Do Doctors really need to know the Krebs cycle?

Painful though it was to learn (both times - see later), the answer must be yes. But how much time should be spent on learning such basic science, at the expense of clinical experience? Or indeed, instead of other basic sciences such as pharmacology? After a previous glib comment on this, I received a long communique from a new reader who has a strong interest in pre-medical basic science. I'll reproduce it in full then add my comments later.

I am glad to have a discussion with you regarding the role of the basic sciences in premedical and medical education. This is the focus of my career, such as it is, but please take into account that I am not a medical doctor. I can only point to a mountain of work I have done in the wild west of MCAT preparation, helping United States premedical students master the undergraduate science curriculum in the United States before their big exam. Long ago I decided to put off medical school indefinitely to pursue this work because I felt it could be beneficial to others and it immerses me. I hope your readers will forgive my lack of credentials and look at my ideas in themselves. It is valuable for me to share ideas with you. In fact, I am going to be proposing myself as an applicant for a few MD PhD programs next year in the hopes of dedicating the PhD portion to development of reformed premedical curriculum and looking at the first two years of medical school to see how I might be helpful as well. I am beginning to work my courage up to contacting potential advisors at various institutions who have similar interests, so the opportunity of discussing these ideas with you is really valuable to me.

In the United States, medical school starts later than in the United Kingdom because students must first earn their four year undergraduate degree before they can begin medical school. Although a premedical student can major in any subject, all students must complete a full year each of college physics, chemistry, organic chemistry and biology. There is also strong encouragement for calculus, biochemistry, physiology and molecular genetics as well. Most premedical students are biology majors and take many other science courses. Medical school itself in both the United States and the UK is probably analogous to a severe hazing ritual, but the educational custom in the United States leads doctors to start practice three or four years older than their UK counterparts which probably makes our doctors more self pitying.

Alfred North Whitehead in his great essay 'Science in the Modern World' pointed out that the explosion of knowledge in modernity made the 'Renaissance Man' no longer possible, and that to be effective, a modern person had to content themselves with being a specialist, and this was in the 1920's! I think this predicament of modernity creates a real tension for medical education, especially, because the human body is a microcosm of the universe, of the whole of science, not only in the sense of complexity but in the sense that a person's health is bound to it, so it is very difficult for any person studying medicine to leave off something potentially important just because the mind has limited capabilities. Furthermore, there is a tradition which makes it hard for any teaching generation to make things easier for today's students than they themselves had it in their own education. However, the rate of increase of the knowledge base means that even if the discipline doesn't change, the disposition towards the knowledge among educators has to change. You can't learn everything. In biochemistry, as you mentioned, today's medical students are asked to retain an incredible amount of information regarding mechanism after mechanism, but this was true even twenty years ago. However, in the intervening years students have been given a new encyclopedia to learn in the field of molecular biology. Within the field of eukaryotic gene expression alone, there are now elaborate signaling pathways and mechanisms like alternative splicing and RNA interference which have been elucidated only in the past ten years. So there needs to be a lot of debate about what to teach and what not to teach.

Of course one important standard is whether a piece of information is relevant to clinical judgment. You mentioned the Krebs cycle, which is likely only important in clinical practice for a subset of metabolic disorders. Within every clinical specialty there are fundamental principles from basic science which are important for understanding of symptoms and treatment on a daily basis, but not for other specialists. Bernoulli's Principle and Poisseuille's Law for the cardiologist. Solution and acid-base equilibria for the nephrologist. Hooke's Law for the orthopaedist. An infectious disease specialist is not going to think about these things very often I suppose. In fact, the specialists themselves probably don't think about them too much on a daily basis, except in difficult cases, but the knowledge must be there in the first place for the specialist's education to have been coherent when they received it. This is where I have an issue with choosing the Krebs cycle as an example of irrelevant information, which to me is like the wheel at the center of the living system. