Category Archives: curriculum

Empathy in medical education

I have been busy writing some modules for clinical teachers’ CPD and just got started on one about teaching communication skills.  I moved on a bit in the literature to “empathy”- that elusive quality that I recall being reported to decrease either through medical school or once graduates land in the clinical years and the hospital system (a 2011 systematic review of studies on the decline of empathy is here https://www.ncbi.nlm.nih.gov/pubmed/21670661).  There is often debate as to whether this is to do with, among other things, lack of specific teaching, devaluing of “soft skills”, work and training stresses or the powerful influence of role models and the “hidden curriculum”.  Some of the research also overlaps with the concept of patient-centredness.

A recent article in the August 2019 edition of Medical Teacher was a little less pessimistic and not so conclusive when it described a meta-analysis of empathy studies and noted that significant negative changes were noted, but mainly with one particular tool, that studies relied on self-report and that the various tools may not even be measuring the same thing.  So, as is often the case, methodology issues and more research needed!

Over the years there have been various suggestions (and attempts) to expose medical students to humanities subjects on the assumption that this can engender empathy.  Of course, if these observations are true, it could be a chicken and egg situation.  Are potentially empathic people more drawn to the humanities?  And how often do rather unempathic staff “prescribe” such solutions, with students responding in the way they usually do to unwanted curricular requirements? 

This article in The Conversation lobbed into my email inbox earlier this year https://theconversation.com/empathy-in-healthcare-is-finally-making-a-comeback-113593 .  It comes from “The Oxford Empathy Programme.”   It’s a very readable summary and notes that studies have suggested that “empathic communication” can be taught.  The article notes the connection to Communication Skills which are mandatory in curricula now.  The author even raises the question of the cost-effectiveness of empathy.  Some of the comments on the article noted the effect of resources on empathy, the decline in GP:patient ratios, the increasing use of telephone consultations, less holistic approaches and the “avoidance techniques” used with patients to cope with time factors. 

Other articles relate decreasing empathy to concepts of burn-out as in this blog https://www.kevinmd.com/blog/2019/03/whats-happened-to-clinician-empathy.html Two years ago I attended a play at the Edinburgh Fringe which basically described GP burnout in the UK (the picture shows the blurb about it) and I discussed this in a previous post http://mededpurls.com/blog/index.php/2017/08/30/self-care-in-the-curriculum/ .

It is therefore of note that perhaps the time pressures in the UK system are now requiring consultations to be more “efficient” and with a subtle move away from the patient-centred idealism of a few decades ago.  The Consultation Hill Model described here https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2894394/ summarises some of that in the registrar context.  There is a bit of cognitive dissonance here when we think of the exhortations to greater empathy inherent in much of the training.

Another Conversation article, from 2017, https://theconversation.com/are-our-busy-doctors-and-nurses-losing-empathy-for-patients-68228  also has the common caveat that “With more demand on doctors and nurses and a push for quicker consultations, clinical empathy is being dwarfed by the need for efficiency”.  This article focussed on the impact of technology lessening direct patient contact time.  Here are two recent articles on how technology may be affecting empathy in health care – although unfortunately they are behind a paywall https://journals.sagepub.com/doi/abs/10.1177/0141076818790669 and https://journals.sagepub.com/doi/abs/10.1177/0141076817714443?journalCode=jrsb

I would suggest it is good to have a look at the literature and see what evidence there might be about empathy training if you are going to try and insert it into the syllabus. There seems to be a Cochrane Review in process.  It is a complex topic and there has been interesting research on its place in general practice, including how perceptions of empathy vary according to measures of economic deprivation http://eprints.gla.ac.uk/104350/ . Of course, there is a much broader collection of opinions on how social media may be affecting empathy in society.

I would also suggest there is another influence on developing empathy which has a parallel with the effects being felt in the health system.  It is worthwhile noting the similar changes occurring in the medical education sector:  a decline in the ratio of lecturers/educators/tutors to students/registrars; more reliance on technology than interpersonal communication (do you get to know the learners?); simulation and online delivery of teaching; more emphasis on exam results and paperwork; more rigid rules and box-ticking for accountability and so forth.  Again, a type of cognitive dissonance is experienced.  We find arguments convincing that explain the behaviour of some adults because of the environment in which they grew up so perhaps it isn’t too much of a stretch to imagine that the environment and role models that learners are experiencing will have an influence on the sort of doctors they become. Ticking learning outcomes may not be quite enough.  There are various responses that can be made to the tensions in a potentially dysfunctional system and it’s good to make these in a conscious way.  It’s worth thinking about in relation to empathy and medical education.

Teaching critical thinking – and other “soft skills”

I noticed this tweet and reply this week. When indeed did critical thinking become a soft skill? That response was by a medical researcher. No wonder we have to keep thinking about teaching it, if it isn’t given priority in the previous levels of education. Perhaps critical thinking is not welcome when it comes to voting but in the field of medical practice a critical mind is crucial. It’s obviously crucial in research and its crucial in all stages of applying evidence based practice.

