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 https://www.dermnetnz.org/    or  http://www.pcds.org.uk/ )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 https://www.racgp.org.au/afp/2017/may/skin-biopsy-in-the-diagnosis-of-inflammatory-skin-disease/

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.

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

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” https://pasisahlberg.com/next-big-thing-education-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 https://docs.wixstatic.com/ugd/bbd630_9068591ed32045ef9e10c04cdf3086a2.pdf

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

The Teacher

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

Six Random Thoughts

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

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

The document quotes a great definition of frailty

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

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

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

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

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

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

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

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

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

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!

A New Year challenge: medical education and …..politics?

As usual, I have to confess that the latest interesting thought about medical education was a link I saw on Twitter. It actually distracted me from the post I was in the middle of writing. The piece is worth a read https://www.statnews.com/2018/01/05/politics-medical-school-education/

Although bear in mind that it is written in the American and undergraduate context. It notes the importance of politics to health systems and delivery and the lack of relevant teaching in medical schools.  Examples it quotes include issues such as prescribing an epi-pen to a child when the family can’t afford to buy it.  In the UK context the parallel question might be “what’s the point of prescribing something if the NHS can’t afford it?”  And the equivalent in Australia?  Somehow, many of these issues come down to the problem of money – and who pays.  Implementing access and interpreting fairness in this context is a political question.

The article points out that it is felt by many that politics should be kept out of medicine. The important thing is for the individual to be a good doctor.  It also comments on the naivety of this view.  Ironically, it is much more likely that there will be discussion of religious values than of political views even though personal and social ethics are involved in both spheres.  When I was a social worker I gravitated initially to the non-political, one-on-one casework approach but age, experience (seeing the limits of what an individual approach can do) and what I read in my early undergraduate studies led me to acknowledge the crucial relevance of politics. As a GP this is apparent on a daily basis.

Politics and health

It’s obvious that Public Health is inherently political. However, domestic violence and its consequences are a political matter.  As are issues in Aboriginal and Torres Strait Islander health and refugee health.  There were some challenging sessions on racism and “equity pedagogy” at the AMEE medical education conference in Helsinki, as shown by these tweets at the time.

   

The informative plenary by Catherine Lucey https://amee.org/getattachment/Conferences/AMEE-2017/AMEE-2017-APP-DATA/Plenary-6b.pdf opened up new concepts that definitely included a broadly political component.  Here is a tweet about it at the time.  Of course some medical schools were established on the basis of social and political issues – specifically located in disadvantaged areas or focussed on the community.

When to learn about it

It works better for all concerned if students learn at the point of need. Motivation is high. In addition, learners also prioritise their learning needs. These are strongly influenced, in post graduate time, by both the need to pass the exam and the need to cope clinically.  “Softer”, non-medical subjects are not rated highly.  So perhaps it is best to put in the groundwork in medical school and have courses that broaden these bright students’ view of the world.  In post-graduate training it is probably more appropriate to include these aspects as discussion points situated in case-based learning.

However, as noted, politics does not just influence health status and health care systems. It also influences health care education.  This can be seen in length of training, cost of training (and hence the way it is delivered), who delivers it, who gets in, the definition of outcomes and even the content of training.  Should educators, therefore, pay more attention to politics and medical education?  What you do is not just led by pure educational theory. So let me leave you with this new year challenge to reflect on how political decisions have affected the way you as educators are now teaching. I have a few opinions myself but in good teaching style I’ll just leave you with the question – and what you might then do about it.

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

https://www.youtube.com/channel/UCtQNtW9vDOqWOX1KNwrBVmA/videos?disable_polymer=1

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.  https://docs.wixstatic.com/ugd/bbd630_9068591ed32045ef9e10c04cdf3086a2.pdf 

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) http://mededpurls.com/blog/index.php/2016/10/31/teaching-multimorbidity-part-one/   and Care of the Ageing http://mededpurls.com/blog/index.php/2017/05/15/perspective-on-teaching-aged-care/   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..

 

To everything there is a season

I have always liked that quote (from Ecclesiastes 3:1 in case you were wondering), probably reinforced by the fact that it was turned into a song in the 60s (and a hit by the Byrds – who remembers them?) in my impressionable youth.  

There is a time for being serious and academic and evidence based in medicine and medical education -and that is probably most of the time – but thank goodness the BMJ has a seasonal xmas edition with lots of light heartedness.  One of my favourites this year was “Does Peppa Pig encourage inappropriate use of primary care resources?” http://www.bmj.com/content/359/bmj.j5397  which was apparently taken as a serious suggestion in some quarters.

In medical education there are also times to be serious and occasions on which to be more light hearted, though generally it is within the overall context of imparting a learning experience. Sometimes it’s just for the purpose of enhancing the  interpersonal part of education which is in decline in current programs.  A Christmas quiz in a workshop setting can always include answers such as “Christmas disease” and questions about red noses and liver function tests.  Of course one can’t guarantee this method will be appreciated by all participants.  Some years ago I included a lunchtime “trivia” quiz at a workshop.  All the exam-style questions focussed on topics presented during the workshop day and four out of five were serious.  Twenty per cent were real trivia.  For example there were questions on respiratory disease and then some where the answer might be a rock band with a song title about “air’ or “breath” etc.  Out of a few dozen feedback sheets there was one comment that a trivia quiz was “unprofessional”.  They obviously felt it wasn’t the right season and maybe it’s all about the framing and expectations.

There have been many seasons in medical education. There was a long era of lectures and a shorter epoch of small groups.  There has been an evolution of overhead presentation technologies and we have entered the age of performance in the TED (technology, entertainment, design) talk template.   My daughter is a stand-up comedian and I observe similarity between the preparation for a six minute comedy set and a six minute Pecha Kucha.  There have been other more innovative approaches and, for the researcher and presenter there have been books, libraries, index medicus, online journals and, praise be, Google.  In terms of seasons, it is probably Spring heading into Summer for the use of various aspects of social media in medical education.

If we go far enough back there have also been dire warnings, at a society level, about TV replacing radio and cinema, screens replacing books and too much time spent on video games or social media. So it goes on. Perhaps the main issue is the end point – informed and reflective individuals – and there are stimuli aplenty to thinking and reflection in the whole range of media.  Afficionados of one approach to education are very much inclined to bag other approaches but perhaps there is wisdom in the quote that started this post and which still resonates with me after all these years.  “To everything there is a season and a time to every purpose under heaven”.   It all depends on appropriateness (and there is professional judgment in that) and that may depend on purpose and context (in its broadest sense).

Take some time over the Christmas season to take in a good (or bad) film, an interesting book, concert, gallery, magazine or blog and exchange views on social media or in person. I hope we can all find some time to relax, reflect and relate (and start the new year revived).

and the presenting problem is……

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

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

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

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

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

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