Category Archives: educational methods

Some reflections on medical education at the end of a plague year


A year ago I was in the UK.  Some years the cycles repeat themselves like ecclesiastical dates or  “terms” in the academic year but, sometimes, something happens and nothing is ever quite the same again.  I’m sure the daffodils are flowering again in Finsbury Park but medical practice and education are still in a state of flux.

This post was part written at the end of August and, like many things in this year of Covid, it got postponed.  August was an upside-down month for me.  My usual August for the last few years has involved attending the Edinburgh Fringe Festival (where my daughter performs) followed later by an event with a different vibe – the AMEE conference somewhere in Europe.  So, there I was with no presentation to prepare, saving money by registering online and hoping the technology worked.  I saw a few interesting sessions and came across some relevant online posters when browsing but the vibe was certainly different.  A few months later saw me having to change a 1.5 hour workshop at another European conference into a 45 minute presentation.  Not sure if anyone saw it.

I was indeed fortunate to continue being involved with writing and delivering some online modules for a Certificate in Clinical Teaching and Supervision during the year and I was able to do that from home.  Currently these can be found at  and the twitter link is ModulesInClinicalTeaching @GPCertModules  The last module was on e-learning and teaching.  Later in the year we started some online live webinars – so a few new skills acquired!  Those deadlines provided some structure.   In fact the third Zoom online, on the topic of Feedback, is happening on March 9th (more information at

In between, I read a lot, ensured I did more daily walks than usual and set myself some drawing projects.

What is happening to education and training in the glow of corona?  I guess the answer to that is not yet complete, it’s not the same in every country and probably will continue to change, depending on what is happening in each country regarding Covid-19 (and now the vaccinations).

This year has revealed (in Australia) the significance and extent of casualisation in Universities.  One might speculate in what ways this influences the quality of education, training and the morale of teachers and researchers.  It’s an issue that won’t go away but may eventually become unquestioned and something to just “live with” (as some say), but perhaps it warrants a few minutes’ thought.  Moving from face-to-face to online is different from moving distance learning to online.  At many levels the effect of the virus has been unequal and the enormous work of changing courses to online at short notice also fell unequally.  Of course, let’s not forget that more workers in the arts sector also lost their jobs and, for some, their careers in one fell swoop.

We all knew that we were moving slowly toward more online and less personal contact but this suddenly accelerated and I reflected on educational aspects of that in my last post in May.  It’s had its challenges but it’s also been interesting.  There will no doubt be lots of presentations at next year’s medical education conferences about what worked and what didn’t.  As educators we are hopefully moving from getting it done, to doing it well (but what are we measuring?)  There are lots of “tech” things happening and that provides opportunities to some.

We changed our ways of engaging and communicating and some words and phrases got used a lot more frequently or developed different meanings: zooming, you’re muted, podcasts, WhatsApp it, virtual conferencing, breakout rooms, asynchronous webinars etc.

Other training organisations were already losing funding in many instances, and is it possible that online training may be seen as a panacea, not just to the viral context but to the economic context?  However, it is not often acknowledged that to do online “well” is not necessarily cheaper.

Will education be changed for good (or for the better)?  Will we reassess the place of interaction and the interpersonal in health professional education – but also in the area of health care generally?

I have no answers to any of this but I confidently predict some interesting PhDs and books in the coming years.

Going viral: some lockdown thoughts on e-learning

And apologies for the overused pun in the title. When I recently returned from the UK it seemed like there wasn’t much to say on medical education at the moment.  Suddenly life and death issues were raising their heads instead.  At the time Covid-19 started to flare up I was on my way to the UK to help out with grandkids.  This suddenly became more complicated.  With family there involved at the scary front line of the NHS and the numbers predicted to rise, it suddenly began to dominate our thoughts even further.  So much so that we were persuaded to return to Australia ten days early in the expectation that things would be better here for someone in a relatively high-risk category.  The weekend we left, the reported deaths in the UK numbered 10 and within a month were in the thousands.  The rest is history – still in the making.