I had previously had in mind to do a blog post of the “non-clinical skills” that are required to be taught in training. This was stimulated by a talk I went to in September at the EURACT conference which talked about the new capabilities framework in the UK https://www.gmc-uk.org/-/media/documents/Generic_professional_capabilities_framework__0817.pdf_70417127.pdf to be applied to all postgraduate training. The talk was by someone from the RCGP who described how the GMC have now mandated new domains to be continually assessed during training. These include, for example, capabilities relating to patient safety and quality, leadership, research, professional knowledge, education and training and so forth. So far so good.  It did not sound too different from the roles in the Canmeds framework (although the “continually assess” sounded a bit ominous). The speaker stated that these were to have equal emphasis with clinical knowledge and skills. They had enthusiastically embarked on teaching a research component in GP training which had been evaluated positively by selected and engaged supervisors and registrars. They reported they were now faced, however, with rolling it out to everyone and admitted there might be challenges with non-engaged supervisors and struggling registrars.

These non-clinical skills are obviously relevant for clinical people and perhaps even more so for those involved in education. I recall from my student days when students (and some staff) tended to give a bit of a nod and a wink to the equal weight given to the different domains in the curriculum. Similarly it is quite frustrating as an educator when learners object to spending time on “soft stuff” that we think is crucial and worthwhile. On the other hand it is quite understandable for learners to feel under pressure from an increasingly busy curriculum, the need to pass assessments and the perceived safety of patients if their clinical skills are not up to scratch.

I think there are a few points that can be noted from this. There is a responsibility for educators to evaluate the curriculum and ensure it is not just comprehensive and responsive to various stakeholders (academic, political, legal or regulatory bodies) but also meaningful to the learners. We also need to convey why these other domains are important and how multiple competencies contribute to the performance of a clinical activity. From an educational perspective are these capabilities teachable and are they assessable? From a teaching perspective it is also preferable to teach in context. So, “critical thinking skills” are more effectively taught in a context meaningful to the adult learner (probably the clinical context for most medical learners) and not abstracted from the domain specific content which the learners are seeking to master. I addressed this aspect in an earlier post http://mededpurls.com/blog/index.php/2018/10/04/making-the-implicit-explicit-a-core-concept-in-clinical-teaching/  This may help prevent them from being siloed as a “soft skill” but this complexity does however make it more of a challenge to document and be accountable in a managerial sense – and this latter priority often predominates. Learning in the context involves articulating your thinking and this is particularly so for the clinical supervisor.

So, consider, with our increasingly impressive curricula and standards, is there a divide between what is stated, what we actually teach and what we test? And how is it perceived by the learners? We need to monitor the bigger picture of what we are doing in education. Bear in mind that some similar requirements may one day be coming to a training program near you.

 

And now for something more practical – MSK learning for general practice

After a few rather philosophical posts I thought there might be a preference for a return to something practical in regards to teaching a particular topic of the curriculum.

Here’s the problem

Musculoskeletal presentations are incredibly common in general practice (as reported by BEACH data), next to skin/dermatology, and yet many GPs lack confidence and enthusiasm in dealing with them. Those who are keen tend to veer towards (and specialise in) sports medicine and this does not help the vast numbers of the ageing population whose main practical problem is often musculo-skeletal in nature (but not of the elite sports variety).

Why is there lack of confidence and what can be done? How do we prepare learners for future practice?

There is an increasing tendency for patients to go first to physios or even chiropractors as primary carer – which seems reasonable in many ways but also tends to deskill GPs and decrease continuity of care.  Ongoing management is often tricky in terms of sufficient access to allied health care when needed and, of course, many problems are difficult to cure or remediate (and others get better with time). Imaging has also become a point of contention.  In addition there is not a single specialty to ask for advice and problems encompass broken bones / traumatic soft tissue injuries / rheumatological and degenerative conditions / disability etc.  More commonly these days, falls and frailty are also part of the picture.

Is there also some gender stereotyping: tears and smears vs cutting and injecting?

What works? 

Reflect on your own skills and enthusiasm. I got better (for a while) by:

  • studying for the FRACGP – when I read a lot and then ensured I did full examinations on appropriate patients
  • teaching musculoskeletal topics – we all know that teaching is an important way to learn
  • experiencing symptoms myself over the years

Most trainees are young and healthy (but some are ex physios or heavily involved in sport), all are studying for their exams and opportunities for peer to peer teaching can be organised.

The breadth of knowledge relevant to MSK problems is illustrated anecdotally by a recent experience of mine. Six months ago I was improving my musculoskeletal health by exercise (sports medicine) and fell off my bike.  This resulted in a Colles’ fracture (orthopaedics).  After the cast was removed I discovered I had a ruptured EPL.  Meanwhile the pre-existing OA in the PIP and DIP joints on my “good” hand were aggravated (rheumatological).  I still have the functional deficits associated with the tendon rupture, some of the lingering problems were soft tissue related on the ulnar side and I still have decreased range of flexion and extension of my left wrist – not to mention an officially increased “fracture risk” on algorithm and a small amount of subjective “fear of falling” that I didn’t have before (falls and fractures / geriatrics !)  I certainly have a lot more breadth of knowledge now about Colles fractures than I did when I straightened dozens of them in ED under Bier’s blocks years ago.  However, I have long since lost my skills and confidence in dealing with them as my clinical exposure is now so rare (practical skills).

Given the topic’s importance and all the competing demands it is sometimes necessary to fight for an appropriate place in the curriculum and appropriate experiences in practice.

