Education is interpersonal

This last week I noticed this encouraging headline in Australian Doctor in regard to GP Training.

It reinforced the sense that the apprenticeship model for training has a lot going for it and the GP Supervisors at the coal face are perceived to be doing a good job.  It was only when I logged in to the full article that I noted the fine print under the headline – but some are dissatisfied with the support of their Regional Training Organisations. This satisfaction has apparently decreased significantly since the last government shake-up of training and I guess that reiterates the message of my last blog – that there are challenges facing the colleges as they resume oversight of training and that training programs are not just exercises in efficiency.  Neither are they pure academic exercises. They are affected by politics and ideology and it is necessary to keep in mind that the learning environment we are setting in place now will affect future generations.  Training systems are crucial in creating a positive learning environment and if you are involved in training it is good to keep this broader perspective in mind.  Education is more than what you do in a lecture or small group or the feedback form you fill in for the individual learner.

Some dialectical choices for GP training

We could see some of the issues perhaps as dialectical choices facing future decision makers. The first obvious tensions are those of professionalism vs managerialism and collegialism vs corporatism. A managerial approach may have been seen as a solution to inefficiencies in education and training but it has also sidelined educational debate.  It has been recognised in education for a couple of decades. Managerialism has itself gone through several incarnations with neoliberal managerialism emphasising competition and markets and now neo-technocratic managerialism focussing on metrics at the expense of other values.  Here are a couple of interesting articles I read previously on this topic.’new-managerialism’-in-education-organisational-form-of-neoliberalism

Even our way of speaking about health or education has been infiltrated by the managerial lexicon and thoughts and actions soon follow the language.   Neo-technocratic managerialism reduces the technical expert to being a content provider while education is reduced to what can be measured and reported.  We start to think only about what we can measure. The BMJ article I’m sure will spark surprising recognition. It’s a tongue in cheek article describing this whole process as Management Language Syndrome which has now become a chronic disease  – and like obesity it is supported by the environment.

This is why it is important to consider the personal vs metrics.  It is very easy, when managerialism encourages priority of efficiency over other values, to be tempted by the panacea of IT and online solutions for everything.  Sadly, experience in other countries has already demonstrated that the cons can be just as crucial as the pros.  The related challenge to this is to keep reminding ourselves of the place of IT.  Is it functioning as tool or master?

Having spent time in the UK I have observed a stretched health system where individuals are held responsible for system failures.  There is an increasing international tendency to talk about teaching “resilience” (apparent in the recent AMEE conference) but we shouldn’t need to teach resilience so people can survive unhealthy systems.  The issue of support for trainees and students is crucial to quality training.  In fact, our systems should model the values we are trying to instil.  If we feel it is important to produce GPs who are able to relate, to nurture, to have empathy, to take note of evidence, to communicate well, to respond to the whole person, to be curious and adaptable – then ideally the training environment should exemplify these values and attitudes. We are all aware of studies where experience in a hospital system can negatively affect values inculcated in early medical school.

In this corporate world it is almost mandatory for organisations of all types to claim to have “world best practice” and to have mission statements regarding quality etc.  In the educational sphere we need to hang on to the reality that quality is not just about repeating “we are the best”.  Brand and marketing are ubiquitous in today’s culture and we are not immune.  It is obviously important in selling a product but we need to acknowledge that not all human activity can be reduced to selling products, people are not just consumers and education and health are not merely business.  There is often a choice of brand versus substance.

How do we know we are “world class” if we are not outward looking enough to know what the rest of the world is doing and to evaluate it?  This brings me to another dialectic of parochial vs global.  I have recently been at AMEE with between three and four thousand medical educators from the rest of the world and there is much we can learn and from which we can benefit.  A speaker in a session on feedback was describing studies on written versus audio feedback (the latter being preferred by students) and quoted from a 2014 study which still concluded that “It is only the relationships between the student and the instructor which can enhance learning.”  A symposium on dilemmas in supervision raised many of the complexities of supervision and assessment and the fact that existing systems do not always support quality supervision.

