Category Archives: Resources

We need to adapt

In the last few days there was an East Coast Low off the coast of NSW which caused amazingly high seas on our local beach. The bird (? Cormorant) at the top of this blog (or a relative of his/hers) had to adapt and take refuge on a lamp post. As educators we have to adapt to changing contexts.  As the tsunami of students ramps up the numbers, teachers may have to take refuge on their own pedestal of the lecture platform instead of wandering with small groups on the rock platform.  Or maybe distance requires online contact.  The other thing we have to do is to adapt resources for the audience. Teaching in and for the GP context, for instance, is not the same as in the hospital.

The learner

It’s often the case that we may invite a cardiologist to talk to GP registrars about atrial fibrillation or a gastroenterologist about the meaning of liver function tests. GPs may attend talks given by geriatricians or workshops run by Palliative Care Physicians.   In all these instances the listener needs to consider how the information is relevant to the GP context.  Similarly, when teaching in the clinical setting it is good to refer to EBM but often the evidence has come from studies done in hospitals and in different patient populations.  In the Welsh resource I referenced a month ago

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

The Teacher

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

Six Random Thoughts

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

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

The document quotes a great definition of frailty

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

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

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

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

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

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

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

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

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

The internet doesn’t take annual leave

-which is nice when you have a bit of holiday time to browse. In the middle of the festive season I came across references on Twitter to two interesting medical teaching and learning resources.  They involve two different media, are in different disciplines and are directed at different audiences.  As I noted early on in this blog, I try to link to relevant and useful articles etc to pursue and peruse rather than assume I am an expert in all these different areas and for me these topics are also different in terms of my own comfort zone.  The first is designed for undergraduates and the second for hospital doctors but in both cases there is also relevance for learning in general practice.  The first resource is a collection of thirteen videos in pre-hospital treatment in Emergency Medicine and the second is a document on Care of the Elderly (COTE in the UK and both are from the UK context).  In fact, GPs often have to adapt their learning from other specialised contexts.  The different content of the two resources also lends itself to different approaches to teaching and learning.

I must admit a conflict of interest with the first one as the videos have been done by Dr Luke Regan to whom I am related! They are part of the Inverness Undergraduate Prehospital Care Course.  Emergency Medicine is something in which I have become rather de-skilled over the years but if you are a GP Educator who supervises GP registrars and medical students I think these very short videos have useful content and could be a starter for discussion, particularly in rural settings

Of course, I’m sure there are also some Australia- specific ones if you are working in that context. They were a good reminder to me of some basic principles. After the intro videos the topics include: upper limb injuries, respiratory, interosseous insertion, traumatic cardiac arrest, thoracostomy, analgesia, traction splinting, airways, pelvic stabilisation, paediatrics.  What I like about them (apart from the appropriate outdoor setting) is that they are short (generally 3-5 minutes), nicely paced with a clear delivery and highlighted take-home messages.  Despite recent opinions about our inability to multi-channel as we learn (in relation to bullet points on Powerpoints) I am actually a fan of sub-titles (even on TV movies at times) and I guess if the presenter had been talking in a broad Scottish accent I would have appreciated them even more!  For me they reinforced the message.  If the videos are not exactly what you want they could be used as a stimulus for something you produce yourself on your i-phone (these were shot on an i-phone).

The second resource is in an area that has been an ongoing interest of mine (clinical practice and teaching in the area of geriatrics / aged care) and was the focus of my PhD research.  It is in the form of a thirteen page PDF document that lists some important and succinct take home messages when dealing with older patients. 

The topics addressed include: confusion, delirium, dementia, frailty, medication review, UTIs, falls, and advanced care planning and when to investigate. This is quite a different collection of problems compared to the pre-hospital trauma topics. It includes a couple of eye-catching headings such as “end PJ paralysis” and “acopia is not a diagnosis”.  They are set out in an engaging format (arresting headings, do’s and don’t’s lists) that sets out fairly didactic (almost dogmatic) principles which may come as a surprise in some instances. What I liked about it is that it is a concise summary of a huge (and hugely important) topic, it highlighted some important issues and was presented in a readable format.