Strategies

  • Small group learning – but this needs to be well structured
  • Case based – should be well prepared and resourced
  • Practical sessions are always requested – but bear in mind that these can degenerate into just standing around and not using the time optimally
  • Practice based – this is probably the most useful resource and yet the most difficult to organise. There is unpredictable variability in the interest and expertise of supervisors in such areas which is quite reasonable. It would be of educational value to know the learning environments, potential experiences and resources of placements across the full sweep of training for each registrar but this is difficult with rapidly increasing numbers of practices and decreasing personal knowledge of them. Orchestrating the learning environment is becoming less popular and being replaced by testing competencies
  • Internet resources – these have multiplied over recent years and are always changing. It is useful to ask your registrars what they have become aware of (often from undergraduate years). Examples to explore would be the University of Wisconsin, department of family medicine http://www.fammed.wisc.edu/category/media/musculoskeletal/ or just search youtube (preview any you plan to use and note their quality and how long they are)
  • Peer to peer teaching – this could involve guidelines’ review or recruiting learners with existing expertise (if you know them)
  • Registrars are often good at guidelines for acute conditions – you can build on this
  • Other evidence-based resources such as Choosing Wisely, National Prescribing Service, Cochrane Database are useful – although they often have a limited focus (particular conditions, imaging, medications, procedures)

Summary suggestions

The best educational outcomes result from considering the total learning environment so if lectures and workshops can be linked to practice experiences this will enhance learning. Some people also learn best from hands-on experiences so practical sessions should be included.  Musculoskeletal medicine is also an area where interdisciplinary collaboration is crucial so get to know some allied health presenters who are keen to engage with GPs.  If you aren’t an expert, have someone there who is. Any educational session should be well planned (ask yourself what are you aiming at, how are you going to achieve it, what methods might work best, what was the previous feedback, how will you measure your success).  Elements of a Flipped Classroom can be included by sending out links to short videos or other online resources as preparation.  Take the opportunity in small groups to interact with the learners and ask them about their experiences and clinical experience so far as this can motivate others or reveal learning opportunities.  As always, a case-based approach is appreciated and a patient-centred approach adds value.

Finally, this is an area in which to encourage excellence and advise those who are keen (or not so keen) about other opportunities for further study. If you are good at something you tend to feel good about it.  As with other areas of general practice, the experiences and engagement that occurs during training often dictates the direction and enthusiasm of future practice (beyond just exams).

When to teach “how to teach”

The answer to this question is probably “when someone on the curriculum committee tells us to” or perhaps when it is mandated by a government who suddenly wake up to the fact there may not be enough willing teachers for the graduates being produced.

Today I went for a walk along the Foreshore. Half way along I realised I had left my phone behind.  I nearly turned back.  What is the point of walking that distance if your steps aren’t being formally counted by your pedometer and recorded?  This is how far I have descended into the tick-box culture!  Similarly, in the workplace, when documentation assumes such importance we are tempted to stop doing other things that are difficult to document.  This reminded me of an article I was alerted to two days ago in Medical Teacher   http://onlinelibrary.wiley.com/doi/10.1111/tct.12591/full/ Are Australian medical students being taught to teach?

This article noted the accepted line of the increased demand for teaching and supervision (because of growth in numbers) and the study aimed (via a 22 item questionnaire to 19 medical schools) to find out what there is in terms of programs for “teaching skills”. Not surprisingly there was a variety of compulsory and elective courses.

I guess a larger question is whether utilising all these busy, variably-trained students and doctors-in-training is the cheap solution policy makers are always looking for? Interestingly two schools reported that they did not offer peer-to-peer teaching opportunities because of time and staffing constraints but also the belief that the quality of expert teaching is superior.  Certainly this is an issue not to ignore and short and long-term feedback should be sought on peer and near-peer teaching.  As with many good ideas, the implementation makes the difference.  Post graduate colleges have also diligently added teaching skills to their requirements in the last couple of decades and, of course, several of the inter-related CanMEDS roles relate to this.

The upskilling of junior and senior hospital doctors in teaching skills has frequently been raised and courses such as Teaching on the Run have gone a way toward filling in the practical gaps here and competence to teach certainly gets a mention in the curricula for RACGP and ACRRM. Training organisations are entrusted with teaching these somewhat labyrinthine curricula but what does it mean to tick that particular box?  There can be a gap between curriculum, syllabus and what actually happens on the ground – even if they are written in terms of competency outcomes.  What is required in post-graduate training also raises the issue of what skills can be assumed to have been effectively acquired at undergraduate level.

The RACGP curriculum notes that GPs may teach both patients and other health professionals and that “All GPs have the capacity to inspire, to be teachers, mentors and leaders in the art of general practice to improve outcomes for their patients and for the broader community.” https://www.racgp.org.au/Education/Curriculum/General-practice-teaching http://www.racgp.org.au/download/Documents/Curriculum/2015%20Final/curriculum-for-australian-general-practice-core-skills-unit.pdf and they document specific outcomes such as:

CS4.3.1 Professional knowledge and skills are effectively shared with others  At the registrar level this includes:

CS4.3.1.1b Develop strategies to share recently acquired skills and knowledge with peers

CS4.3.1.2b Assist peers and colleagues to identify and prioritise areas of clinical knowledge and skill that are in need of development

CS4.3.1.3b Identify strategies to create an inclusive team-based approach to teaching and leadership

These outcomes are reasonably limited to the specific context but it may be a challenge to measure when outcomes are achieved and it is not very specific in terms of teaching skills.  Similarly, in ACRRM there is a Research and Teaching chapter and one of the essential skills is the ability to communicate scientific information effectively with patients and colleagues. There is an expectation that (6.12) doctors “Teach and clinically supervise health students, junior doctors and other health professionals” and there is some detailing of the sub-skills required for teaching and supervision under “definition of terms” (perhaps relevant to the skills and competencies that supervisors are utilising in teaching the trainees).

