Category Archives: learning environment

Empathy in medical education

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

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

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

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

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

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

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

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

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

The learning environment and safety

This week, even in Australia, there has been discussion (on two ABC radio programs: Saturday Extra and The Health Report) about the Bawa Garba case which has stimulated so much discussion in the UK. I won’t summarise it except to say a paediatric trainee was ultimately struck off by the GMC after being convicted of manslaughter when a young patient died in 2011.  There has been much angst on Twitter and articles in the BMJ and lengthy discussion about workload, understaffing, whistle-blowing, the role of supervisors, the use of reflective journals in training and so forth. I could illustrate this blog post with any number of Tweets. There has subsequently been a justification of their position by the GMC on their blog (links below).  You can read the details yourself but the issues I feel it raises for educators are those of patient safety and a “safe” learning environment for learners.

For any educators responsible for work-based training it is important to consider what sort of learning environment is provided by the work environment. The GMC claim a strong emphasis on patient safety as do all health systems and training programs.  Their explanatory document maintains that clinical supervisors are required to adhere to high standards. The impressively titled document Promoting excellence: standards for medical education and training repeatedly notes that patient safety is the first priority but notes that Patient safety is inseparable from a good learning environment and culture that values and supports learners and educators.  I don’t work in the NHS but I am well acquainted with documents about training standards. In the Twittersphere many in the NHS are commenting on their current work load, even as they head in to a shift, and asking on Twitter, in effect, should I work today when it is not safe?  The GMC advises they should work and follow their algorithm for making complaints but other tweets make comments that this algorithm does not work in the real world.  Policies, standards, statutory regulations and accreditations seem only able to delegate accountability rather than to ensure the quality of the system.

The other recent popular response is to focus on producing “resilience” in doctors – yet again focussing on the individual for the solution, rather than on the system for some responsibility.

Discussion has progressed about strategies for maximising patient safety in various health system contexts. Professionals are trained within a health system which also provides the learning environment and this is a complex situation. How can the safety (for patients and learners) of this training environment be ensured and whose responsibility is it when issues occur?   Can you always be a good or safe doctor in an unsafe environment? A further question might be whether we can rely on increasing rules and regulations (and increasing delegation) to really ensure quality and if not, what does?  When is it the responsibility of the medical educator or supervisor to not only comply and tick the relevant boxes but also to speak up when the system is not functioning to facilitate the safety of the learner or the patient?  It is probably not enough to introduce a module on resilience in the hope that learners in future can cope with a dysfunctional system should it arise.  I am sure the debate will continue.

Links

  • A very interesting account of what happened clinically by concerned UK consultant paediatricians.

http://54000doctors.org/blogs/an-account-by-concerned-uk-paediatric-consultants-of-the-tragic-events-surrounding-the-gmc-action-against-dr-bawa-garba.html

http://www.bmj.com/bmj/section-pdf/960296?path=/bmj/360/8139/This_Week.full.pdf

  • The link for the GMC blog explanation is on

https://gmcuk.wordpress.com/2018/02/02/faqs-outcome-of-high-court-appeal-dr-bawa-garba-case/?utm_campaign=9088224_Doctors%20-%20January%202018&utm_medium=email&utm_source=General%20Medical%20Council&dm_i=OUY,5ESIO,PGBN9B,KXV14,1

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