When we got back – to self-isolation – I noted GPs getting themselves organised for the predicted onslaught with discussions about sourcing protective equipment and changing over to telephone or video consultations.  Within not too long a time the government gave this their imprimatur when they came up with a medicare item number for telephone consultations.  Suddenly they were “a thing”.   Meanwhile my university colleagues (in all faculties) were suddenly under the pump to change everything over to “online” in an incredibly short time frame as rules for social distancing, group gatherings and working-from-home came into effect.  I will not be attending AMEE in Glasgow this year, sadly.

Just now we all have a very volatile work and social situation which is very different from country to country and with negative economic implications still developing world-wide.

Meanwhile I was still working on the (already online) CPD modules for the Certificate in Clinical Teaching and Supervision (general practice) for which most modules had been uploaded on Open Blackboard.  All my social interactions turned into Zoom get-togethers.  As the weeks progressed and the country’s response seemed to have worked (as I write) in holding Covid numbers down, some GP colleagues actually noted practices being quieter as patients stayed away – no doubt a temporary hiatus as other presentations can no longer be deferred.  But there is talk about General Practice itself having changed for the future and who knows for the tertiary education sector. So, it was suggested we add a tenth module on “e-learning” (instead of leaving it as a parenthesis in some previous modules).

Thus, I have been pondering and reading the (not very extensive and not always very current) literature around the topic and here is my current, unfinished list of thoughts and queries which I’m sure will start being addressed by the next generation of educators

  • When we have sessions on “consultation skills” in the future we will have to have one also on the subset of “telephone consultation skills” and “video consultation skills”.
  • When we think about presentation skills and running small groups we may be adding in “Zoom Skills”.
  • We are well versed in some important pedagogical skills for medical education but how are these being put into practice in the online environment?
  • The move to “online” had been already happening – often with the managerial impetus of cost efficiency rather than educational value – but suddenly it has accelerated and become all pervasive and we are not all necessarily up to speed. There is little spare time to acquire the skills and management need to consider their responsibilities in this regard.
  • On the other hand, it will no longer be OK to be proud of being an eccentric Luddite, not knowing how to switch your computer on, how to download an app or the name of the latest social platform used by your students. The gap between teacher and student may widen.
  • Many of us subscribed to a view that education is emphatically interpersonal. How does that stand up now?  Previously we had perhaps turned to Blended Learning to make up in some areas for the growing lack of interaction in others.
  • On the other hand, let’s face it, not all lecturers related to their students, even in the “good old days”. So, let’s not idealise it and let’s move on to how we can interact in the brave new world.
  • A more generic Covid related educational issue that has come up (to which my husband alerted me) is the whole issue of health messaging to populations (with evidence from different countries, or even states, with different systems, cultures and politics) and by extension communicating with and educating of patients.
  • It will be nice to have some evaluation of what is actually effective in the new environment, not forgetting to research the actual experiences and wellbeing of learners and teachers.
  • Online learning is an interesting area where we need to apply some basic and long-standing principles with which we are very familiar to what is a very changed environment – a constantly changing context of tools, resources, platforms, apps, connectivity etc
  • A bigger challenge may lie in the previously expanding area of work-based learning especially in the community. This will be particularly in question for undergraduate health professional students, depending on what happens re Covid-19 in the near future with its implications for safety.
  • There are exciting ways to utilise technology to enhance education but this is likely to still be constrained by bureaucracy
  • Meanwhile we also need to not fall into the trap of being driven completely by the technology where we only value what can be measured in the newly constricted context or where any innovation is responded to with a “computer says no”.

I’m sure we will all think of a few more points over the coming days and months.

To PPT or not to PPT – that is the question

Whether or not to use a (now almost “traditional”) PowerPoint (PPT) presentation when asked to run a session is certainly a good question but it’s not necessarily THE question.  There are many more important questions in education.  However, it is worth thinking about when you are asked to present on a topic to a large number of people.  In medical education, there are a minority of instances in which a single lecture is better (educationally) than a small group or a reality-anchored, case-based discussion in the clinical context.  However, there are increasing instances when budgets and logistics require it – either in person or online.