Thus, there is the curriculum and accountability approach but it is obviously difficult to find a balance between core and non-core skills in such an area and therefore difficult to simultaneously assure basic competencies and encourage excellence and expertise.  On the other hand, reflect on how you became interested in and enthused about teaching. For me it started decades back when I was a medical student in the first year of the Newcastle Medical School. It was the first school to implement Problem-Based Learning in Australia and it was impossible to be a learner in the system and not be aware of the commitment and enthusiasm of the staff to a philosophy of education. So while we were acquiring the “facts” we were also debating the “process” and many of us took this into later learning and teaching – without being told to do that.  The commitment of teachers and staff in a program is a crucial factor.

At this point I would just point out some practical questions worth asking from an educational point of view:

  • Is the transfer of these skills happening in your program? What is an effective rather than efficient approach? There are studies in the literature that address some of these individual questions and it would be nice to base practice on some evidence.
  • Is there a learning environment to facilitate it within the training system?
  • At what level of training is it best to learn how to teach – given that learning is optimal at the point of need (and other needs – such as passing exams – may be competing)?
  • Who is it best to teach – should it be a requirement for everyone or should energy be expended differentially on those who express interest and aptitude?
  • How do people get enthused about teaching?

The article started with the assumption that numbers are increasing and this also has implications for the organisation of teaching. Do we know what is the benefit of a huge number of learners completing an online module compared to, for instance, having a process of identifying and mentoring a smaller number of future educators?  Are there gradations of involvement that could be encouraged?

So if you are a medical educator teaching a class of 80 trainees how might you best enthuse and skill them for future teaching? If you are a supervisor in a practice with one or more trainees, how might you achieve similar outcomes in your own particular environment- which may actually be more conducive to this?  How can educators and supervisors work together toward this goal and how will a training program meaningfully evaluate their effectiveness in this area?  Do you know if your learners are finishing their training program keen to come back as teachers and supervisors? Because this is what is needed for sustainability.

It may be a waste of time to demand learners achieve goals about teaching skills when they are distracted by upcoming and high-stakes exams. It is probably both unfair and ineffective.  It may also be a waste of time if they do not get the chance to reinforce these skills during training.  At the post-graduate level their need to acquire knowledge and skills to treat patients is a powerful motivator (and competing factor).  You could take a more holistic approach where the educator unobtrusively conveys (but documents!) these skills through modelling, engagement and involvement and this may require more detailed planning of learning activities. . There is much evidence in the literature about the power of the role model in medical education (mentioned before in this blog) and it is often at this level that the supervisor has the most influence, along with a bit of nudging and supporting of the registrar to step up themselves (perhaps in a practice clinical meeting).  It is not unusual for learner feedback to comment when someone is “a great teacher”. As with other skills, they learn by observing and practising so repetition of the skills throughout training is preferable. Bear in mind that implementing a broader approach goes above and beyond usual requirements and therefore is less likely to be acknowledged. There are many worthwhile outcomes which are difficult to measure (and document) – just as lifting a few weights and going a really long walk with your phone in the wrong pocket will not look as impressive as it should; and struggling up an ancient spiral stone staircase to a scary rooftop is worth it for the exercise and the different perspective rather than the step count.

PS I have now worked out how to add steps to the ongoing tally on my phone – once I have already done the hard yards on the ground that is!  I guess this raises the issue of the temptation to document in an “optimistic” fashion!  But we won’t go there.

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.  .http://www.bris.ac.uk/news/2017/august/prescribed-edinburgh-show.html 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.

http://blogs.bmj.com/bmj/2017/08/22/rachel-clarke-the-professor-the-politician-and-the-advent-of-huntsplaining/  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.

https://www.mja.com.au/journal/2017/207/2/antibiotics-acute-respiratory-infections-general-practice-comparison-prescribing

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

https://m.youtube.com/watch?v=qYvdhA697jI  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

http://www.cardiobrief.org/2016/01/21/why-guidelines-are-bad-for-science/

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”.

 

Teaching Dermatology – essential, multi-faceted and, sometimes, “innovative”

Back in 1999 I wrote an article (in Education for General Practice) entitled Teaching dermatology in general practice : the potential of digital cameras and information technology”.  How things have changed!  Back then we bought a Canon digital camera with a 0.6 megapixel camera and lent it out to registrars so they could come to workshops armed with photos to illustrate the cases they presented to their peers – now we all have phones with around 12 megapixel cameras and can send pictures to specialists for an opinion.

Why did we do it? Because dermatology is so visual and it seemed good to utilise technology.  Learning around real cases is more powerful than lectures and the presentations also developed their teaching skills.

