Category Archives: general practice

On the smell of an oily rag: risks for teaching in a resource poor environment

From an educational perspective there has been much talk of the benefit of learning in the clinical setting.  In addition, the increase in the numbers of “learners” across the board and the shorter stays in hospitals has also created an imperative to divest some of the learning to the community context. As the numbers of students and registrars increase there appear to be expectations that more and more doctors will be trained in that generic environment called “the community.” But like many things transferred to the community, funds rarely follow.   The positives of learning in the community setting are huge but there are also challenges, especially where community practice is largely private practice. 

The benefits include the broad clinical scope and the chance to see earlier presentations and undifferentiated symptoms instead of the already diagnosed and streamed.  It also creates opportunities for experiencing prevention, continuity and seeing patients in their broader social settings.  And much more.  However, how do we ensure equivalence of clinical exposure across disparate settings and supervisors, maintain quality control across an environment over which we have little control generally and how do we generate enthusiasm for teaching when taking time out to teach is a financial loss?  I think there is general agreement that expectations are increasing but support, resourcing and funding are not keeping up (in Australia).

Resources for medical education are variable.  When there is a new medical school opened to great fanfare there is often a welcome flush of funding.  In many instances the medical school proclaims a new approach to medical education and there may be a well-resourced medical education unit – for a while at least.  On the other hand, teaching within the hospital environment can also be very variable and dependent on local policies, funding and priorities.  Often there is time allocated (in theory) for the education and training which is written into many of the relevant standards for post graduate training.  Each country has its own systems.  The funding pool may come from universities, the national government or local health networks and those who are in training are often buffeted between systems operating in silos.

Doctors are supposed to be teachers, or so it is maintained when the etymological origin is noted in the Latin verb “docere”.  In the middle ages it meant “learned person” and “doctor of the church” and I guess we have moved quite a way from that.  There is also a handy assumption that if you are a good doctor you will be a good teacher or that it is something that is easy to pick up along the way and doesn’t require many extra skills.  And, of course, in practice, the demands of clinical professional development necessarily compete with those of teaching skills.  So how many doctors are indeed teachers?  It’s impossible to know really but certainly in the hospital context there is an expectation that the more senior doctors teach the more junior ones.  In General Practice, functioning as a small business, it is a choice as to whether to take it on.  Does everyone go into medicine or general practice expecting to teach?  And what is the motivation for teaching? The status of a teaching role varies across different systems – have a think about this – and this is perhaps reflected in the priority given to professional development in this area.   This has been brought increasingly to my attention as I am working on some modules on clinical teaching and supervisio

So how do you teach effectively in an increasingly resource poor and yet increasingly managerial environment?  Individuals, as always, squeeze it in to busy days while trying to maintain quality and funders and managers focus on efficiency. Do we put up with mediocre and variable, will it become bureaucratised or do we combat it by paying well and maintaining the standards or by somehow creating a supportive community of practice?  It is indeed possible that we are relying on a rapidly drying up source of good will and altruism.  GPs can just say “I’ve had enough” when the paperwork escalates or the resources decrease beyond a tipping point. 

Obviously institutions and policy makers will continue to take the most economic course possible as their own resources are stretched but those making the decisions need to know that the way the organisation functions may make the difference between enthused and engaged teachers and dispirited ones ready to give up.  A few “ifs” to consider: if policy makers want positive outcomes for patients and the community; and if the quality of the education influences the quality of the professional at the end of training; and if you want a sustainable educator workforce then perhaps you need to be looking at the implications of this and advocating at various levels.

In many parts of the health system, space is not made for teaching and training and in others, GP teaching is not always taken seriously.  Value can be added by providing appropriate support and professional development but it is a challenge.  Efforts can be made to make the total environment more positive for learning and utilise the whole health care team.  This blogpost really has no answers at the moment and is more of a warning. In some ways it will be up to the next generation.  There will always be enthusiastic and brilliant teachers but will their efforts be sustainable?  Will it be a rewarding career option?  Will it be enjoyable?