A lot of these debates and dilemmas could be approached by keeping in mind that education is interpersonal. This is very much underlined by sociocultural theories of learning and the literature on the influence of mentors and role models.  Do our systems, processes, methods etc facilitate or hinder the interpersonal aspects of education?  What can be done to mitigate the threats?  How can we support the learners if we don’t know them and they have become just numbers?  If the personal is lost this will be to the detriment of good training and the quality of our future medical workforce.  It is a challenge to be consciously faced in medical education by educators, policy-makers and managers.

Threats, challenges and opportunities in planning programs of training

I was doing my due diligence as a College member, reading the statements from and interviews with candidates for the RACGP presidency and I noticed one saying that one of the most important issues was the college’s resumption of GP training.  He noted several issues including that the college “needs to defend and strengthen the apprenticeship model of training in the face of pressure from cheaper online or classroom-based teaching. Supervisors and registrars need to be supported and nurtured through the process”  http://medicalrepublic.comau/college-hystings-dr-bruce-willett/15384?utm_source=TMR%20List&utm_campaign=Of3d397085-Newsletter_June_30_06_18&utm_medium=email

This is certainly recognition of some of the threats to GP training (already in process) and of the challenge in the transfer of training – that is, if it is to be done well rather than assuming business as usual.  There are other things at the top of my list when I think of general practice as a whole but that is not the focus of my blog.  On the other hand, it is right up there when you think of the opportunities for the colleges and for training, at this juncture.

It would be good to build on previous quality and strengths rather than just on our laurels.  There is much that the College used to do in training twenty years ago.  Phrases such as “Education Evaluation” and “flexibility in training” come to mind.  They were also moving to regional training. It would be a step forward if the colleges (and the managers of training) were able to interrogate the concepts of quality and success more seriously (and in an evidence-based way) and to do this educationally rather than corporately – a distinction that still remains (just).  Numbers are not the only important outcomes.

Why is good training important?  I will go back to a point I made in a recent presentation that there is a connection between the way training is structured, the sort of GP we produce and the way they then go on to educate others.  This will then impact on the care received by patients and the health of the community.

The presentation was a Pecha Kucha I delivered at a medical education meeting (and which I mentioned a couple of posts ago when I was preparing it).  I learned a few things from the experience and had other impressions confirmed including (but not limited to): Pecha Kucha may pack a punch for one good idea or one short story; it’s probably good if we assume a short attention span of the audience; it’s good for engaging the audience but not so good for engaging WITH the audience; it’s not as good for getting across complex ideas; I am not primarily a performer; I’ve always struggled to learn lines and we strive to entertain rather than educate at times.  This was also supported by the written feedback I was handed!   Similar analysis should be applied to models of training – not all models and methods suit all contexts or all desired outcomes.

As my presentation was about the challenges for future GP training I might discuss a couple of the thoughts in subsequent posts.  The first point I made was that such transitions (such as the transfer of training) involve looking both back and forwards like the Roman God after whom January was named.  Some will want training to return to what they perceived as a mythical golden age and others will wish to move forwards with all the trendy disruption and technical innovation that is available.  Either approach should consider the evidence.  The greatest disappointment would be if there was no change at all and all the changes of the last 18 years (good or bad) were accepted as givens. 

This includes the move to corporatism. 

The most recent changes have resulted in a loss of corporate memory and knowledge in many areas.  As Santayana said “Those who can’t remember history are condemned to repeat it” or even as Hegel wrote “what we learn from history is that we don’t learn from history.”  Training programs are not just exercises in efficiency.  Neither are they pure academic exercises. They are affected by politics and ideology.  However, keep in mind that the learning environment we are setting in place now will affect future generations

Alliterative Attitudes for Medicine and MedEd

Recently on Twitter there was some discussion about what were the essential characteristics of a good doctor. The initial tweet said:

This was followed by replies suggesting other words beginning with C: “I’d add curious and concerned.” And “whatever synonym for humble that begins with c”. Others said “great mnemonic. I might add: Considerate.”  And  “Can I add a fourth C?  Communicative”.  All worth discussion. The occasional game tweeter suggested additional words beginning with A.


