Monthly Archives: August 2017

Self-care in the curriculum

Despite the title this is not a how-to on self-care. I used this title because I thought it would appeal more than anything verging on the political. As educators many of us decide to leave politics (and policy) alone, no doubt to the relief of our funders, employers and government (who try to stifle debate in various ways).

I have been attending the Edinburgh Fringe and, as my daughter is a comedian, tend to go solely to comedy shows but this more serious one caught my eye l and I went to watch it a few days ago.  . It is a performance piece but it drew my attention because it came out of research at Bristol university which involved interviews with struggling GPs. The topic appealed but it also seemed like an attempt to disperse research findings in a different way. The interesting thing is that art tends to give more space for audience interpretation and I think I took away a slightly different message to that described as the focus of the researchers (which I read about later).


At the same time, there has been a twitter debate going on, surprisingly ignited by Stephen Hawking and Jeremy Hunt (health secretary). This is about Hunt’s use / misuse of evidence regarding the issue of weekend cover in the NHS. Then, today, I saw this piece in the BMJ.  It resonated with the issues in the Festival show and one of the common themes was morale.

How is this relevant to education? Well, in the performance piece the GP detailed her familiar history of school and extra curricular achievements (school captain and Duke of Edinburgh award all demonstrating her resilience and leadership skills) and her academic progress. She went on to describe her training and then the increasing requirements of GPs in the NHS – forty patients a day, consultations less than ten mins, more bureaucracy – the inevitability of mistakes and the lack of support. It’s a story of the well-meaning and high-achieving individual burning out.

The research apparently had a focus on the barriers to help-seeking for those suffering with symptoms of mental illness but the performance piece very much highlighted the role of system issues in aggravating the problems. As the Festival blurb said, the GP in the performance is “a fallible human being who, like the system, can only take so much before she really breaks.”

This was all Interspersed and illustrated with dance and music. She interestingly portrayed the solutions of the compulsory well-being coffee break (stress-inducing) and exercise (temporary respite only). Much of the text was apparently verbatim quotes from the interviews. Basically she describes burnout induced by the system and the implication is that advice on “self-care” is insufficient. There needs to be more care in the system.

Why does this matter to those in education? Well, “self care” and such are part of the curriculum and we perhaps should ensure this goes deeper than just ticking a curriculum box, more even than just trying different ways to teach it. The piece reinforced (through different media) the issues and discussions I have heard in other fora but it stimulated me to think at the end, as we departed the theatre, “so, what next?” Does anyone do anything other than agree about the problems?

I then moved on to the AMEE conference in Helsinki. There were around a dozen presentations about mindfulness and stress reduction (unsurprisingly) but one I attended was a brief talk by Menno de Bree (a philosopher) entitled “The cruelty of mindfulness” . He noted that “if we address burnout only on the individual level we give them the implicit message that they have to adjust themselves to a demanding environment (and not vice versa)”

The Edinburgh play quoted the analogy of the boiling frog. Do we stay silent as we watch the trainees enter a system that might harm them or as their education is squeezed? Do we give the message that a few self-care principles will help them survive whatever the system dishes up to them (if they are resilient enough) or do we question the system itself? The training environment has more potential to be able to model the values and attitudes that could improve things and perhaps trainees would then be more likely to take this culture into the broader health system. Other health systems may not be so close to meltdown as the NHS but perhaps educators are a group who need to practice speaking out, to ensure things are still heading in the right direction, take on the professional role of advocacy and exercise those muscles, before they gradually lose the ability to do so.


Medicine by numbers – teaching guidelines

I was thinking about guidelines when, a couple of weeks ago, there was a report on the radio of a study that found that GPs prescribe antibiotics “up to nine times higher than guidelines”. This seemed impressive. You can read the report in the MJA on estimated prescribing for acute respiratory infections in general practice.

Now, ignoring other specific issues with antibiotics (such as agricultural use, specialist / hospital use of newer generation drugs or the fact that, for drug companies, research into new antibiotics is less profitable than is developing new drugs for chronic disease) GP prescribing is an important part of the bigger picture and it would be good for GPs in-training to develop sound skills in this area.

As with much in education it is a bit of a diversion to focus solely on one activity just because it can be documented. Teaching about guidelines can be much more holistic and incorporate other essential skills. The study above related to prescribing (therapeutic) guidelines but, of course, there are numerous other guidelines with algorithms for investigating and managing various conditions. These can become more subjective / concensus based and this can lead to good discussion on differences in health systems.

