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 https://bit.ly/3detS5S 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 gpcertificate@newcastle.edu.au).
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.
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.
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).
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.
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.
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.
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.
This is my fortieth post so I thought I would veer away from the serious and look at some visual distraction. 
And here is a polymorphic eruption, on a less than clear day.
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).
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 
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.
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 
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.
Thus there was music (from an era I love, especially when it features period instruments and recorders) and paintings (from a school I really like) and this was accompanied by three dancers who also introduced an element of physicality and humour. There were even some background noises suggestive of a Dutch seventeenth century streetscape (but not the smells). At the end we had a further fifteen minutes to browse the exhibition. This was an event that recruited multiple senses.
I wondered if I learnt more this way. So here is some immediate feedback from a sample of N =2 (I include my husband who noted he appreciated the ability to focus on several different things). It was initially a little disconcerting to hear applause for the dancers in the previous space while the musicians were playing in the next one. It certainly wasn’t boring. It wasn’t too long and I appreciated being able to walk, stand or sit on the portable stool as needed. I wasn’t therefore distracted by physical discomfort (brief snack could be had beforehand). There was certainly an ambience.
We might sit in our comfy arm chairs of an evening and share some interesting titbits of information that lead on to further discussion (and maybe a Learning Plan involving Google). I have also recently started a botanical drawing course so I took a deeper interest in the Dutch still-lifes. Sometimes the full impact of a learning event can be broader than you think.
Prior to the concert we walked through the Botanical Gardens and I enjoyed the height-of-summer cottage garden flowerbed. It reminded me tangentially that there often seems to be added value if you attend a conference in a pleasant place. Such things are hard to measure but maybe should be a topic for further research!
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).
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).
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).
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.
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.