Someone else noted it reminded them of a poster for the 6 C’s (in the NHS) and a reply to that was “Interesting. “C” is obviously key.  The signs I put up in our department are “Caring, Clean and Courteous”.


My contribution was to note the three  words beginning with C that I used to quote, for many years, to GP registrars at the end of an observed session of consulting. When worried about the exam I tried to encourage them that, as long as they Cared, had Curiosity and were Conscientious they would be good doctors.  Why did I say this?

I wasn’t promising them that they would pass the exam on their first attempt. I wasn’t even promising that they would tick all the required competency boxes in the next twelve months. This was more about capability (when they need to keep learning), patient safety and future career satisfaction – maintaining enthusiasm and avoiding burnout.   It was more about continuing professional development than measuring a good doctor in the here and now.  More about attitude than current knowledge or skills.

About ten years ago I thought this off-the-cuff advice through in a bit more detail and with a bit more rationale to see where the options might lead.   The powers that be want those finishing training to be competent.  I took this as the starting point (at least as judged by various training assessments) and then looked at what might happen if they were also caring, curious or conscientious.  My exploration produced a few more words beginning with C along the way.  Perhaps a negative way to view this is to speculate on what happens if one of these attributes is not present.  If you miss one of these things, it can all go awry.   I guess I could have constructed the algorithm in a few ways but here is one version anyway (I’m sure you could come up with your own list to generate discussion).



I agreed with some of the tweeters that curiosity is essential. If you’re not curious you can stagnate.  You might not seek out the new knowledge you need to manage problems, develop new skills or be intrigued by new presentations.  If you’re not curious about the people you see every day you are at risk of boredom.  You might still be caring and well liked but eventually you risk becoming incompetent without being aware of it.  Perhaps this picture demonstrates curiosity along with a bit of tenacity!

If you are curious about medicine and about people you will never be bored.


If you aren’t conscientious, safety goes out the door. If you are conscientious you will keep up your professional development (regardless of any carrots and sticks) and you will follow up patients and ensure their safety.  But without the curiosity and the caring this might become a soulless pursuit or even an anxiety ridden approach.

That over-used concept of caring

Caring is a bit of a vague (and over-used) concept but in some of its manifestations it modifies the other two attributes. If you care about the person in front of you, you will be more inclined to conscientiously follow up and be curious about what is happening to them.  Caring can imply compassion for the person or passion for medicine and the profession.  If you don’t care – you will find it difficult to develop a doctor patient relationship, you will lose interest and motivation to head into practice each day.  A curious and conscientious doctor is likely to still be competent (and safe) in ten years’ time but they may miss some of the rewards of general practice that come with caring.  If you care about people and care about your profession then you have motivation and passion that helps you hang in there.

Obviously, if you lack all three attributes things may not turn out well, regardless of the starting point, and I would acknowledge the growing relevance of collaboration (and perhaps collegiality) in the initial tweet.  it should be somewhere in an expanded algorithm!

Here is where I add a “Caveat”. Will caring always make you more content in your career and help you avoid burnout?  Not necessarily so.  Problems with boundaries or system constraints that limit how you can help patients may cause frustration and burnout so these are things to bear in mind.  You may be a good doctor for your patients but not for yourself!  A discussion for another day.

The above is just a discussion that attempts to go beyond the current focus on measuring competencies to what keeps us going in a challenging career. In rapidly changing times we need to be capable as well as competent.  The conclusion for me is that GP training and education should also focus on these other aspects.  A training program should encourage and reward curiosity. It should recognise that sometimes a focus on ticking boxes and the often perverse incentives of quality frameworks can decrease the intrinsic conscientiousness that is part of professionalism.  It should explore the importance and implications of caring and being compassionate.  Perhaps this may also lead into the recognition of broader system issues that affect our ability to be good GPs and providers of effective primary care.