Why the emphasis on dermatology?  I had been involved in CPD and every needs analysis on established GPs had dermatology at the top of the list. Personally, it would probably still be the most common area in which I call in a colleague for a quick second opinion.  Registrars, too, find skin problems daunting. Teaching at the undergraduate level is scant and experience in residency is patchy (no pun intended) yet skin problems comprise 10-15% of GP presentations so it is important that it is addressed in vocational training.  But what is the content of these presentations and what therefore needs to be taught?

In dermatology texts, a chapter on blistering diseases might focus on pemphigus and bullous pemphigoid but we might see one or two in a lifetime. Bites, infections, allergies and burns will be encountered more often as a cause for blisters in a general practice patient.  Other conditions will have an intermediate prevalence and varicella has slipped down the list. Despite the vast range of dermatological diagnoses, a previous survey of what they see in practice had shown that a dozen conditions represent three quarters of the GP caseload.  Fifty per cent would be the different types of dermatitis and infections including fungal problems.  A further twenty five per cent is made up of various isolated skin lesions followed by acne and psoriasis. Solar keratoses, BCCs, seborrheic keratoses and SCCs are not high on the list for registrars, reflecting their patient demographic.  Do at least have a plan and rationale for what is being addressed.  Dermatology is not just skin cancer (which is a large focus of CPD) but knowing how to manage this well is very relevant in Australia.  The practice context is the most crucial for learning the relevant skin procedures and the quality of the practice learning environment is therefore important.  Additional input from those with expertise in specific areas is invaluable but often depends on availability in non metro areas.  Technology may plug these gaps in the future.  Outside of training programs CPD workshops and lectures can often be recommended to supplement learning (and reinforce lifelong learning).

In the relatively short time generally allocated to formal teaching about skin problems it is pertinent to focus on the practical management of common conditions in order to instil confidence in the learner – but with a GP emphasis on a patient-centred approach (what is the psychological effect on the patient, can they afford the treatments suggested etc). However, time still needs to be given to the diagnostic strategies for approaching rarer or atypical presentations.  Doctors are great at saying “come and see this rash” and it adds value to probe the learner about their reasoning as in the one minute preceptor approach http://www.practicaldoc.ca/practical-prof/teaching-nuts-bolts/one-minute-preceptor/It’s useful to ask them about the urgency of a particular diagnosis and remind about possible serious differential diagnoses. A little bit of revision of underlying pathology is interesting and has a place but a repeat of undergraduate learning is not always the most relevant emphasis.  A visit to the chemist might be informative to see the range of lotions and potions and, in practice, useful tips can be gained from specialist letters.  An audit of histopathology reports of biopsies and excisions can be informative. A lot is learnt from that GP approach of time as a diagnostic tool and issues of follow up and safety netting are integral.

The learning environment has changed and there are now lots of great internet resources (eg www.dermnetnz.org and Telederm) to which registrars can be pointed for self-directed learning.  The rapidly improving technology is an irresistible focus for “innovation” so experiment with it but there is always the challenge to not forget sound educational methods such as case-based learning. It is a challenge to find approaches that are successful (so think in terms of evaluating outcomes).  It is an area where teaching diagnostic strategies may compete with the universal feedback of “just lots more pictures please”.  The use of images also raises the necessity to discuss ethical issues and consent.

* NB consent was obtained (from me!)for all photos (of bits of me) in this post : ant bites; reaction to band-aid; mild golfer’s vasculitis

Perspective on teaching Aged Care

Teaching Aged Care for general practice – getting perspective

How do we appropriately prepare doctors for care of the ageing, particularly in general practice? What is the relevant curricular content (what do GPs see or what do they need) and how is it best taught?

Let’s start with the caveats. Not all practices are the same and not all doctors are the same.  Despite statistical observations about average patient populations there are some doctors who see scores of nursing home patients and some who see none.  There are GPs who focus on kids or women’s health or travel medicine.  Some sub-specialise in palliative care, sports medicine or skin procedures.  The list goes on and, certainly, newly Fellowshipped doctors are more likely to see (on average) a younger patient load in their early years.

A lot of the fuss about aged care is because it often seems complex but it is also at the forefront of discussion because it is high on the government agenda. Policy makers of course are concerned about anything that is a significant cost to the health system and this includes hospital admissions and residential care, in which areas older patients are well represented.

Demographics and “Aged Care”

Our population is undeniably ageing, chronic disease is increasing, the cost of dementia and residential aged care is increasing and the cost of the final year of life is disproportionately high. These are the issues that make headlines and influence policy and funding.  Unsurprisingly, therefore, I have noticed that when Aged Care is mentioned these days it often refers only to those in Residential Aged Care Facilities (RACF) as if this were the most important area of caring for the ageing patient.  In fact, the proportion of those over 65 in residential care has actually declined over recent decades.  However, given the increasing proportion of older people overall, the absolute numbers are still increasing.  Of the 85 + age group a quarter are in RACF whereas in the 65-74 years age group it is only 2%.

The median length of stay in RACF is five months (the average is higher owing to some with very long lengths of stay) and half die within 6 months of nursing home admission. Today, over half of people die in hospitals and around thirty percent in residential care.