Should you use Powerpoint or not? Opinions are divided – and strong.  But sometimes the opponents seem to be opposing a straw man (the bad PPT).

With ideas or technologies (as with drugs) there is often a bit of a dialectic: a phase of enthusiasm, a phase of backlash and then a more reasoned compromise.

Powerpoint does have its proponents in education. One argument is that it helps the more modestly skilled performer to get their material across (rather than constraining them). The critics make the point that a lecture is actually a performance anyway (and should be a good performance).  I suspect those who are keen to ditch PPT probably have some natural performing skills already.

I have been around long enough to remember when the usefulness / appeal/ memorability of a lecture depended on how enthusiastic and charismatic the lecturer was. Some certainly weren’t worth going to. Others were most enjoyable and entertaining but the content dissolved into the mists of time and had no permanent impact.  This was the “BP” era – the days Before PowerPoint.  It was quite a relief when we were able to expect that a lecture would have a structure with bullet points and take home messages

The backlash

A Guardian article sums up some of the complaints about PowerPoint, claiming it is making us stupid. It has been around for thirty years and concern about it began early.  It is relevant to note how it followed on from the overhead projector and was initially geared toward desktop graphic projection in meetings.  Of course it has now moved on to the point where slides are compulsorily loaded onto websites and students feel no obligation to attend as all the information is assumed to be on the slides.  The Guardian article also notes that students have been known to demand it back when it is withdrawn.

Some critics feel it limits the way we think and oversimplifies issues. Some feel that the intrinsic nature of the design of PPT templates is to blame for poor presentations and others feel that the way information is put on slides can inhibit learning because humans are only designed to learn in a particular way. If you are interested in some of the neuropsychological arguments you could look at work by Stephen Kosslyn (book called Clear and to the Point) who has drawn more optimistic and detailed conclusions about how to structure presentations to achieve better learning outcomes.

Discussion is fairly opinionated and, of course, it is notoriously difficult to get strong, replicable and generalizable evidence about educational methods that are guaranteed to work for you.

Critics also tend to focus on the obvious failures in some presentations. This presentation by Ross Fisher is titled “Everything you know about presentations is wrong” and brings up many useful points including tips for improving presentations. It’s a long but listenable-to presentation. He maintains presentations often fail because of “cognitive load”.  He is a paediatric surgeon and well known to many medical professionals involved in education. His “P cubed” framework focusses on story, media and delivery   The aim is to keep people awake and he comments that the value of a presentation is what the audience thinks it is.

There are some interesting assumptions about how we (all) learn which it would be great to test. If someone talks and has words on a slide does this help learning or does it impede it?   Does it help some learners but hinder others?  Is it better to have an engaging picture while someone talks or is that distracting for some people?

How do we learn?  

There are theories about how we learn and numerous specific studies about the factors influencing effective learning. This article is broader than just presentations: “Applying the Science of Learning: Evidence-Based Principles for the Design of Multimedia Instruction”

demonstrates how complex may be the underlying theories. The cognitive theory of multimedia learning states that people learn more deeply when they build connections between verbal and visual representations of the same material and this paper lists studies demonstrating the success of strategies predicted to enhance this. One of the practical messages is not to overload the visual channel. This is quite a specific study on visualisers and verbalisers and the main lesson is probably that it is very complex, there are individual differences and it is very hard to apply in practice.  It was interesting that only for visualizers was learning success substantially impaired if pictures or animations were missing. Certain professions scored differently on the spatial imagery scale, the object imagery scale and the verbal scale.  There was also a suggestion of a gender influence.