To PPT or not to PPT – that is the question

Whether or not to use a (now almost “traditional”) PowerPoint (PPT) presentation when asked to run a session is certainly a good question but it’s not necessarily THE question.  There are many more important questions in education.  However, it is worth thinking about when you are asked to present on a topic to a large number of people.  In medical education, there are a minority of instances in which a single lecture is better (educationally) than a small group or a reality-anchored, case-based discussion in the clinical context.  However, there are increasing instances when budgets and logistics require it – either in person or online.

Should you use Powerpoint or not? Opinions are divided – and strong.  But sometimes the opponents seem to be opposing a straw man (the bad PPT).

With ideas or technologies (as with drugs) there is often a bit of a dialectic: a phase of enthusiasm, a phase of backlash and then a more reasoned compromise.

Powerpoint does have its proponents in education. One argument is that it helps the more modestly skilled performer to get their material across (rather than constraining them). The critics make the point that a lecture is actually a performance anyway (and should be a good performance).  I suspect those who are keen to ditch PPT probably have some natural performing skills already.

I have been around long enough to remember when the usefulness / appeal/ memorability of a lecture depended on how enthusiastic and charismatic the lecturer was. Some certainly weren’t worth going to. Others were most enjoyable and entertaining but the content dissolved into the mists of time and had no permanent impact.  This was the “BP” era – the days Before PowerPoint.  It was quite a relief when we were able to expect that a lecture would have a structure with bullet points and take home messages

The backlash

A Guardian article sums up some of the complaints about PowerPoint, claiming it is making us stupid. It has been around for thirty years and concern about it began early.  It is relevant to note how it followed on from the overhead projector and was initially geared toward desktop graphic projection in meetings.  Of course it has now moved on to the point where slides are compulsorily loaded onto websites and students feel no obligation to attend as all the information is assumed to be on the slides.  The Guardian article also notes that students have been known to demand it back when it is withdrawn.

Some critics feel it limits the way we think and oversimplifies issues. Some feel that the intrinsic nature of the design of PPT templates is to blame for poor presentations and others feel that the way information is put on slides can inhibit learning because humans are only designed to learn in a particular way. If you are interested in some of the neuropsychological arguments you could look at work by Stephen Kosslyn (book called Clear and to the Point) who has drawn more optimistic and detailed conclusions about how to structure presentations to achieve better learning outcomes.

Discussion is fairly opinionated and, of course, it is notoriously difficult to get strong, replicable and generalizable evidence about educational methods that are guaranteed to work for you.

Critics also tend to focus on the obvious failures in some presentations. This presentation by Ross Fisher is titled “Everything you know about presentations is wrong” and brings up many useful points including tips for improving presentations. It’s a long but listenable-to presentation. He maintains presentations often fail because of “cognitive load”.  He is a paediatric surgeon and well known to many medical professionals involved in education. His “P cubed” framework focusses on story, media and delivery   The aim is to keep people awake and he comments that the value of a presentation is what the audience thinks it is.

There are some interesting assumptions about how we (all) learn which it would be great to test. If someone talks and has words on a slide does this help learning or does it impede it?   Does it help some learners but hinder others?  Is it better to have an engaging picture while someone talks or is that distracting for some people?

How do we learn?  

There are theories about how we learn and numerous specific studies about the factors influencing effective learning. This article is broader than just presentations: “Applying the Science of Learning: Evidence-Based Principles for the Design of Multimedia Instruction”

demonstrates how complex may be the underlying theories. The cognitive theory of multimedia learning states that people learn more deeply when they build connections between verbal and visual representations of the same material and this paper lists studies demonstrating the success of strategies predicted to enhance this. One of the practical messages is not to overload the visual channel. This is quite a specific study on visualisers and verbalisers and the main lesson is probably that it is very complex, there are individual differences and it is very hard to apply in practice.  It was interesting that only for visualizers was learning success substantially impaired if pictures or animations were missing. Certain professions scored differently on the spatial imagery scale, the object imagery scale and the verbal scale.  There was also a suggestion of a gender influence.