How will the next generation be trained – and will they indeed be trained rather than educated?

A few rhetorical questions: Do you value your educators and supervisors? Do you know them? Do you enthuse them? Do you support them?  These are places to start.

Making the implicit, explicit – a core concept in clinical teaching

Learning in a work place such as general practice has its challenges. A student may give feedback that they feel the placement is a waste of time.  They sat in the corner of the consulting room observing the GP interact with many patients but did not feel they learnt anything.   A trainee may complain that their supervisor doesn’t seem to follow evidence-based guidelines in their management of patients.  It is a different learning context to the classroom and I have been thinking about this recently.

I have just attended the EURACT (European Academy of Teachers in General Practice/Family Medicine)  conference in Leuven, Belgium. It’s the first time I have been to this conference and, in fact, this is only the second of planned two yearly conferences. There were just over 200 attendees and this contrasted with the AMEE conference in Basel which had between three and four thousand participants. The other big difference is that AMEE caters for all those involved in medical (and other health) education and largely at the undergraduate level. That is a huge field.  EURACT was focussed specifically on teaching in general practice “in the real world” but it’s breadth lay in the diversity of countries represented, extending from Ireland to Turkey. I was the sole Australian and when queried about why I would attend a European conference I did liken it to Australia being in Eurovision!

I attended because I am currently involved in writing modules for a certificate in clinical teaching, geared specifically for GP supervisors of undergraduate students.

In at least three of the conference sessions I attended there was mention of making the implicit, explicit or the invisible, visible. This had already been an emerging theme as we developed the certificate modules.

It is described in the literature on learning theories (such as the cognitive apprenticeship model) where there is an emphasis on articulating what you are thinking.  We had discussed it at length when exploring how to teach clinical reasoning – a topic missing from many courses but one that is highlighted when supervisors later encounter trainees who appear to lack good clinical reasoning or fail exams because of this.  Clinical reasoning is a crucial skill for doctors (obviously) but there are nuances in the GP context.

At the conference the strategy of making the implicit, explicit was mentioned in several contexts – in relation to teaching both clinical examination and diagnostic skills and in the teaching of evidence-based medicine (EBM) in practice (rather than in a didactic series of lectures).  At the University it may be possible to didactically present content. The teachers may not necessarily be involved in the muddy waters of clinical practice (and may be dismissed as inhabiting the ivory towers of academia by those who perceive themselves to be at the coal face).  It is rarely so straightforward in practice.

We often claim that work-based learning is the most effective but it is also variable and unpredictable. The idea of making the implicit, explicit can be seen as a theoretical underpinning or as a strategy.  For instance, you have a clinician teacher who developed his or her skills during their training (in various ways) but these skills are applied (as experts do) almost automatically and unconsciously in the clinical situation. The underlying thinking or the way of putting the skills together does not seem obvious to the learner. Their consequent learning is laboured or hit and miss. The teacher’s application of their knowledge has also been modified by experience and context and it is a challenge for the learner to extract the principles from the wealth of detail in the clinical practice they are observing.  Thus it falls to the clinician teacher to articulate how they are thinking when puzzled by a diagnosis, to explain the complex influences that led them to prescribe a particular medication in this consultation or to justify their choice of examination or investigations at this point in the process.  It goes further than just listing the available evidence but puts it into context.  EBM is about applying evidence to the individual ‘s situation- but this is only realised in clinical practice, so students can make the most of this opportunity.  

How do we apply this in practice?  As an educator, remember to ask questions and expect the student to ask questions. Why do you think I did this?  Do you have any questions about what I just suggested?  What would you have done?  What is influencing my decision here?  Do others do it differently?  What is the latest on this according to what you are learning at University?

Get into the habit of asking yourself questions ie reflection.  Have I changed my management over time and why?  Am I up to date in this area?  In addition, it is the supervisor’s role to facilitate the learner to articulate their own thinking as they examine a patient or present a case. “I think I can guess why you did that but can you describe your thought processes that led you to it?”  Sometimes it is sufficient to be able to identify and describe the learning within the consultation so that it is recognised by the learner.