Care for those in RACF is becoming rather separated from usual GP care, partly because there is often a change of doctor as patients are obliged to move to a different geographical area. Instead of following a patient’s care to the nursing home a GP often takes on multiple patients in one location, which is a different style of practice.  Residents are also older and sicker than they were decades ago.  Recruiting doctors to work in RACF is problematic (for many reasons) but we also know that those who care for nursing home patients as a registrar are subsequently more likely to do this once fellowed so, despite the low numbers, it would seem to be useful to address this area in teaching.

What is not celebrated

Along with the decreased proportion of older patients living in RACF, it should be noted that not only are Australians living longer but most of those additional years are free of disability.  Nevertheless, there are often years at the end of life where multiple services are required.  Despite a tendency toward greater use of health services with age, someone over 85 with no chronic diseases is less likely to need services than someone under 85 with several chronic diseases. The problem is not just age.

The implications for general practice

The average GP has 20 patients die each year in GP practice in the UK (with higher patient loads) and if we can extrapolate to Australian practice, a full time GP might have between one and two per cent of their regular patients die each year – which leaves some hundreds of older patients requiring other sorts of care.

Topics taught in aged care courses generally include diseases such as Parkinson’s, dementia, stroke and so forth and yet these are a minority of the problems presented by older patients in primary care. Nevertheless, if you are looking after nursing home patients the proportion with these conditions is very much higher.

In terms of population proportions, the 15-64 year old age group has remained stable whereas the under 15s have decreased and those over 65 have increased, with the over 85s growing at a faster rate than other segments of the population. But they are still only at 2%.  Over 65s are a similar  proportion to under 15s. This will be reflected in general practice but, as older people tend to have more conditions, more medications and more illness, the GP will be seeing them much more often.

The “average” (but with incredible variation) GP probably only has a couple more nursing home patients than they might have had in the 1990s. For every 1000 patients in a practice there may now be 20 who are over 85 of which 5 might be in RACF but there will be 15 in the community – with all that this implies about complex care needs.  There might also now be 130 between 65 and 84 – the age group where chronic diseases are increasing but where appropriate preventive activities may still make a substantive difference.   Basically, this is where the changes are most apparent in general practice and this indicates the skills that are needed.

The majority of GP patients are not in nursing homes, nor in the final year of their lives or requiring palliative care. In addition we are not dealing just with patients who have been judged to have entered the geriatric paradigm although it is useful to be aware of the concepts of geriatric syndromes and functional status etc.  However, GPs care for patients transitioning through some of these stages.

GPs, in the community, hopefully see patients over a period of time – continuity of care. We manage their acute illnesses (despite the spin being that these days GPs see only chronic disease) as well as their injuries.  We listen to their problems and we try to implement appropriate preventive interventions.   Somewhere along this journey they likely acquire some chronic diseases and the ongoing management becomes a little more complex.  Crucially we need to recognise impending frailty or acute deterioration. All this constitutes caring for ageing patients.

So what should we be teaching GPs?

First, we should still start (and finish) with being patient/person-centred and we need to convey this in a system which is becoming more of a challenge to continuity and patient-centredness. The doctor/patient relationship still matters. We often need to be advocates for elderly patients in an increasingly impersonal system.  Second, the skill of clinical judgment is more important than ever.  GPs need to identify when it is appropriate to apply differing paradigms for management (such as prevention, geriatric principles, palliative care approach, teamwork etc).   In addition to all this, of course, are the skills of prescribing, managing polypharmacy and multimorbidity which are most appropriately utilised in the general practice context.  For the majority of ageing patients the GP is crucial in terms of delaying progression of disease and functional decline.  It is a challenge to enthuse learners about prevention when outcomes are hard to measure and not obvious.

This still misses a couple of things. One is the necessity of knowledge about other services and the requirement for teamwork.  This is quite a challenge in our fragmented system and mentors, role models and supervisors are invaluable.  The practice placement makes such a difference.  The next crucial factor to consider is the carer.  People are staying in the community and being cared for by others often with their own health needs.  This adds an extra dimension to the health care and moves appropriately into the ethical, professional, legal and organisational domains of curricula.

So, if we are keen to teach what is relevant in terms of GP clinical exposure and workload we need to keep the realities of practice in mind. Certainly teach about palliative care and focus on the specific skills for the increasingly differentiated processes of care in RACF (there are some useful AFP articles such as http://www.racgp.org.au/afp/2015/april/models-of-general-practitioner-services-in-residential-aged-care-facilities/ ) and ensure experience in this area.  However, the useful long term outcome is to have fewer patients requiring this sort of care so don’t forget about the continuum of ageing care and the large number of relatively healthy, ageing patients and what can be done for them – which may then influence the development of dependence and frailty and quality of life at the end of life.

In terms of how it is done, the suggestions would be similar to those in the post on Multimorbidity. Although lectures can be useful for becoming acquainted with important concepts (frailty, functional status, geriatric syndromes, recognising delirium), case studies and case discussion give learners the opportunity to practice the complexity of diagnosis and management in this group of patients. However, many of these skills are honed in practice as one’s patients age.  It is a very relevant topic for ongoing CPD.

 

Some interesting references with figures on the population, ageing, chronic disease and service use etc if interested

Teaching multimorbidity – part three

Practical suggestions

This post follows on from the previous two and focuses more on what supervisors might do (and what has been tried) to help registrars learn, in the practice context, how to manage these particular patients.