Let me confess something. I was probably a serious teenager and I used to attend church to hear sermons that were not short homilies. I enjoyed hour long lectures on topics I liked and had no problem concentrating but now we advise stopping after ten or twenty minutes because of the general issue of concentration span.  I assume a lot of it was to do with motivation, expectations and sub-cultural factors.  I can still remember  the title (but not the content) of a sermon of the 19th century preacher Spurgeon that I read in a rather lengthy collection:  “Hope yet no hope, no hope yet hope.”  I remember it because my great Auntie Ethel saw it over my shoulder when I was reading it and read it out in a broad Yorkshire accent commenting “It’s enough to give you brain fever!”  There are now similar concerns that Powerpoint, in a different way, is giving us “brain paralysis”.  We have certainly moved from a very wordy culture to a more graphic one – although prior to literacy there was much supporting illustration on church walls for instance. A perusal of 19th century newspapers or novels suggests the population was accustomed to more “wordiness” without pictures (even still ones).  When I reflect I realise that I prefer to read a book than listen to an audio version and I compulsively read ahead on PPT slides.

The synthesis / compromise – what works

I am never going to be a dynamic presenter. Just an adequate one.  But it shouldn’t be all about me anyway!  Perhaps we can still structure effective learning experiences.  There are some common themes that emerge from all the reading (and viewing) I have done – in terms of the principles for effective presentations.

This study on Presentation vs Performance: Effects of lecturing style in Higher Education on student preference and student learning actually seemed to examine the differences between a “good” and a “bad” presentation.  The basic PPT presentation describes PPT at its worst.  The Performance approach included slides with much less text, more images, relaxed manner and varying tone of the speaker, use of personal anecdote and audience interaction.  Needless to say it was more popular and more effective.

Ross Fisher’s positive tips were not too different from the earlier advice for good powerpoint presentations or the article on presentation vs performance. He suggests the slide set, handout and script should be different, he notes the importance of story and suggests a “star moment” in a presentation. He alludes to font size, not being distracted by logos or too many words and he emphasises the importance of any performance: projecting to the audience and practising.

The following are two nice brief pages from University of Leicester of practical hints about presentations.

This readable article reviews some of the evidence regarding the learning outcomes of lectures with and without powerpoint.  It indicates that PowerPoint has no significant impact on learning – but students like it.  However, the way it is used affects learning.     An assertion-evidence approach is best (read the article for the details) and with or without PowerPoint, lectures are less effective than methods using active learning. This is a good warning to not be seduced into providing only lectures, however good, and to assess your goals, the audience size, the topic, the venue and so forth as you choose an appropriate method.  It is an encouragement to continue the broader task of structuring  learning experiences in all the contexts of learning.

Currently I am preparing a PechaKucha presentation (a style originating in a Japanese architecture office) and trying to apply a few of the principles above – quite a challenge!

Eyes only – visual variety in presentations

This is my fortieth post so I thought I would veer away from the serious and look at some visual distraction. Dermatology is very visual and I have often interspersed presentations of skin pathology with various bits of nature with tangential connections. I’m not sure if this has made the diagnoses any more memorable but it has meant that I still can’t observe some natural features without making the connections.  Just recently I couldn’t help but comment on a keratoacanthoma at the beach.

And just for a diversion see if you can give some diagnoses to the following lovely tree trunks:


A colleague sent an interesting photo of lichen recently.  Whether on rocks or trees, there are certainly dermatological echoes of lichenification.

If you stretch the analogy, here are some floral versions of various pink and erythematous rashes (and similarly all looking the same to the untrained eye of my spouse, apparently, despite their very different appearances and contexts)!

       And here is a polymorphic eruption, on a less than clear day.

Then there are the evocative descriptive terms such as spider naevi, serpiginous rash, cobblestone papillae, strawberry tongue and geographic tongue or descriptive words that have Greek or Latin for illustratable things like coins, tear drops, bran or nets (nummular, guttate, pityriasis, reticular) that could be in the corner of your slide as an aide memoire.. The list is endless.

And what does this, on my local rock platform, make you think of? I could go on, but I won’t. Spicing up presentations with apposite holiday snaps with visual metaphors can be quite diverting and make the task a little more creative.



Teaching when you don’t know the answers

Fortunately it is often effective to use the perplexing case as a teaching tool and sometimes it is possible to have the patient as a partner in the teaching and learning process. It also gives the opportunity to treat the learner as a colleague.

This approach can be used for either medical students or registrars. Supervisors often call in registrars to see a “classic” rash and this is great in increasing clinical exposure.  Sometimes we are tempted to leap in with answers rather than leading the learner to work out the solution to a diagnostic or management dilemma.   However, if there isn’t yet an “answer”, there can be an even more valuable learning exercise.

In the past I have asked those finishing a gastro term for suggestions on abnormal LFTs or a student with a previous life as a physio for advice on musculoskeletal problems, but this is still seeking answers. The patient I have in mind is where we are still puzzled and are trying to work out how to proceed.  This brings in the opportunity to make clinical reasoning skills a bit more overt.  This calls to mind when I had  a patient with an itchy annular lesion that wasn’t quite “classic”(barely visible scale)  and was getting worse.  The registrar and I discussed the top-of-the-list differential diagnoses and the most useful investigation to do as the next step.  It raised the issue of tinea incognito (which skin scraping confirmed).

Sometimes you see a patient’s name on your session list with a medical student booked in also. You have gone a certain distance in the diagnostic process but all is not clear.  I might speak with the patient beforehand and ask them to be part of the learning process.  I guess this is more than just signing the consent form before they enter the room.  You might admit to the student that you still don’t have an answer so your “interrogation” of their history and examination is not an attempt to catch them out (or demonstrate your superior expertise).  When the patient has a skin problem, you might structure it by leaving the student to take a “dermatology history and examination” and return to ask them to present their findings (with the patient to comment as need be).  You can add anything they might have missed in the history (and discuss why it’s important) and also chat about how to describe things in “dermatological language”.   You might share your own diagnostic process so far (and this can be informative for the patient). You may lead the student to the next diagnostic step that you perhaps already have in mind.  With the patient gone you can put the learner on the spot a bit more with asking them to commit to (say) three differential diagnoses and  ask them to identify some questions that remain – for self-directed learning.  You can share online resources for instance if relevant (useful sites might be    or )or share brief stories of other cases if relevant.

I thought I would use this approach a couple of weeks ago but then the patient went off on holidays so I had to adapt. The patient had already given me permission to take a photo and use it to discuss with colleagues or for teaching. In fact she was happy for this to happen since we didn’t have a diagnosis as yet. It was on a nicely unidentifiable part of the body. The evening before the session I put the picture into a power point and structured the slides historically with the questions that arose as the case unfolded.  I put questions at appropriate points and printed out the half dozen slides. I  had also sent a question around my colleagues at the practice asking their opinion and one of them said it reminded her of an article she had just read in AFP on skin biopsies which I printed off and gave to the student to read later

The session had my usual collection of older complicated patients with multiple problems, some with diabetes, a couple of teenagers, a person with an unexpected result to explain etc. We took five minutes between patients and I suggested we pretend the patient was there and we worked through the printed case thus far.  We reasoned through it and I asked for suggestions.

This particular student was very knowledgeable and the diagnosis (revealed at biopsy later) was on their list of differentials. At the end of the session as they left they said “Oh, and thanks for the teaching session with the dermatology case. It was great.”  And I thought I was teaching the whole afternoon!  Amazing what a bit of structure does.