In the academic environment, clear principles and curricular content may be presented. In the real world of clinical practice we need to draw out the principles and curricular substance within  the complex human interactions – to make the implicit, explicit and to guide students on the path from novice to expert.

 

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!

and the presenting problem is……

Textbooks in various specialties often tend to group problems pathologically or by some other logical system. Thus a dermatology text may have a contents page with chapter headings on infections and infestations, bullous diseases or vascular disorders and so forth.  Internal medicine will divide itself into systems and musculoskeletal and orthopaedic problems may be organised according to anatomy or causes such as trauma, inflammation, degeneration etc.  This is useful as it helps systematise and broaden our knowledge and directs our thinking to causes and management for particular diagnoses.  Sometimes curricula are framed in this sort of way.

However, general practice patients don’t always present with a specific diagnosis at the ready and management cannot always be restricted accordingly. This is why trainees often prefer to learn with case-based discussion and why Murtagh’s General Practice has been so useful with many of its chapters based on commonly presenting symptoms. Similarly in Problem-Based Learning even the learning of basic physiology and anatomy is stimulated by the problem presented by the patient.  It is helpful for learning to be based in the real world but the educator’s challenge is to then ensure that the learner is also made aware of the broader context of the curriculum in its entirety.

The last post was about teaching in the musculoskeletal medicine area. The presenting problem may be a sore shoulder – but turn out to be cardiac pain or polymyalgia rheumatica rather than adhesive capsulitis or rotator cuff injury. The presenting problem may be a sore foot but turn out to be a plantar wart or tinea rather than a Morton’s neuroma or gout, thus drawing in the broad area of dermatology.  And all these possibilities are relevant to the trainee GP.  With cases it is possible to explore other important factors in general practice and to emphasise the importance of patient-centredness, the biopsychosocial perspective and whole person care.  

Perhaps a pain has become more significant because of other things happening in the patient’s life and functional deficits may become more crucial if the patient is also a carer or becomes unable to do their job.  There may be a cure for a particular problem within a limited time frame – or the condition may be chronic, requiring ongoing care and support where the doctor patient relationship is crucial and this should be articulated. It may even be possible to include concepts such as coping with uncertainty.  The presenting problem can be a window onto much more.

At the end of a successful educational session (in its broadest definition) the outcome could be expected to include increased confidence, increased skills (competencies), and their implementation in practice – but also an increased understanding of the uniqueness of the general practice context and its possibilities and limitations.

Don’t let learning be limited to a dot point in a curriculum document!  There are broader horizons.

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

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

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

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

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

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

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

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

Perspective on teaching Aged Care

Teaching Aged Care for general practice – getting perspective

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

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

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

Demographics and “Aged Care”

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

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

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

What is not celebrated

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

The implications for general practice

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

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

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

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

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

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

So what should we be teaching GPs?

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

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

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

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

 

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

Being a mentor and role model – guest post from a supervisor

In a world where the answer to any unticked educational box is an on-line module created by a third party, preferably on a contract, it sometimes seems as if the interpersonal nature of education and training has been lost.

path-upA supervisor whom I have known for twenty years, and who has been a supervisor for thirty years, commented to me that he thought the most important activity of the supervisor is to be a role model.   This is not always spelt out in textbooks, the literature and course curricula.  The emphasis is often on “teaching skills.” Over the years I have heard many GPs spontaneously recall John Vaughan’s influence on their careers whether they encountered him as a student or a registrar.  They have often commented that he takes the trouble to keep in touch with them well beyond their completion of training.  Because I respect him enormously I threw it back to him and asked him to jot down half a dozen points about being a role model. I think these comments also include (conceptually)  aspects of mentoring.  Here they are (grouped in sections):

Ten points of mentoring and role-modelling:

