topics in medical education but could also introduce some ideas about teaching specific clinical topics given that different methods may be more appropriate to different disciplines. The issue of the teaching of the topic has emerged following the increasing recognition of multimorbidity as a growing challenge for the health care system, not to mention its funding.   At some point clinicians and educators started to realise that multimorbidity was more than the sum of its parts and this is very relevant in an era of sub-specialisation. Some educators are also concerned that GP registrars do not have adequate experience managing complex older patients so in 2014 I decided to trial and evaluate a specific teaching approach.  In the process we also looked at registrars’ clinical experience plus feedback from them and from supervisors about what is actually perceived as useful in GP training in this area.  We collected the usual routine feedback and evaluation data that you tend to collect as part of a commitment to quality improvement and augmented this with some specific questions about how the approach worked (because it was different).

In this, and a couple of other posts, I’ll look at

  1. A framework for a workshop program
  2. GP registrars and multimorbidity
  3. Practice teaching ideas and multimorbidity teaching overall

A framework for a workshop session

smily-face-stones

Given the pessimism around both managing and teaching multimorbidity, and my conviction that the negatives are somewhat overplayed, we took an optimistic and evidence-based approach which built on the co-morbidities already well-covered in training (eg hypertension, diabetes, hyperlipidaemia, chronic renal disease, COPD etc). We treated guidelines as a resource for clinical judgment but emphasised the primacy of being patient-centred.  This is overt in the guidelines from the American Geriatric Society https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4450364/  and is even more appropriate in general practice.  The structure was as follows:

  • We followed a Flipped Classroom model with pre-viewing of some online resources (links, powerpoints) on a blog site which had been set up previously for aged care, polypharmacy and multimorbidity. This introduced the concepts to registrars. It could also be accessed at any time after the session.
  • A conceptual matrix for thinking about Multimorbidity was presented briefly at the workshop http://www.bcregan.com/MM/ In later sessions this was presented just as a few powerpoint slides.
  • A specifically designed multimorbidity template (updated more recently) for management planning was used in small groups in order to work through registrar cases and / or pre-prepared cases.
  • Registrars completed feedback forms in order to evaluate the process and the usual feedback on achievement of Learning Objectives was completed.

The “matrix” model was presented at an AMEE conference in 2014. http://www.amee.org/getattachment/Conferences/AMEE-2014/AMEE-2014-APP-Data/10H-SHORT-COMMUNICATIONS.pdf It was used as a conceptual framework for thinking and learning rather than as a clinical tool and was an attempt at a 2D version of the multi-dimensional thinking and multi-tasking that goes on when managing patients with multimorbidity.  It was a reminder to think about:

  • The interactions between conditions, between medications and between conditions and medications
  • The knowledge gaps that might exist for the doctor
  • The relevant guidelines
  • Patient information resources
  • The patient perspective in negotiating management decisions (the most important aspect)

flowers3  flower-border villandry2

The matrix gave contrasting examples of “easy” and “complex” patients with five co-morbidities. In some ways it was an attempt to simplify complexity – but not too much – and add a conceptual framework to something that can appear random or chaotic.

Outcomes

These were reported on at the GPTEC conference in Hobart in 2015 Teaching multimorbidity is important, do-able and effective and requires a multi-pronged approach. multimorbidity-gptec-aug-2015

The feedback was positive. The small-group discussion was judged to be valuable and pre-prepared cases were the most useful.  The most surprising incidental outcome was that subsequent Learning Plans were noted to include several which (unusually) listed managing multimorbidity as a priority!

In this first twelve months the multimorbidity session was run separately for both Term 1 and Term 3 registrars.

    • 75% Term 1 and 50% Term 3 accessed the online resources prior to the session
  • Interestingly the overall package was evaluated more highly by Term 3 (an average rating of 4.7, on a scale of 1-5, in agreeing to the statement that The session (online resources, ppt and small gps) presented a potentially useful way of looking at patients with multimorbidity 
    • Learning objectives were evaluated after the sessions and, again, Term 3 were more likely to agree strongly that these were achieved (ratings of 4.1 to 4.6)
    • Both groups found the small groups helpful
    • Free text comments showed that the “patient-doctor agenda” focus had been appreciated and some new concepts were found to be useful.
    • Comments and ratings raised the issue of timing – whether the most effective learning in such a complex area occurs rather later in training after gaining some clinical exposure (and despite the fact that they were less likely to access the online resources prior to the session). This would be a good topic for future research. However, funding is focussed on Terms 1 and 2.

Given that most learning occurs in the practice environment we then turned our attention to that aspect. Meanwhile we continued evaluating the approach over the twelve months and monitored the registrars’ confidence levels.  We thought this was important because a lack of confidence is probably the first barrier that hinders initial engagement with the area.  Once registrars are engaged, and if not feeling too intimidated, we reasoned that they would identify learning needs and respond to them.  In addition, it is not a simple area in which to assess “knowledge”, and “effective management” is extremely difficult to measure.

I feel like a fraud….

AKA Impostor Syndrome

I was motivated to revisit this topic after reading an October 4th blogpost by  Anthony Llewellyn, a local Hunter psychiatrist involved in medical education for years.  The blog itself is https://icenetblog.royalcollege.ca/ and I heard of this from a post by GenevieveYates on the AMEN facebook page (are you on this group if you are an Australian Medical Educator?).  See, how social media can be informative?  You can also see interesting posts on Genevieve’s own blog https://genevieveyates.com/category/blog-posts/ .