Clinical practice

  • Managing multimorbidity requires particular clinical and other skills
  • It is appropriate that trainee GPs acquire these skills – despite other systems being also relevant to care
  • The relevant patient presentation is one with multiple problems (diagnoses / symptoms) and multiple treatments (more complex than chronic disease paradigms)
  • Good care requires being aware of the multiple ways these may interact with each other and how all this impacts on the patient
  • The practitioner needs to be aware how this “burden” may affect effective management

Suggestions from supervisors re teaching multimorbidity

  • Break it down into smaller chunks and teach over the whole term.
  • Use it as an opportunity for a GPMP/TCA in collaboration with the patient to             reveal the patient goals and agenda – which may be different.
  • Demonstrate your own GP Management Plans
  • Check up on social factors and be non-judgmental re non-compliance
  • Suggest tidying the computer record – medications, problem and diagnosis list and teach the use of actions and reminders.
  • Encourage the registrar to speak up as they are viewing the patient with new eyes.
  • Discuss polypharmacy and raise changing medications.

Actions to support teaching in the practice  

We previously developed a practice teaching module with learning objectives which included recognising complex multimorbidity, consulting relevant guidelines, taking a patient-centred approach, utilising appropriate item numbers and consulting with health and other professionals. Tasks included a pre-session activity, case discussion, direct observation of a consultation and follow-up by random case analysis and review of identified learning goals.

jacarandaWe also developed a practice-based, structured assessment tool – one of several Entrustable Professional Activities (EPA) which were discussed in a previous post. It was phrased as: the registrar can be trusted to manage, in the GP context, the ongoing care of an older patient with multiple morbidities and multiple medications (with guidelines on how to assess this).

These two innovations were not able to be adequately implemented (or evaluated) before the government changes to the delivery of GP training but, hopefully, activity will continue in this area and supervisors can take some of these ideas on board.

A suggested approach by registrars to multimorbid patients in practice

  •  Take ownership of the patient
  • Create a Problem list
  • Review the medication list
  • Are there knowledge gaps?
  • Address and negotiate the patient vs doctor perspectives and priorities – do we understand each other?
  • Who is part of the treating team?
  • Preventative health
  • Goal planning
  • Be aware of billing and item numbers
  • Follow up/anticipatory care
  • Use of digital technology

To manage multimorbidity well 

  • You need TIME
  • You need continuity
  • You need patient-centredness
  • You need teamwork, systems etc

To teach and learn effectively about multimorbiditytree-trunk

 We know that learning is more effective if multiple methods are used and if reinforced in different contexts so it is likely that teaching multimorbidity would be best with a multi-pronged approach – given also what registrars find helpful (from surveys & focus groups). This approach ideally would involve workshop teaching, practice teaching, linked formative assessment and self-directed learning.  It should be built on an evidence base of what is effective and it is preferable to research and evaluate what we do as we go.  My preference from previous reading and work in the area is that teaching on the topic should be overtly linked to patient-centredness (rather than just concentrating on multiple chronic disease guidelines). A conceptual framework can be helpful. 

Foundation to build on 

Registrars potentially see sufficient patients with multimorbidity. When given a choice, registrars describe multimorbid patients as “challenging” or “interesting” rather than difficult or frustrating so this is encouraging. They reported, mostly, being able to have long enough consultations (less so in Term 3) and to organise follow up consultations.  Focussed workshops are useful and there is concensus that specific  experiences (hospital terms for instance) and teaching methods are helpful in developing their skills.  Resources and development for supervisors could enhance the practice experience.

Still a way to go and future challenges

These previous pilots of multimorbidity teaching demonstrate some increased confidence but could we do better? The challenges noted included the difficulty of implementing multidisciplinary care in general practice and initiating changes to medications – all very practical issues.

The standard definitions of multimorbidity (2 or more, or 3 or more comorbidities) include a range of multimorbidities which are not always too challenging and may have minimal impact on the patient. However, there has been more recent discussion of complex multimorbidity – sometimes defined as problems in two or more systems or multiple morbidities combined with psycho-social problems.  These are much more challenging. Hard to treat musculoskeletal and pain problems are also common comorbidities with other conditions.  Multimorbidities begin earlier and are more prevalent in areas of socio-economic deprivation and patients with such demographics often have less access to services.

rock-patternIf management is challenging then so is teaching about it – and so is measuring the effectiveness of that teaching.

“Complex multimorbidity” is where the focus needs to be in the future – the next challenge.

 

Teaching Multimorbidity – part two

Just an initial parenthesis about multimorbidity

If you ever wondered about the importance of multimorbidity, then wonder no more. Late yesterday (a Friday) the Australian government announced a summary of its revamp of funding policies and parameters for the “Health Care Home”.  These apply to general practice and refer to patients variously described as having chronic diseases and complex chronic illness – in short, it includes multimorbidity.  There are many really interesting articles and studies out there raising complex aspects of how to define, classify and research (and hence add to the evidence base of) multimorbidity, but from now on it will probably also be defined and counted by the Department of Health.  If you were wondering which patients we are generally talking about in referring to multimorbid patients, it is interesting to dip into a couple of articles. An interesting one in the Australian context is Brett T et al. Multimorbidity in patients attending 2 Australian primary care practices. Ann Fam Med 2013; 11(6): 535-542. http://www.annfammed.org/content/11/6/535.full In general practice, maybe a third of patients will have some sort of multimorbidity (defined as 3 or more co-morbidities) and more than half of these will not be elderly, but the clinical significance will also depend on severity and multimorbidity is more common in deprived populations. The estimated proportion of these patients will also depend on the classification system – eg whether cardiovascular is a category or individual diagnoses such as IHD or AF are listed and whether risk factors such as hyperlipidaemia are included. As Einstein said, “Not everything that can be counted counts, and not everything that counts can be counted.” Well, I guess it can but how meaningful it is may be in dispute.