Self awareness

  1. Be aware of being a role model (it happens whatever we do). By this I mean we need to be conscious of our actions at all times, particularly in the presence of registrars and not only in our dealings with them directly but in the way we interact with practice staff and nurses as well as colleagues and contacts beyond the practice environment. Registrars are absorbing much of this behaviour consciously and unconsciously and will model themselves on it or use it as a lesson in how not to behave.
  2. Be willing to accept and acknowledge your own limitations as a doctor and a supervisor

The supervisor’s approach to the registrar (mentor role)

3. Demonstrate interest and get to know the registrar as a person. Without being intrusive, it is so important to learn about and understand the registrar in the context of their world. It is particularly important, for instance, to try and learn where overseas trained doctors have come from and where they wish to take their careers in the future. The other group that comes to mind are those female practitioners who may lack confidence, despite often being outstanding practitioners and whom I have observed, over the last thirty years, to go on to achieve excellent Fellowship exam results.  

4. Encourage registrars, demonstrate confidence in them and take time to support them. It is invaluable.

5. Be sensitive to the registrar’s needs. This moves into a more pastoral role.   Be aware of their moods and state of mind, providing pastoral support when it is needed. Sometimes registrars can become a little lost in the morass of practice and picking up on this and enquiring about their needs and their concerns can be crucial. It is not all about education!

Specific attributes and attitudes that are worth consciously modelling

6. Enthusiasm for general practice – enthusiasm is contagious. By modelling our own enthusiasm for the role of a GP and the privileged entree into people’s personal lives, our registrars develop similar attitudes. The opposite is also true.

7. A positive response in challenging situations – especially when things go a little pear shaped clinically as they sometimes do.

8. A sense of lifelong learning can be promoted. It is not all about the Fellowship exam. Model your own learning for them and demonstrate the fact that you are constantly learning and open to this.

9. Collegiality – with the registrar

  • Acknowledge your own limitations as doctor and supervisor
  • Encourage questioning and accept criticism and constructive suggestions Encourage questioning – especially of you as a supervisor. We are all in this profession together and should not be afraid to accept criticism and constructive suggestions so that it becomes a two-way process.

10. Collegiality – with other doctors and health professionals. Too much of medicine is based on putting our colleagues down instead of understanding where they are coming from. Doing this with our senior colleagues can model behaviour for our registrars.

walking-together  Mentoring can be described as “a personal process that combines role modelling, apprenticeship and nurturing”. The article, True Mentorship in Medicine, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3038821/ describes some qualities of good mentors: “they exude genuine and infectious enthusiasm; they modify their teaching strategies according to learners’ needs; they consistently reflect on their roles; they have excellent interpersonal skills; and they are knowledgeable. These qualities act synergistically to create non-threatening learning environments……..Learning is not about obtaining good evaluations; it is part of the overarching goal of becoming a better physician. The atmosphere generated by a good mentor promotes self-esteem and the importance of lifelong learning…..Mentors, in addition to teaching through words and deeds, show us care and respect and empower us to confidently approach the myriad complications inherent to the human condition.shoes In the end, we must repay our gratitude to our mentors by providing excellent patient care and evolving into effective role models ourselves.”

I think this echoes what John demonstrates and what he has so clearly described above.

 

Another lengthier and more academic look at the process is found (for those interested) at http://www.tandfonline.com/doi/pdf/10.3109/0142159X.2013.806982

Teaching multimorbidity – part three

Practical suggestions

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

Clinical practice

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

Suggestions from supervisors re teaching multimorbidity

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

Actions to support teaching in the practice  

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

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

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

A suggested approach by registrars to multimorbid patients in practice

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

To manage multimorbidity well 

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

To teach and learn effectively about multimorbiditytree-trunk

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

Foundation to build on 

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

Still a way to go and future challenges

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

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

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

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

 

The curriculum walks through the door – sometimes

This was a favoured concept in the days before college curricula existed (hard to believe, I know). Certainly a gifted teacher can turn any clinical encounter into a multi-faceted learning opportunity (often done on teaching visits). Plus, the self-directed learner will fill in their perceived gaps and GPs are the sort of doctors who can turn their hand to anything (a uni colleague of mine headed out bush after a single RMO term in obstets and delivered babies for years). But those were the good old days and the assumptions were a bit idealistic. The pendulum has swung decisively in the opposite direction.

