Tag Archives: policy

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 Training Environment – micro and macro

Education and training does not just depend on the teacher / learner dyad in isolation. They are just part of a bigger training environment.  We are probably well aware of the micro environment of the practice or clinical setting which includes attitudes and involvement of the non-supervisor medical staff, the busyness of the service (in either direction), the variety of clinical cases, the supportiveness of non-medical staff and so forth.   These can be even more variable in community settings (compared to hospital) and can be harder to control.  However, they may often need to be accounted for.  If a particular practice has a patient load that is largely acute presentations, repeat scripts and medical certificates with little continuity of care (not uncommon in some settings) then educators should be aware of this and able to direct the registrar to a different type of experience in a later term  It can be more subtle within a practice where “female problems” are directed to a female registrar who then gains less experience in other areas.  A registrar may feed back that a supervisor is not very helpful  but yet the environment is conducive to learning because office staff are supportive and other medical staff are knowledgeable and involved.  The one thing you can say is that the issues are complex and a training system needs to take account of this.

There are a few points made in the following article (about education in residency training) regarding the importance of the “intangibles of the learning environment”.  The author claims that “At its best, the residency experience must be conducted as professional education, not as vocational training.” It goes further than mere training or credentialling and should focus on things that are obvious to many good supervisors : the assumption of responsibility, reflective learning, primacy of education and continuity of care.  http://www.jgme.org/userimages/ContentEditor/1481138241158/06_jgme-09-01-01_Ludmerer.pdf However, I do not agree with the negative interpretation of the limiting of work hours and suspect the principle of continuity should be addressed in other ways. A positive training environment can certainly encourage the learners to be curious about the outcomes of patients they see in the context of good handovers and teamwork.

He suggests there is a need to prepare “residents to adapt to the future, not merely learn for the here and now…excellency in residency training is not a matter of curricula, lectures, conferences, or books and journals…. Nor is it a matter of compliance with rules and regulations. Excellence depends on the intangibles of the learning environment: the skill and dedication of the faculty, the ability and aspirations of trainees, the opportunity to assume responsibility, the freedom to pursue intellectual interests, and the presence of high standards and high expectations.” You can sense his frustration at the increasing bureaucratisation in learning environments.  I am aware of many great supervisors in general practice who do all of this almost intuitively and we rely on their skills and commitment when broader systems are not adequate.

It is not so immediately obvious that the macro environments also have a significant influence on the learning culture.  These can include the ethos of a hospital, training organisation or government policy frameworks.

If the varying stakeholders (government, colleges, standard setters, accreditors, funders) emphasise outcomes and competencies, this can move the learning environment towards one that focusses on assessment and box ticking.  This may have benefits but there may be intangible losses which are not acknowledged.  If efficiencies are sought through larger institutions and faculty mergers, then the interpersonal nature of education may be lost.

Standardisation may increase the quality of training or lead to a lowest common denominator approach and the implementation of IT platforms  is extremely unpredictable in its outcomes.  At its worst, educational quality ends up at the mercy of unresponsive systems and learners and teachers feel they are part of an industrial process.  At its best, resources become more accessible to learners and reflective and self-directed learning can be enhanced.

In the clinic setting a positive learning environment is encouraged when the learner feels free to ask questions and when they observe a culture of learning in their colleagues;  where all staff acknowledge the importance of education and the learning task; where the supervisor is able to admit when she doesn’t know something and where the learner is treated with respect.  Learning is facilitated when there is sufficient challenge matched by the appropriate level of support – the concept of “flow” (another topic of its own) – which is not always easy to achieve and is a shifting dynamic.  The learning environment must also be safe for learner and patient and this often relates to the quality of supervision.

There are other learning environments which include the “workshop” setting. There is more to it than standing up in front and presenting relevant or required content to a group of learners.  The focus of evaluation is often on the presenter but a fantastic performer or an attractive collection of slides does not always ensure the most effective learning. Similarly, pre-prepared learning objectives may have limited relevance to the learning that is actually occurring. The size of the group will affect how active or passive the process is (300 is very different to 30).  Consider the members of the particular group of learners – are they at the same level, do they already know each other, do the presenters know them, have they travelled far?  What about the size of the rooms and the acoustics?  Are the small group facilitators well prepared?  Which of the educational staff takes note of (or has power to influence) these “small” but important issues.