pasha-bulkaGovernments have persuaded us of the impending doom to the health system and solutions are proposed. The Health Care Home (if implemented, not just piloted) will affect the way we fund (and manage) the majority of consultations in general practice, if not the majority of patients (given that these patients, unsurprisingly, attend more frequently).  This will affect the way that we teach about the management of multimorbidity in the future but it will still be important to understand the experience of the patient, the clinical issues regarding effective treatment and the challenges faced by health professionals. This is an interesting summary of the latter point: Sinnott C et al doi:  10.1136/bmjopen-2013-003610 GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research

Registrars confidence levels – 2014 snapshot

As part of routine feedback, evaluation and quality improvement in training, a survey was done in 2014 which was a snapshot of confidence levels across registrar terms and in different curriculum areas. Basically, registrars appear to increase in confidence in all areas by term 3 (over 18 months), as might be expected.  On a scale of 1-5 the average difference in confidence levels, between Term 1 and Term 3, in managing various patient groups and problems was 0.6 (from 3.3 to 3.6).  However there was quite a range – from 0.3 to 0.9.  The areas rating 4 or above in levels of confidence by Term 3 were:

  • uncomplicated older patients (also high initially)
  • young children with acute presentations
  • patients with hypertension, hyperlipidaemia, diabetes
  • women’s health problems.

Of course, this could reflect a high initial level of confidence, effective teaching or natural improvement with appropriate experiences. It would be nice to have the opportunity to tease this apart.  In our then Regional Training Provider there was a significant focus on education in cardiac risk factors and diabetes and numerous sessions on women’s health and mental health.

Interestingly, therefore, the lowest Term 3 level of confidence was with multimorbid patients (with three or more chronic diseases / morbidities). The difference in confidence between Term 1 and Term 3 in this area was relatively small and from a low base. There had been no focussed specific input except that some of the registrars may have heard a one-off lecture by a visiting international speaker.  Interestingly, also, the broadest range of confidence levels (averages don’t always tell the whole story) were in child health, women’s health and multimorbidity (2-5) so perhaps not everyone needs the same interventions in each area and learning needs to be individualised, as we know.

After the implementation of the new multimorbidity education approach in late Term 1, the confidence levels were followed in this cohort. They already demonstrated a relatively high confidence with uncomplicated older patients despite educator concerns about lack of clinical exposure.  Multimorbidity started at a low base and then increased by 0.6 which was just below the average increase in confidence over the period.  We asked a new question in the final round about confidence levels in “patients with multiple morbidities PLUS polypharmacy or psychosocial problems”.  This only achieved a level of 3.3 (the lowest in term 3).

I suspect that “complex mutimorbidity” is the new frontier.

What registrars see

Registrars felt that they were seeing sufficient multimorbid patients for learning. In end-of-term feedback on their perceptions of the variety of patients in their placements, registrars (on average) reported seeing a good proportion of children, older patients, chronic disease and multimorbidity along with only slightly less mental health and women’s health.  On the other hand many registrars had limited experience in men’s health, palliative care and nursing home visits.  However, numbers and statistics do not always reveal the full picture.

In the practice

A registrar may see more than the average number of older patients or chronic disease diagnoses and yet they may be having shorter consultations with low markers of continupaperbark-fernleighity and unexpectedly lower than average number of problems per consult. It’s good if a training program collects, utilises and feeds back this sort of data in order to close the educational loop. This type of picture may possibly be interpreted as less engagement with the complexity.  On the other hand a registrar seeing fewer such patients may be encouraged by their supervisor to gain the maximal learning from their experiences. The potential is there but there needs to be an individualised approach – the experience for each registrar in each practice can be widely different at different points in training and a supervisor can adjust their teaching in the light of this.

What is helpful – the registrars’ retrospective view

A summary of points from previous survey and focus group data

  • It is useful to experience the continuity of staying in the same practice for more than six months.
  • Initially consultations tend to be “repeat script” appointments but by Term 3 they were taking more ownership.
  • This was affected by how much supervisors “owned” their own patients.
  • It was limited also by the variability of supervisor’s expertise in the area
  • The top three useful strategies were: 1. case discussion 2. prior hospital experience (gen med, aged care, pall care and ED terms) and 3. workshop sessions.

Registrar suggestions to maximise effective learning in this area

  •  Learning needs to be patient-based in the practice and involve case review with the supervisor (with the patient if needed) plus discussion of common combinations of co-morbidities.
  • There is a preference for case-based teaching in workshops.
  • Medication review discussions should happen with supervisors.
  • Early exposure to guidelines and read up when not confident.
  • “Co-ownership” of a chronic disease patient with the supervisor.
  • Involvement in nursing home care
  • Emphasis on information re local resources