Let me confess something. I was probably a serious teenager and I used to attend church to hear sermons that were not short homilies. I enjoyed hour long lectures on topics I liked and had no problem concentrating but now we advise stopping after ten or twenty minutes because of the general issue of concentration span.  I assume a lot of it was to do with motivation, expectations and sub-cultural factors.  I can still remember  the title (but not the content) of a sermon of the 19th century preacher Spurgeon that I read in a rather lengthy collection:  “Hope yet no hope, no hope yet hope.”  I remember it because my great Auntie Ethel saw it over my shoulder when I was reading it and read it out in a broad Yorkshire accent commenting “It’s enough to give you brain fever!”  There are now similar concerns that Powerpoint, in a different way, is giving us “brain paralysis”.  We have certainly moved from a very wordy culture to a more graphic one – although prior to literacy there was much supporting illustration on church walls for instance. A perusal of 19th century newspapers or novels suggests the population was accustomed to more “wordiness” without pictures (even still ones).  When I reflect I realise that I prefer to read a book than listen to an audio version and I compulsively read ahead on PPT slides.

The synthesis / compromise – what works

I am never going to be a dynamic presenter. Just an adequate one.  But it shouldn’t be all about me anyway!  Perhaps we can still structure effective learning experiences.  There are some common themes that emerge from all the reading (and viewing) I have done – in terms of the principles for effective presentations.

This study on Presentation vs Performance: Effects of lecturing style in Higher Education on student preference and student learning actually seemed to examine the differences between a “good” and a “bad” presentation.  The basic PPT presentation describes PPT at its worst.  The Performance approach included slides with much less text, more images, relaxed manner and varying tone of the speaker, use of personal anecdote and audience interaction.  Needless to say it was more popular and more effective.

Ross Fisher’s positive tips were not too different from the earlier advice for good powerpoint presentations or the article on presentation vs performance. He suggests the slide set, handout and script should be different, he notes the importance of story and suggests a “star moment” in a presentation. He alludes to font size, not being distracted by logos or too many words and he emphasises the importance of any performance: projecting to the audience and practising.

The following are two nice brief pages from University of Leicester of practical hints about presentations.

This readable article reviews some of the evidence regarding the learning outcomes of lectures with and without powerpoint.  It indicates that PowerPoint has no significant impact on learning – but students like it.  However, the way it is used affects learning.     An assertion-evidence approach is best (read the article for the details) and with or without PowerPoint, lectures are less effective than methods using active learning. This is a good warning to not be seduced into providing only lectures, however good, and to assess your goals, the audience size, the topic, the venue and so forth as you choose an appropriate method.  It is an encouragement to continue the broader task of structuring  learning experiences in all the contexts of learning.

Currently I am preparing a PechaKucha presentation (a style originating in a Japanese architecture office) and trying to apply a few of the principles above – quite a challenge!

Eyes only – visual variety in presentations

This is my fortieth post so I thought I would veer away from the serious and look at some visual distraction. Dermatology is very visual and I have often interspersed presentations of skin pathology with various bits of nature with tangential connections. I’m not sure if this has made the diagnoses any more memorable but it has meant that I still can’t observe some natural features without making the connections.  Just recently I couldn’t help but comment on a keratoacanthoma at the beach.

And just for a diversion see if you can give some diagnoses to the following lovely tree trunks:


A colleague sent an interesting photo of lichen recently.  Whether on rocks or trees, there are certainly dermatological echoes of lichenification.

If you stretch the analogy, here are some floral versions of various pink and erythematous rashes (and similarly all looking the same to the untrained eye of my spouse, apparently, despite their very different appearances and contexts)!

       And here is a polymorphic eruption, on a less than clear day.

Then there are the evocative descriptive terms such as spider naevi, serpiginous rash, cobblestone papillae, strawberry tongue and geographic tongue or descriptive words that have Greek or Latin for illustratable things like coins, tear drops, bran or nets (nummular, guttate, pityriasis, reticular) that could be in the corner of your slide as an aide memoire.. The list is endless.

And what does this, on my local rock platform, make you think of? I could go on, but I won’t. Spicing up presentations with apposite holiday snaps with visual metaphors can be quite diverting and make the task a little more creative.



Teaching when you don’t know the answers

Fortunately it is often effective to use the perplexing case as a teaching tool and sometimes it is possible to have the patient as a partner in the teaching and learning process. It also gives the opportunity to treat the learner as a colleague.