Both these resources

  1. can be used as learning resources (and as teaching resources)
  2. are good starters for discussion on the various sub-topics
  3. can be adapted to different contexts

For the second one, I agree that there are some important take home messages in this very readable document which is obviously very relevant for those working in hospital.  For those in GP Terms I think there needs to be some attention to context. I would change the emphasis and make a few important caveats (particularly to do with prevalence in community practice).  I have previously posted on the topics of teaching about Multimorbidity (X3)   and Care of the Ageing   but I might look briefly at some of the component topics (in relation to learning in general practice) over the next month – in between saunters along the beach..


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’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 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

Resources for professional development – where to start looking

at the beachI was going to probe a bit further into “feedback” or jump into another topic but I decided, instead, to make some early suggestions about where to go for ideas on medical education. That way you can answer your own questions in your own time!


The Association for Medical Education in Europe (AMEE) is a great resource It organises a conference in Europe every year.  This generally attracts several thousand people – with a contingent from Australia. Like most medical education meetings there is a big emphasis on undergraduate education but as there are lots of choices of concurrent sessions it’s always possible to find something relevant.  They also run Mededworld Webinars on education topics.

The headquarters of AMEE are in Dundee, Scotland. If you become a member you also receive the journal Medical Teacher.  AMEE publishes multiple medical education guides on specific topics. There are over ninety of these and range from core topics to the slightly more esoteric but they can be purchased individually (cheaper in the electronic version).   AMEE also publishes BEME guides (Best Evidence in Medical Education) which are reviews of evidence in particular areas.  I recall going to a session a few years ago on their BEME of portfolios in post graduate training.  This influenced our program planning.

AMEE also runs a distance medical education course called Essentials in Medical Education (ESME).  These modules can contribute towards a later Diploma or Masters.  ME colleagues who completed this course found it added value to do it at the same time as a group of other colleagues.  Ronald Harden runs this course and has written a textbook called Essential Skills for a Medical Teacher.

AMEE 2016 conference is in Barcelona and has a pre-conference 2 day summit on Competency Based Education which would be well worth attending. Generally, if you could get to one international conference this would be it. Sadly it clashes, yet again, with the dates decided for GPTEC (our main local conference) which is on the Gold Coast this year .  In Australia there is also the Australian and New Zealand Association for Health Professional Educators (ANZAHPE) whose conference is in Adelaide in July 2017.  This group has a broader remit and includes allied health.

Three more   journals

The UK Association for the Study of Medical Education (ASME) publishes the journal Medical Education. I’ve read many useful articles in this but they do tend towards the theoretical at times and are not specific for GP training.  ASME also has another journal – The Clinical Teacher.  The most readable occasional articles I have found have been in Education for Primary Care, however, the subscription is significant.

Texts on medical education

 ASME has published a 2010 book called Understanding Medical Education.  This fairly lengthy textbook is quite reasonably priced and is available in a kindle version.  At a similar price for a more succinct BMJ publication you could look at the ABC of Learning and Teaching in Medicine, although I think it is only in hard copy as a book.  It is a similar presentation to their ABC books on clinical topics. However, the fourteen individual articles are available online in the BMJ via PubMed

A specifically Australian book is the fairly concise Practice-Based Teaching by Richard Hays.

If you work for an educational organisation it is possible that they might invest in some of the modestly priced resources in order to support the professional development of education staff. If you have a university connection the journals would be accessible in their libraries. My suggestion would be to use individual articles as the starting point for professional discussion with a group of interested colleagues (maybe electronically if you all work different days) and to dip into the evidence-based literature when education policy changes are mooted.

There are lots of other resources out there, especially when you start exploring online. There is increasing use of social media particularly among those active in emergency medicine / critical care areas (see SMACC conferences). 3 has some educational material and exam prep amongst the clinical content. Genevieve Yates (medical educator and GP) has a well established blog with a variety of content including educational posts There are a limited number of podcasts in I-tunes from Medical Education and Clinical Teacher and presumably there will be more of this sort of resource in the future.  The Australian Medical Educator Network (AMEN) has just set up a blog and will soon be conducting some webinars.

Has anyone else found anything particularly useful?