Pisa-2006- 051The question remains unanswered regarding how much clinical exposure / experience is adequate in various areas but this does not stop people making policies. There is the much repeated “ten thousand hours” to become an expert and proceduralists in the US assert that shorter working hours by trainees means that specialty training should be longer.  Well, no one is going to win that argument as regards Australian GP training as long as the government is effectively in charge of training.

In GP training clinical exposure varies greatly because of the variability of practices. A registrar might do only 18 months in general practice (or less with ACRRM) and might work in only two locations. Previously we collected end of term registrar feedback data on multiple aspects of the practice experience and could state with confidence which practices were at one end of the distribution curve of older patients or kids, for instance. Sometimes there were surprises.  Registrars may do far fewer minor procedures in a rural practice with a part-time surgeon than in a keen urban practice. Sometimes you have to dig deeper than the statistics. All this enabled evidence-based training and was useful in advising choices for subsequent placements – but only if educational priorities are as high as training location priorities.  In any case, such data is now lost in databases which are defunct due to the recent changes to training.

Growing with your patients

Still, does it really matter in the long term?  Currently, in the climate of doom saying about population demographics and health system “sustainability”, there is a lot of angst around about how registrars see fewer older patients than established GPs.  Is anyone surprised?  Even BEACH figures showed that younger (Fellowed) GPs see fewer older patients – and someone still needs to see the kids!  My second GP job was in an inner city practice whilst still working weekends in ED for two years.  I was happy with acute presentations, became something of an expert in STIs and contraception (and some later occupational health) and augmented this by doing the FPA course in my holidays.  I left there to move to the suburbs and a group practice to do more “family medicine” in a practice with two GP obstetricians.  Northumb-2006- 059The years passed and I did some extra dermatology and paeds, a women’s health course  and some research into menopause.  I didn’t do a lot of extra mental health because I had trained as a social worker and worked as a counsellor. If we had moved to the country I would have upskilled again in emergency medicine. I then did a geriatrics course followed by a PhD on frailty.  You can see where this is heading. Some years later, for curiosity, I looked at the demographics of “my patients” – those who generally only saw me (no mean feat given I am part time in clinical practice).  Their mean age was 60 – which, fortuitously, was my age!

Let’s face it, aged care will require a whole new set of knowledge and skills in twenty years and GPs will be up-dating most of what they learnt as registrars.  Oh dear, all that wasted time learning about how to bill GP Management Plans!

Recognising the curriculum knocking on the door – relevant up-sEdinburgh-2006- 154killing

I have taught aged care for twenty years (and I will talk about teaching aged care in a later post) and am keen on it but that doesn’t mean I think all registrars need to see a lot of it or be as enthused as I am.  General practice is dynamic across a lifetime and we need to encourage registrars to recognise community needs and do something about their gaps.  They need to know the basics and take responsibility for the patients they see.  “Just a script” should be the chance to reflect on polypharmacy, rational prescribing and de-prescribing.  Multimorbidity is not limited to older patients so experience can be gained with younger age groups.  of course, exams need to be passed.

Registrars all have different back stories and maybe the ex-geriatric registrar actually needs to see more kids and sports injuries. Maybe the ex-orthopaedic registrar needs to do more mental health.  Maybe they can be directed to useful extra curricular courses and CPD to set a pattern for lifelong learning.  There is nothing like a bit of extra knowledge to open our eyes and help us to see patient problems we overlooked before and to address them more effectively.

As educators and supervisors we have the opportunity to (hopefully) individualise the vast resources that are the curricula and to go a bit beyond the mandatory syllabuses that need to be ticked off.

Given the brevity of GP training, and the breadth and dynamism of general practice, a disposition to ongoing professional development is the crucial priority.