This approach can be used for either medical students or registrars. Supervisors often call in registrars to see a “classic” rash and this is great in increasing clinical exposure.  Sometimes we are tempted to leap in with answers rather than leading the learner to work out the solution to a diagnostic or management dilemma.   However, if there isn’t yet an “answer”, there can be an even more valuable learning exercise.

In the past I have asked those finishing a gastro term for suggestions on abnormal LFTs or a student with a previous life as a physio for advice on musculoskeletal problems, but this is still seeking answers. The patient I have in mind is where we are still puzzled and are trying to work out how to proceed.  This brings in the opportunity to make clinical reasoning skills a bit more overt.  This calls to mind when I had  a patient with an itchy annular lesion that wasn’t quite “classic”(barely visible scale)  and was getting worse.  The registrar and I discussed the top-of-the-list differential diagnoses and the most useful investigation to do as the next step.  It raised the issue of tinea incognito (which skin scraping confirmed).

Sometimes you see a patient’s name on your session list with a medical student booked in also. You have gone a certain distance in the diagnostic process but all is not clear.  I might speak with the patient beforehand and ask them to be part of the learning process.  I guess this is more than just signing the consent form before they enter the room.  You might admit to the student that you still don’t have an answer so your “interrogation” of their history and examination is not an attempt to catch them out (or demonstrate your superior expertise).  When the patient has a skin problem, you might structure it by leaving the student to take a “dermatology history and examination” and return to ask them to present their findings (with the patient to comment as need be).  You can add anything they might have missed in the history (and discuss why it’s important) and also chat about how to describe things in “dermatological language”.   You might share your own diagnostic process so far (and this can be informative for the patient). You may lead the student to the next diagnostic step that you perhaps already have in mind.  With the patient gone you can put the learner on the spot a bit more with asking them to commit to (say) three differential diagnoses and  ask them to identify some questions that remain – for self-directed learning.  You can share online resources for instance if relevant (useful sites might be    or )or share brief stories of other cases if relevant.

I thought I would use this approach a couple of weeks ago but then the patient went off on holidays so I had to adapt. The patient had already given me permission to take a photo and use it to discuss with colleagues or for teaching. In fact she was happy for this to happen since we didn’t have a diagnosis as yet. It was on a nicely unidentifiable part of the body. The evening before the session I put the picture into a power point and structured the slides historically with the questions that arose as the case unfolded.  I put questions at appropriate points and printed out the half dozen slides. I  had also sent a question around my colleagues at the practice asking their opinion and one of them said it reminded her of an article she had just read in AFP on skin biopsies which I printed off and gave to the student to read later

The session had my usual collection of older complicated patients with multiple problems, some with diabetes, a couple of teenagers, a person with an unexpected result to explain etc. We took five minutes between patients and I suggested we pretend the patient was there and we worked through the printed case thus far.  We reasoned through it and I asked for suggestions.

This particular student was very knowledgeable and the diagnosis (revealed at biopsy later) was on their list of differentials. At the end of the session as they left they said “Oh, and thanks for the teaching session with the dermatology case. It was great.”  And I thought I was teaching the whole afternoon!  Amazing what a bit of structure does.

We need to adapt

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

(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!

Summer holiday learning: some tangential thoughts on multimedia

Here I am, diverted from the intended topic of my next blog because something came up that made me think laterally (which may or may not be a good thing).

Last night we drove to Sydney and attended Rembrandt Live. This was a concert by the Brandenburg Orchestra but, instead of being in a concert hall, it was held in the NSW art gallery.  We followed the musicians (in period dress) as they moved from room to room through the Dutch Masters exhibition of paintings from the Rijksmuseum.

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.

It is obviously entertainment rather than learning but the element of engagement is common to both. It made me think about multiple media in teaching and the theories of effective learning and multiple modalities in Continuing Medical Education.   I won’t list the evidence (or lack of) right now as it really was just a thought bubble but perhaps it is one for you to consider as an educator.

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.

