Category Archives: educational methods

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.  https://www.theguardian.com/commentisfree/2015/sep/23/powerpoint-thought-students-bullet-points-information 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” https://www.youtube.com/watch?v=8Cl0xskA9fM 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 http://ffolliet.com/   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: http://result.uit.no/basiskompetanse/wp-content/uploads/sites/29/2016/07/Mayer.pdf “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.

http://onlinelibrary.wiley.com/doi/10.1002/acp.3300/full 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  https://eric.ed.gov/?id=EJ959028 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.

https://www2.le.ac.uk/offices/ld/resources/presentations/delivering-presentation

https://www2.le.ac.uk/offices/ld/resources/presentations/visual-aids

This readable article reviews some of the evidence regarding the learning outcomes of lectures with and without powerpoint. http://www.hagerstowncc.edu/sites/default/files/documents/14-fletcher-powerpoint-research-review.pdf  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 https://www.dermnetnz.org/    or  http://www.pcds.org.uk/ )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 https://www.racgp.org.au/afp/2017/may/skin-biopsy-in-the-diagnosis-of-inflammatory-skin-disease/

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 https://docs.wixstatic.com/ugd/bbd630_9068591ed32045ef9e10c04cdf3086a2.pdf

(about Care of The Elderly) there are some very good reminders about frail patients – but it is good to contextualise for the community context.  To utilise it appropriately for GP registrars, the differences need to be addressed.

The Teacher

As an educator you might research the relative importance of certain presentations in hospital patients versus GP patients. As a supervisor you could suggest your registrar reads the document and then discuss how they think it might apply to general practice. Or you could be more specific and read it in relation to particular patients.  The Welsh document has some Top Tips for geriatric medicine and on the first page are

Six Random Thoughts

Number five stated: For confused patient, a collateral history is vital – it is important to determine if the patient has dementia, delirium, or both.

This is a good starting point for a discussion on confusion in general practice. Delirium is less common in general practice – but on the other hand it is therefore likely to be missed, so the message is to think of it. Delirium is addressed on page 8 of the document. Discuss how it may present (especially quiet delirium).  The other relevant point in general practice is to discuss the possibility of delirium with a patient (and family or even surgeon) when they are facing hospital admission.  The GP can often identify when a patient has risk factors for development of delirium before they get there.   Of course, in general practice it is worthwhile also having Depression in your DDx.

The document quotes a great definition of frailty

“Frailty is characterised by a vulnerability to stressors which would not affect non-frail people. These stressors can range from a bereavement to septicaemia. These stressors can lead to a rapid decline in both functional status, and in some cases physiological deterioration. This decline may be reversible, but in many cases the person will not return to their baseline.”

GPs see patients earlier along the Frailty spectrum and are in a position to act when these stressors occur and to check on the patient and initiate actions that may help reverse or slow down the decline. Putting in place relevant supports at the appropriate time can help re-balance the scales in their functional status. Ask registrars how frail they judge a particular patient to be (and why) and brain storm with them about what services might benefit a particular patient with multimorbidity and polypharmacy, a recent hospitalisation, a recent fall or bereavement.

One section notes some very useful dos and don’ts of de-prescribing

 These are really worth discussing and a teaching session that involves reviewing a patient’s medications is always worthwhile. In general practice there is a smaller proportion of very frail patients and the clinical judgment required to make sound prescribing / de-prescribing decisions is challenging.  At what point might you discuss stopping preventive medications?  It will not necessarily depend on age.  Because we know patients over time they can sometimes decline imperceptibly and the prescribing decisions may need to change.  A registrar can cast new eyes over a patient so ask for their thoughts.

Often frailty scales are used more to keep patients out of hospital or decide if they need a palliative care approach or whether more resources are needed. My PhD was about developing a scale for general practice – to predict those at risk of frailty.  The importance of this is that you might make a difference at a much earlier stage.  The definition of frailty is very helpful but In the GP context I would suggest stating some of those hospital messages slightly differently.  Some points to emphasise might be:

  • A patient may become gradually more frail while you’re not looking
  • Carer or relative observations are important
  • What are some predictors you can pick up which might suggest a patient is more vulnerable -this might be information to pass on to the hospital when relevant
  • How can help be obtained in your geographic area in a timely fashion rather than leaving it too late? (bearing in mind that knowledge of community systems is crucial to being an effective GP)
  • Check for cognitive impairment
  • Frailty is a continuum rather than an either/or and care is also continuing rather than a one-off.

Other topics are UTIs, falls and end PJ paralysis. For the GP, what are the strategies for encouraging and maintaining mobility in patients in the community? The last topic in the document is Advanced Care Planning.  There are impressive figures given about death rates of in-patients and those in residential care so it is a very relevant issue. General practice has many more healthy, resilient coping patients. Not many of our patients die in a twelve month period  (and meanwhile we are seeing babies, teenagers, young families etc, all requiring a different paradigm of care).  Registrars, in particular, might have a patient load of which only a small percentage is over 65. However, we do see those transitioning to frailty, at risk of frailty.  This makes it a challenging topic in general practice which is worth discussing.

It is always worth directing attention to up to date guidelines but, even then, it is worth a discussion about how you might need to adapt them in practice. Even if there is a screening tool which will work on data entered into the electronic health record it is important to discuss the relevant concepts and issues with the learners in the practice.  There are protocols and there is clinical judgment.

And the document finishes with some book reading suggestions – always a good idea!

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?” http://www.bmj.com/content/359/bmj.j5397  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.

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).

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. https://pasisahlberg.com/next-big-thing-education-small-data/ 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 https://pasisahlberg.com/wp-content/uploads/2017/08/AMEE-Talk-2017.pdf 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 https://pasisahlberg.com/the-leaning-tower-of-pisa/ 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)

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