In the last few days there was an East Coast Low off the coast of NSW which caused amazingly high seas on our local beach. The bird (? Cormorant) at the top of this blog (or a relative of his/hers) had to adapt and take refuge on a lamp post. As educators we have to adapt to changing contexts. As the tsunami of students ramps up the numbers, teachers may have to take refuge on their own pedestal of the lecture platform instead of wandering with small groups on the rock platform. Or maybe distance requires online contact. The other thing we have to do is to adapt resources for the audience. Teaching in and for the GP context, for instance, is not the same as in the hospital.
The learner
It’s often the case that we may invite a cardiologist to talk to GP registrars about atrial fibrillation or a gastroenterologist about the meaning of liver function tests. GPs may attend talks given by geriatricians or workshops run by Palliative Care Physicians. In all these instances the listener needs to consider how the information is relevant to the GP context. Similarly, when teaching in the clinical setting it is good to refer to EBM but often the evidence has come from studies done in hospitals and in different patient populations. In the Welsh resource I referenced a month ago https://docs.wixstatic.com/ugd/bbd630_9068591ed32045ef9e10c04cdf3086a2.pdf
(about Care of The Elderly) there are some very good reminders about frail patients – but it is good to contextualise for the community context. To utilise it appropriately for GP registrars, the differences need to be addressed.
The Teacher
As an educator you might research the relative importance of certain presentations in hospital patients versus GP patients. As a supervisor you could suggest your registrar reads the document and then discuss how they think it might apply to general practice. Or you could be more specific and read it in relation to particular patients. The Welsh document has some Top Tips for geriatric medicine and on the first page are
Six Random Thoughts
Number five stated: For confused patient, a collateral history is vital – it is important to determine if the patient has dementia, delirium, or both.
This is a good starting point for a discussion on confusion in general practice. Delirium is less common in general practice – but on the other hand it is therefore likely to be missed, so the message is to think of it. Delirium is addressed on page 8 of the document. Discuss how it may present (especially quiet delirium). The other relevant point in general practice is to discuss the possibility of delirium with a patient (and family or even surgeon) when they are facing hospital admission. The GP can often identify when a patient has risk factors for development of delirium before they get there. Of course, in general practice it is worthwhile also having Depression in your DDx.
The document quotes a great definition of frailty
“Frailty is characterised by a vulnerability to stressors which would not affect non-frail people. These stressors can range from a bereavement to septicaemia. These stressors can lead to a rapid decline in both functional status, and in some cases physiological deterioration. This decline may be reversible, but in many cases the person will not return to their baseline.”
GPs see patients earlier along the Frailty spectrum and are in a position to act when these stressors occur and to check on the patient and initiate actions that may help reverse or slow down the decline. Putting in place relevant supports at the appropriate time can help re-balance the scales in their functional status. Ask registrars how frail they judge a particular patient to be (and why) and brain storm with them about what services might benefit a particular patient with multimorbidity and polypharmacy, a recent hospitalisation, a recent fall or bereavement.
One section notes some very useful dos and don’ts of de-prescribing
These are really worth discussing and a teaching session that involves reviewing a patient’s medications is always worthwhile. In general practice there is a smaller proportion of very frail patients and the clinical judgment required to make sound prescribing / de-prescribing decisions is challenging. At what point might you discuss stopping preventive medications? It will not necessarily depend on age. Because we know patients over time they can sometimes decline imperceptibly and the prescribing decisions may need to change. A registrar can cast new eyes over a patient so ask for their thoughts.
Often frailty scales are used more to keep patients out of hospital or decide if they need a palliative care approach or whether more resources are needed. My PhD was about developing a scale for general practice – to predict those at risk of frailty. The importance of this is that you might make a difference at a much earlier stage. The definition of frailty is very helpful but In the GP context I would suggest stating some of those hospital messages slightly differently. Some points to emphasise might be:
- A patient may become gradually more frail while you’re not looking
- Carer or relative observations are important
- What are some predictors you can pick up which might suggest a patient is more vulnerable -this might be information to pass on to the hospital when relevant
- How can help be obtained in your geographic area in a timely fashion rather than leaving it too late? (bearing in mind that knowledge of community systems is crucial to being an effective GP)
- Check for cognitive impairment
- Frailty is a continuum rather than an either/or and care is also continuing rather than a one-off.
Other topics are UTIs, falls and end PJ paralysis. For the GP, what are the strategies for encouraging and maintaining mobility in patients in the community? The last topic in the document is Advanced Care Planning. There are impressive figures given about death rates of in-patients and those in residential care so it is a very relevant issue. General practice has many more healthy, resilient coping patients. Not many of our patients die in a twelve month period (and meanwhile we are seeing babies, teenagers, young families etc, all requiring a different paradigm of care). Registrars, in particular, might have a patient load of which only a small percentage is over 65. However, we do see those transitioning to frailty, at risk of frailty. This makes it a challenging topic in general practice which is worth discussing.
It is always worth directing attention to up to date guidelines but, even then, it is worth a discussion about how you might need to adapt them in practice. Even if there is a screening tool which will work on data entered into the electronic health record it is important to discuss the relevant concepts and issues with the learners in the practice. There are protocols and there is clinical judgment.
And the document finishes with some book reading suggestions – always a good idea!
Thus there was music (from an era I love, especially when it features period instruments and recorders) and paintings (from a school I really like) and this was accompanied by three dancers who also introduced an element of physicality and humour. There were even some background noises suggestive of a Dutch seventeenth century streetscape (but not the smells). At the end we had a further fifteen minutes to browse the exhibition. This was an event that recruited multiple senses.
I wondered if I learnt more this way. So here is some immediate feedback from a sample of N =2 (I include my husband who noted he appreciated the ability to focus on several different things). It was initially a little disconcerting to hear applause for the dancers in the previous space while the musicians were playing in the next one. It certainly wasn’t boring. It wasn’t too long and I appreciated being able to walk, stand or sit on the portable stool as needed. I wasn’t therefore distracted by physical discomfort (brief snack could be had beforehand). There was certainly an ambience.
We might sit in our comfy arm chairs of an evening and share some interesting titbits of information that lead on to further discussion (and maybe a Learning Plan involving Google). I have also recently started a botanical drawing course so I took a deeper interest in the Dutch still-lifes. Sometimes the full impact of a learning event can be broader than you think.
Prior to the concert we walked through the Botanical Gardens and I enjoyed the height-of-summer cottage garden flowerbed. It reminded me tangentially that there often seems to be added value if you attend a conference in a pleasant place. Such things are hard to measure but maybe should be a topic for further research!
Although bear in mind that it is written in the American and undergraduate context. It notes the importance of politics to health systems and delivery and the lack of relevant teaching in medical schools. Examples it quotes include issues such as prescribing an epi-pen to a child when the family can’t afford to buy it. In the UK context the parallel question might be “what’s the point of prescribing something if the NHS can’t afford it?” And the equivalent in Australia? Somehow, many of these issues come down to the problem of money – and who pays. Implementing access and interpreting fairness in this context is a political question.
The informative plenary by Catherine Lucey 
However, as noted, politics does not just influence health status and health care systems. It also influences health care education. This can be seen in length of training, cost of training (and hence the way it is delivered), who delivers it, who gets in, the definition of outcomes and even the content of training. Should educators, therefore, pay more attention to politics and medical education? What you do is not just led by pure educational theory. So let me leave you with this new year challenge to reflect on how political decisions have affected the way you as educators are now teaching. I have a few opinions myself but in good teaching style I’ll just leave you with the question – and what you might then do about it.