So did I learn more this way? Well, I guess that wasn’t really my motivation in being there although I do like to gain extra knowledge from such occasions.  It was certainly a very enjoyable experience.  Actually we had previously attended the exhibition and I had learnt a lot more information from listening to the audio commentary so on this occasion I felt free to be more selective in what I viewed and to revisit particular paintings at the end.  This reminded me of the benefit of repetition for learning (and the Spiral Curriculum in Problem Based Learning).  Of course, before planning any new educational “events” for medicos, bear in mind we can be a serious lot with a disinclination to “waste time” and a tendency to let you know – so perhaps consider my musings as more of a metaphor than instruction manual.

Before we went to the exhibition we read a scathing review of it whose main criticism was that many of the pictures were the same as those included in an exhibition from the Rijksmuseum in Melbourne some years ago. We discussed this and decided that a. we weren’t sure if we had seen that exhibition (although we visited Amsterdam years ago and may well have seen the same pictures); b.even if we had seen them we had probably not appreciated them fully in the few minutes allocated to each in a walk through such an exhibition; c. if you enjoy certain pictures then you enjoy seeing them again when you have the chance (why else would you hang them on your walls).  In the medical education environment I can confidently state from experience that I am capable of sitting through the same lecture on an annual basis and still benefitting from it (things I forgot, things with new relevance etc)

Will my learning persist longer because of the multi-media? Well, we were motivated to buy a book (I am a sucker for museum gift shops)  called “A Worldly Art: The Dutch Republic 1585-1718” so I imagine if we go on to read some of this we will have moved on to a bit of “lifelong learning”. I might download Tulip Fever on my kindle or watch it on Netflix.  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!

To everything there is a season

I have always liked that quote (from Ecclesiastes 3:1 in case you were wondering), probably reinforced by the fact that it was turned into a song in the 60s (and a hit by the Byrds – who remembers them?) in my impressionable youth.  

There is a time for being serious and academic and evidence based in medicine and medical education -and that is probably most of the time – but thank goodness the BMJ has a seasonal xmas edition with lots of light heartedness.  One of my favourites this year was “Does Peppa Pig encourage inappropriate use of primary care resources?”  which was apparently taken as a serious suggestion in some quarters.

In medical education there are also times to be serious and occasions on which to be more light hearted, though generally it is within the overall context of imparting a learning experience. Sometimes it’s just for the purpose of enhancing the  interpersonal part of education which is in decline in current programs.  A Christmas quiz in a workshop setting can always include answers such as “Christmas disease” and questions about red noses and liver function tests.  Of course one can’t guarantee this method will be appreciated by all participants.  Some years ago I included a lunchtime “trivia” quiz at a workshop.  All the exam-style questions focussed on topics presented during the workshop day and four out of five were serious.  Twenty per cent were real trivia.  For example there were questions on respiratory disease and then some where the answer might be a rock band with a song title about “air’ or “breath” etc.  Out of a few dozen feedback sheets there was one comment that a trivia quiz was “unprofessional”.  They obviously felt it wasn’t the right season and maybe it’s all about the framing and expectations.

There have been many seasons in medical education. There was a long era of lectures and a shorter epoch of small groups.  There has been an evolution of overhead presentation technologies and we have entered the age of performance in the TED (technology, entertainment, design) talk template.   My daughter is a stand-up comedian and I observe similarity between the preparation for a six minute comedy set and a six minute Pecha Kucha.  There have been other more innovative approaches and, for the researcher and presenter there have been books, libraries, index medicus, online journals and, praise be, Google.  In terms of seasons, it is probably Spring heading into Summer for the use of various aspects of social media in medical education.

If we go far enough back there have also been dire warnings, at a society level, about TV replacing radio and cinema, screens replacing books and too much time spent on video games or social media. So it goes on. Perhaps the main issue is the end point – informed and reflective individuals – and there are stimuli aplenty to thinking and reflection in the whole range of media.  Afficionados of one approach to education are very much inclined to bag other approaches but perhaps there is wisdom in the quote that started this post and which still resonates with me after all these years.  “To everything there is a season and a time to every purpose under heaven”.   It all depends on appropriateness (and there is professional judgment in that) and that may depend on purpose and context (in its broadest sense).