As guidelines have proliferated some doctors from an earlier generation have felt a bit insulted by this move to “medicine by numbers” in place of being expected to apply their own clinical judgment. On the other hand, I know that GP registrars who have trained previously in the UK really miss easy access to guidelines in consultations and it would be concerning if registrars did not, for instance, check Therapeutic Guidelines in relevant consults. One might speculate whether future generations of doctors will find it hard to make decisions if there is no guideline.

However, there are now so many guidelines in the UK that one of the main alleged challenges in managing patients with multimorbidity is seen to be the problem of somehow combining so many guidelines (not that this approach is particularly appropriate) – hardly surprising, given the current number of “clinical guidelines” on the NICE website alone was over 180 last time I checked. Sometimes the panacea for this manufactured problem is assumed to be in some sort of software program – which takes it all to yet another level of unreality.

Engaging with guidelines

How could or should we utilise guidelines in teaching. It is generally effective and valued if learning is case-based. Firstly, ASK if there is a relevant guideline for the situation. Then, generate some thought about WHY guidelines are developed. This can be an opportunity to discuss patient safety (or even medico-legal issues and the professional responsibility to keep up to date). We all tend to stick with what we knew on finishing medical school and this is quite scary. There is too much knowledge out there to keep it all in our heads (unlike a couple of generations ago). Unfortunately exams sometimes seem to be constructed with the expectation that the content of guidelines has been memorised, which is hardly a reflection of real practice where the crucial issue is the awareness of where to find the information and the recognition of the need to do so. It’s worth discussing HOW guidelines are developed. This could be used as a way of teaching critical thinking – but in reality no one has the time or skills to be experts at this in every situation and it is more constructive to have a healthy skepticism permeating the curriculum than to tick off completion of isolated critical learning modules. It can also be a good exercise to critically review some of the references (in regard to conclusions drawn or relevance to particular patient sub-groups). Perhaps trainees can be encouraged to go further and explore meaningful audits of their own practice. Guidelines are shortcuts and their utility depends on their provenance so it is useful to explore with the learners WHO was involved in the development of a specific guideline – if disease groups are involved then check whether their sponsors are pharmaceutical companies (and this may lead to a useful discussion on influences on prescribing). Of course it is important to raise the issue of recency and WHEN they were produced (and if and why they have changed over time).The next step is to somehow DISTILL the content of guidelines into something manageable. Many individual guidelines are way too long for easy use and have morphed from handy algorithms to comprehensive evidence-based documents. It makes sense for GPs to become acquainted with them while learning and this establishes good practices and familiarity.

In Australia there are particularly useful guidelines for general practice including those for hypertension, CKD and diabetes although the last one is nowhere near as succinct as it used to be. These conditions often occur together and the guidelines include comorbidities so they can be an entry point to multimorbidity. There are newer and lengthy guidelines on osteoporosis which can generate discussion on screening.

It is crucial to discuss how to APPLY guidelines to the individual patient in front of them – to be patient-centred, use clinical judgment, and to bear in mind concepts such as Minimally Disruptive Medicine. This is why case-based learning is appropriate. There is an informative video by Trisha Greenhalgh (Professor of Primary Care at Oxford) on Real Versus Rubbish EBM  which, in part, relates her experience of falls guidelines after a pushbike accident. It is preferable for trainees to be aware of and use guidelines (particularly in a field as broad as general practice with its rapidly increasing knowledge base) but there is an interesting skeptical perspective (particularly in reference to dietary guidelines) in the following post

In Summary

  • Start with a case
  • Ask if there are any guidelines?
  • Critique: why, how, who, where, when
  • Distill them
  • Apply judiciously

In regard to the original issue of antibiotic prescribing we need informed prescribers who know current guidelines – where to find them when needed and to be alert for when they change – but who are aware of when they do not follow the guideline (and why).

Hopefully the days are long gone when patients thought looking something up meant the doctor “didn’t know” the answer and that these days they are reassured when told that the GP is just checking the latest guideline update. The skill set of general practice is not only to treat but also to explain, reassure, educate, negotiate and develop the doctor / patient relationship – practical consultation skills that can be conveyed when “teaching guidelines”.