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.


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

  • The link for the GMC blog explanation is on,5ESIO,PGBN9B,KXV14,1

Happy Groundhog Day – some thoughts on innovation

I wrote this on February 2nd, a date for which I have a soft spot and which is officially known as Groundhog Day in the US. Some of you may remember the film of the same name made way back in 1993! It was sort of “deja vu all over again”. I hear it is now a popular musical by Tim Minchin.

I vaguely recall that Phil, the reporter/weatherman (Bill Murray) is forced to relive this day (and the assignment he disliked) ad infinitum but he eventually tries to utilize it to learn new skills and to change things bit by bit. In Groundhog Day Phil breaks out of the time loop eventually with no overt explanation in the film (all the better to provoke ongoing interpretation and speculation) but discussions speculate on issues of hedonism, self improvement and philanthropy apparently. Without getting all philosophical the idea of a repeating Groundhog Day has still entered the movie goers’ lexicon.

It reminds me of some educational delivery – but not in a bad way. You get up in the morning at the beginning of the academic year, or a new term, and there’s a feeling that it’s just the same thing again. And indeed it is to some degree, especially where the implementers and deliverers have no power to change things. And the larger the bureaucracy the more this is the case. The syllabus has, of necessity, been planned ahead; The curriculum is fixed by a particular body, the infrastructure is designed by some other administrative group, the standards are set and measured by the relevant groups and job roles are spelt out in employment contracts.

However, as in the movie, each day the protagonists try to make incremental changes based on the feedback from previous experience. Let’s change the way we teach this concept; let’s involve the learners more in this workshop or this day at the surgery; how about I try and ask more questions rather than giving easy answers. I mentioned incremental changes automatically – because I’m a fan of this sort of quality improvement – but also deliberately after listening to an ABC Future Tense podcast on “Innovation” (from 19th March 2017) on the way to a short break on the South Coast this week. It’s worth listening to but some of the random points that struck home to me regarding education included the following:

  • It noted that innovation has become all pervasive in the business and political lexicon ( and I’m sure it rings bells in all our educational vision statements)
  • It suggested that it has become too technology focussed and advises ensuring it maintains a people focus
  • It noted that it didn’t always have to be “disruptive” or involve a big new idea. Most effective innovations are incremental improvements on what exists already (like wheels on suitcases) and often ideas are taken from other countries and then applied at home.
  • A useful definition is “new ideas successfully applied” (which emphasized for me the importance of evaluation)
  • It might be a vague buzz word but it is still important
  • Successful ideas and processes in one sector are not always successful in a different sector (business is different from education)
  • Much innovation is transferred through informal relationships
  • Being adventurous can sometimes be necessary as can government funding
  • There was some final advice to “not try to impose innovation on everything that moves.” This was related to the attempt to put an economic value on everything including things that can’t be measured (eg the arts) and reducing things inappropriately to a simple formula.

These thoughts also linked, in my mind, to references that the Finnish educationalist, Pasi Sahlberg (recently relocated to UNSW in Sydney I believe), makes to the use of “small data”  Big data is everywhere and some managers are very excited by it. It’s a great tool and I have often chased bigger numbers and interesting correlations. But it has big limitations and correlation tends to be where it stops. Pasi mentions the human observations and critical reflection that make up small data. It is part of the crucial interpersonal nature of education. Small data at a local level helps illuminate what works best and why and, as educators, we do this on a daily basis.

So, whilst we are in the current time loop, let’s learn new skills and make incremental improvements that probably have a greater (if difficult to measure) effect for good in the training of the next generation of doctors. Pick up ideas from colleagues, conferences and journals, critically reflect and apply and evaluate to ensure they work.. This is innovation. But it would also be a plus if these changes could be communicated to others (for the benefit of all) and noticed and valued by those with decision making power. If you are (or become) an educator who is also responsible for policy then consider these aspects of how education progresses and improves and ensure they are integrated into the system. Keep the people focus, applaud the incremental improvements and value and encourage the small data.