Take some time over the Christmas season to take in a good (or bad) film, an interesting book, concert, gallery, magazine or blog and exchange views on social media or in person. I hope we can all find some time to relax, reflect and relate (and start the new year revived).

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.


  • 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 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).

What’s new, what’s old or what works (from AMEE)

Much of medical education today focusses on being “innovative” (or complaining that older methods cannot possibly be appropriate). A few weeks ago I was at the AMEE conference in Helsinki, looking for “what’s new” but was impressed by one of the keynotes addressing what actually might work in education. It was great to be challenged by some broader educational ideas (instead of just which particular testing method has temporarily replaced the previous one).

The address was by Pasi Sahlberg and looked at Finnish lessons for education – stimulated by their consistently impressive ratings in the PISA results (in school education) from the OECD. These came to light initially in 2001 and it took a few years, apparently, for the Finns to take them seriously and actually believe them – and, therefore, to start looking at reasons behind this. The country’s school children performed well in literacy, then maths, then science.

Australia’s response to their own falling position in the rankings has been to introduce more testing.

Countries that don’t improve

 Sahlberg speculated on some characteristics of countries that don’t improve in educational outcomes: they emphasise competition and choice; they have test-based accountability; teaching is de-professionalised and they are addicted to reform.

What might have worked – in Finland

There is an emphasis in many areas on everything being “faster” but Sahlberg claims that, by contrast, Finland is into “slow learning”.  He characterised the education systems that perform better as including:

  • Collaboration
  • Teacher involvement in curricular development
  • Trust based responsibility
  • Teacher professionalism
  • Systems improvement rather than reform.

An emerging feature was the relationship between quality and equity.

He also raised the issue of using small data.  Big Data has certainly proved useful for global education reform by informing us about correlations that occurred in the past. But to improve teaching and learning, it behooves reformers to pay more attention to small data – to the diversity and beauty that exists in every classroom – and the causation they reveal in the present. In some other venues he has flagged the increasing use of technology as influencing educational outcomes but also now dictating the research agenda.

His slides are here but don’t give the full flavour of his talk (such as playing “Knocking on Heaven’s Door” and getting the crowd of several thousand to sing along).  Of course the PISA rankings have produced their own problems and encouraged teaching to the test in many countries although they do now look also at broader equity issues.  Finland’s top position has been taken recently by several East Asian countries with very different approaches. Some commentators note that, compared to Australia, all these high performing countries have much more homogeneous populations (which is now changing in Finland) – but, on the other hand, Canada has also consistently maintained a higher position than Australia. Whatever that means.

Sahlberg addresses the pros and cons of PISA including increasing commercialisation in this area but also notes there have been austerity measures in Finland since 2008: Finally, what Finland should learn from these recent results is that reducing education spending always comes with consequences. It is very shortsighted to think that high educational performance ….. would be possible when resources are shrinking.

Relevance for medical education

Schools are a long way from the medical education environment (which can be quite privileged) but sometimes it’s good to stretch our minds and consider some broader concepts. Besides which, it is probably also of interest if you have children or grandchildren.  Like all education, the possible variables influencing outcomes are myriad and even the outcomes themselves are debated.  I won’t draw particular conclusions but suggest that it might be interesting to reflect on your own teaching/learning environment and the system in which you work.  Consider which concepts have relevance, the direction in which your education system is heading and the implications of this.

We often encourage post graduate trainees to reflect and there is some literature on whether one can teach “reflection” so perhaps we educators should also be trying to reflect on concepts such as: collaboration, competition, professionalism of and respect for educators, opportunities to use small data to improve, the reasons for reform, resources and funding priorities, the use of tests etc – and whether “slow learning” might be relevant for post graduate GP training?  Maybe an interesting workshop topic.


(silver birches in Finnish forest and airport sculpture)