When I started as a Medical Educator I experienced this syndrome and continue to do so! It’s comforting that it is common and I imagine some of the newer MEs experience it from time to time.  It was bad enough being the sole ME in the region and running workshops for registrars on topics about which I decidedly was not an expert – but at least I could read up beforehand.

However, the time I felt worst (and I know others have felt the same) was running workshops for Supervisors. They were very experienced GPs and were doing the difficult job of supervising registrars that I didn’t do myself.  When I started I had just moved from nearly full-time general practice to very part-time practice in order to do the education work so I felt I was perceived as a part-time, female, urban GP who also happened to be younger than most of the participants.  I could imagine where that placed me in the perceived medical hierarchy of credibility!  It hits also when in the same room as a bunch of other impressive educators.

There are also supervisors who admit to feeling that they are not really “teachers” even though they may be doing an amazing job quite intuitively. There are certainly medical students, newly graduated doctors and those transitioning to fellowed status who experience that feeling described as “not belonging” yet to a particular professional group, a bit out of their depth and thinking that perhaps those treating them as such are mistaken.  They might look the part but feel deep down that they aren’t quite ready, don’t really have the skills and that their peers always appear more capable and confident to them. http://www.kevinmd.com/blog/2014/03/effect-imposter-syndrome-medical-students.html describes it in relation to medical students.

birds-on-boat

You might notice that in the “about” page of this blog I say “I don’t want to present the final word on any of the topics…” I originally phrased this as “I don’t want to put myself forward as an expert….” until I was roundly criticised by someone who knows me well who insisted I must be some sort of expert after twenty years or more.  Somehow I always feel like I am still on the beginning of that learning curve J because I am always identifying things I am not good at. The plus is that it keeps life interesting.

rainbow-bird2

Maybe a small dose of Imposter Syndrome is healthy – keeps us on our toes – and those who have never suffered from any of the symptoms can be, well, insufferable!

However, it doesn’t make you feel good and it can get in the way of contributing your skills for the benefit of others. It probably relates to personality and other factors but here are a few practical reflections:

10 management strategies!

  1. If you are prepared then you can be a temporary and limited expert on a topic and that helps reduce the symptoms at the time!
    1. Even more useful is to know and make use of the expertise in your audience. You can become a facilitator of their expertise. The aim is to achieve certain objectives, not to appear to be a star.
  2. Come to think of it, facilitation is perhaps the skill as an educator that you have (or are developing) and that the audience probably doesn’t have! You may feel like a fraud if you try to teach the specifics of multiple trauma management (for instance) to a bunch of remote doctors (if you don’t have those skills yourself); if you lecture on antenatal care to a group of registrars with obstetrics diplomas; or if you run a sports medicine session when all you see is either sick kids or chronic disease and your clinical expertise is in women’s health or mental health. However, you probably have the skills to plan the session, locate really good resources, know how to give feedback, create great cases for discussion, manage group interactions, encourage the quiet ones and ensure each person gets the most out of the session. These are crucial skills, if not quite as high profile. And meanwhile you too are learning from all the participants.
  3. Sometimes supervisors who are really good educators (ie they move the learners to the next level) don’t self-identify as educators or teachers because
    1. They haven’t learned the language to articulate what they do
    2. Their real skill lies in areas which are not as high profile or do not feature strongly in curricula for teachers and supervisors. I have heard registrars say “he/she is an amazing role model” or “he/she was really supportive during a very difficult time” which are equally important skills.
  4. Get to know yourself and your particular skills and recognise what you are actually good (or even expert) at. It’s unlikely to be everything but it will be something.
    1. You became an educator for any of a number of reasons: you love medicine and want to impart that enthusiasm; you want to support and nurture the next generation of doctors; you enjoy planning and implementing a teaching program; or you thought it could all be done better! It wasn’t necessarily because you thought you knew everything and could impart it in a charismatic lecture.
    2. When I started I was extremely scared of “lecturing”, thought I was sort of OK at small groups and thoroughly enjoyed problem solving with individuals (after all I had been a social worker). Over time I started enjoying preparing sessions and delivering presentations, discovered I had strategic and organisational skills but I still recognise the awesome small group skills that others have and try to remember to put their strategies into practice if I can
  5. Work on some of the things you are less good at. This is what CPD is all about.
  6. We do our best and then we put effort into doing things better next time, so be open to feedback and seek it out. Stand-up comedians refine every second of a five minute comedy set as they practice it multiple times, so your teaching sessions will undoubtedly have scope for improvement in order to end up looking deceptively natural and ad lib.
    1. And believe the positive feedback you receive!
  7. We don’t all have a fan club to tell us how good we are and help us to overcome these responses but perhaps as educators we can start doing this for others (identifying what they did well and what their skills are and consulting them for expert advice when we need it) and maybe some reciprocity will result.superheroes
  8. Maybe focus, every now and then, on what you do know and what you can now do with ease and recall how much that is compared to earlier in your career.
  9. Explore new approaches and pass on what you learn to your colleagues.
  10. Sometimes you just have to bite the bullet and be that imposter until down the track a little way you discover it’s become the real you. You suddenly feel able to say to someone “I’m a medical educator”.