In the bigger picture, consider the effect on the learning environment if service delivery is always prioritised over teaching or if the educational staff have minimal professional development to develop their skills. The “intangibles” of the learning environment that lead to excellence include the unintended consequences of policies and rules.   Learners are enthused to extend their knowledge and skills when they are inspired by mentors, when they can communicate with their educators and interact with their peers, when they feel supported by their supervisors and when the parameters of training include sufficient flexibility to allow for individual needs and rates of progression.

Over the last couple of decades there has been talk of both vertical and horizontal integration in teaching and learning environments. Some of this has been ideological, idealistic or pragmatic. It is affected by the size of institutions, the remoteness of training locations and the training requirements of various health professions. It has been influenced somewhat in Australia by the waxing and waning of funding for the PGPPP (pre-vocational general practice placement program) and it is no doubt also affected by practice economics, student numbers and reimbursement (or otherwise) for teaching.  The GP supervisors group has written about this from a supervisor viewpoint http://gpsupervisorsaustralia.org.au/wp-content/uploads/GPSA-Vertical-and-Horizontal-Learning-Integration-in-General-Practice-Apr2014.pdf  (before the more recent significant changes to the structure of Australian GP training) and there are some notable examples of practices who make a conscious effort to create a learning environment.

Consider the learning environments that you are part of and the factors that are influencing its educational quality. I suggest discussing these with colleagues and considering the broader issues when you are evaluating your teaching sessions and the experience of learners.  We want learners to bloom  (not shrivel up like the pot plants on my windy and salty balcony) and for that they need the right environment!  Bear in mind that you can make assumptions about the factors that create a positive learning environment but, ideally, it would be best practice to actually try to measure this.  The validity of educational methods is very context dependent.

Educators may have limited power to influence decision making at many levels but we have a professional responsibility to inform decision makers when the learning environment can be improved and, especially, when it is under threat.


Teaching Multimorbidity – part two

Just an initial parenthesis about multimorbidity

If you ever wondered about the importance of multimorbidity, then wonder no more. Late yesterday (a Friday) the Australian government announced a summary of its revamp of funding policies and parameters for the “Health Care Home”.  These apply to general practice and refer to patients variously described as having chronic diseases and complex chronic illness – in short, it includes multimorbidity.  There are many really interesting articles and studies out there raising complex aspects of how to define, classify and research (and hence add to the evidence base of) multimorbidity, but from now on it will probably also be defined and counted by the Department of Health.  If you were wondering which patients we are generally talking about in referring to multimorbid patients, it is interesting to dip into a couple of articles. An interesting one in the Australian context is Brett T et al. Multimorbidity in patients attending 2 Australian primary care practices. Ann Fam Med 2013; 11(6): 535-542. http://www.annfammed.org/content/11/6/535.full In general practice, maybe a third of patients will have some sort of multimorbidity (defined as 3 or more co-morbidities) and more than half of these will not be elderly, but the clinical significance will also depend on severity and multimorbidity is more common in deprived populations. The estimated proportion of these patients will also depend on the classification system – eg whether cardiovascular is a category or individual diagnoses such as IHD or AF are listed and whether risk factors such as hyperlipidaemia are included. As Einstein said, “Not everything that can be counted counts, and not everything that counts can be counted.” Well, I guess it can but how meaningful it is may be in dispute.

pasha-bulkaGovernments have persuaded us of the impending doom to the health system and solutions are proposed. The Health Care Home (if implemented, not just piloted) will affect the way we fund (and manage) the majority of consultations in general practice, if not the majority of patients (given that these patients, unsurprisingly, attend more frequently).  This will affect the way that we teach about the management of multimorbidity in the future but it will still be important to understand the experience of the patient, the clinical issues regarding effective treatment and the challenges faced by health professionals. This is an interesting summary of the latter point: Sinnott C et al doi:  10.1136/bmjopen-2013-003610 GPs’ perspectives on the management of patients with multimorbidity: systematic review and synthesis of qualitative research