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!

Summer holiday learning: some tangential thoughts on multimedia

Here I am, diverted from the intended topic of my next blog because something came up that made me think laterally (which may or may not be a good thing).

Last night we drove to Sydney and attended Rembrandt Live. This was a concert by the Brandenburg Orchestra but, instead of being in a concert hall, it was held in the NSW art gallery.  We followed the musicians (in period dress) as they moved from room to room through the Dutch Masters exhibition of paintings from the Rijksmuseum.

Thus there was music (from an era I love, especially when it features period instruments and recorders) and paintings (from a school I really like) and this was accompanied by three dancers who also introduced an element of physicality and humour. There were even some background noises suggestive of a Dutch seventeenth century streetscape (but not the smells).  At the end we had a further fifteen minutes to browse the exhibition.  This was an event that recruited multiple senses.

It is obviously entertainment rather than learning but the element of engagement is common to both. It made me think about multiple media in teaching and the theories of effective learning and multiple modalities in Continuing Medical Education.   I won’t list the evidence (or lack of) right now as it really was just a thought bubble but perhaps it is one for you to consider as an educator.

I wondered if I learnt more this way. So here is some immediate feedback from a sample of N =2 (I include my husband who noted he appreciated the ability to focus on several different things).  It was initially a little disconcerting to hear applause for the dancers in the previous space while the musicians were playing in the next one. It certainly wasn’t boring.  It wasn’t too long and I appreciated being able to walk, stand or sit on the portable stool as needed.  I wasn’t therefore distracted by physical discomfort (brief snack could be had beforehand).  There was certainly an ambience.

So did I learn more this way? Well, I guess that wasn’t really my motivation in being there although I do like to gain extra knowledge from such occasions.  It was certainly a very enjoyable experience.  Actually we had previously attended the exhibition and I had learnt a lot more information from listening to the audio commentary so on this occasion I felt free to be more selective in what I viewed and to revisit particular paintings at the end.  This reminded me of the benefit of repetition for learning (and the Spiral Curriculum in Problem Based Learning).  Of course, before planning any new educational “events” for medicos, bear in mind we can be a serious lot with a disinclination to “waste time” and a tendency to let you know – so perhaps consider my musings as more of a metaphor than instruction manual.

Before we went to the exhibition we read a scathing review of it whose main criticism was that many of the pictures were the same as those included in an exhibition from the Rijksmuseum in Melbourne some years ago. We discussed this and decided that a. we weren’t sure if we had seen that exhibition (although we visited Amsterdam years ago and may well have seen the same pictures); b.even if we had seen them we had probably not appreciated them fully in the few minutes allocated to each in a walk through such an exhibition; c. if you enjoy certain pictures then you enjoy seeing them again when you have the chance (why else would you hang them on your walls).  In the medical education environment I can confidently state from experience that I am capable of sitting through the same lecture on an annual basis and still benefitting from it (things I forgot, things with new relevance etc)

Will my learning persist longer because of the multi-media? Well, we were motivated to buy a book (I am a sucker for museum gift shops)  called “A Worldly Art: The Dutch Republic 1585-1718” so I imagine if we go on to read some of this we will have moved on to a bit of “lifelong learning”. I might download Tulip Fever on my kindle or watch it on Netflix.  We might sit in our comfy arm chairs of an evening and share some interesting titbits of information that lead on to further discussion (and maybe a Learning Plan involving Google).  I have also recently started a botanical drawing course so I took a deeper interest in the Dutch still-lifes.  Sometimes the full impact of a learning event can be broader than you think.

Prior to the concert we walked through the Botanical Gardens and I enjoyed the height-of-summer cottage garden flowerbed. It reminded me tangentially that there often seems to be added value if you attend a conference in a pleasant place.  Such things are hard to measure but maybe should be a topic for further research!