Registrars confidence levels – 2014 snapshot

As part of routine feedback, evaluation and quality improvement in training, a survey was done in 2014 which was a snapshot of confidence levels across registrar terms and in different curriculum areas. Basically, registrars appear to increase in confidence in all areas by term 3 (over 18 months), as might be expected.  On a scale of 1-5 the average difference in confidence levels, between Term 1 and Term 3, in managing various patient groups and problems was 0.6 (from 3.3 to 3.6).  However there was quite a range – from 0.3 to 0.9.  The areas rating 4 or above in levels of confidence by Term 3 were:

  • uncomplicated older patients (also high initially)
  • young children with acute presentations
  • patients with hypertension, hyperlipidaemia, diabetes
  • women’s health problems.

Of course, this could reflect a high initial level of confidence, effective teaching or natural improvement with appropriate experiences. It would be nice to have the opportunity to tease this apart.  In our then Regional Training Provider there was a significant focus on education in cardiac risk factors and diabetes and numerous sessions on women’s health and mental health.

Interestingly, therefore, the lowest Term 3 level of confidence was with multimorbid patients (with three or more chronic diseases / morbidities). The difference in confidence between Term 1 and Term 3 in this area was relatively small and from a low base. There had been no focussed specific input except that some of the registrars may have heard a one-off lecture by a visiting international speaker.  Interestingly, also, the broadest range of confidence levels (averages don’t always tell the whole story) were in child health, women’s health and multimorbidity (2-5) so perhaps not everyone needs the same interventions in each area and learning needs to be individualised, as we know.

After the implementation of the new multimorbidity education approach in late Term 1, the confidence levels were followed in this cohort. They already demonstrated a relatively high confidence with uncomplicated older patients despite educator concerns about lack of clinical exposure.  Multimorbidity started at a low base and then increased by 0.6 which was just below the average increase in confidence over the period.  We asked a new question in the final round about confidence levels in “patients with multiple morbidities PLUS polypharmacy or psychosocial problems”.  This only achieved a level of 3.3 (the lowest in term 3).

I suspect that “complex mutimorbidity” is the new frontier.

What registrars see

Registrars felt that they were seeing sufficient multimorbid patients for learning. In end-of-term feedback on their perceptions of the variety of patients in their placements, registrars (on average) reported seeing a good proportion of children, older patients, chronic disease and multimorbidity along with only slightly less mental health and women’s health.  On the other hand many registrars had limited experience in men’s health, palliative care and nursing home visits.  However, numbers and statistics do not always reveal the full picture.

In the practice

A registrar may see more than the average number of older patients or chronic disease diagnoses and yet they may be having shorter consultations with low markers of continupaperbark-fernleighity and unexpectedly lower than average number of problems per consult. It’s good if a training program collects, utilises and feeds back this sort of data in order to close the educational loop. This type of picture may possibly be interpreted as less engagement with the complexity.  On the other hand a registrar seeing fewer such patients may be encouraged by their supervisor to gain the maximal learning from their experiences. The potential is there but there needs to be an individualised approach – the experience for each registrar in each practice can be widely different at different points in training and a supervisor can adjust their teaching in the light of this.

What is helpful – the registrars’ retrospective view

A summary of points from previous survey and focus group data

  • It is useful to experience the continuity of staying in the same practice for more than six months.
  • Initially consultations tend to be “repeat script” appointments but by Term 3 they were taking more ownership.
  • This was affected by how much supervisors “owned” their own patients.
  • It was limited also by the variability of supervisor’s expertise in the area
  • The top three useful strategies were: 1. case discussion 2. prior hospital experience (gen med, aged care, pall care and ED terms) and 3. workshop sessions.

Registrar suggestions to maximise effective learning in this area

  •  Learning needs to be patient-based in the practice and involve case review with the supervisor (with the patient if needed) plus discussion of common combinations of co-morbidities.
  • There is a preference for case-based teaching in workshops.
  • Medication review discussions should happen with supervisors.
  • Early exposure to guidelines and read up when not confident.
  • “Co-ownership” of a chronic disease patient with the supervisor.
  • Involvement in nursing home care
  • Emphasis on information re local resources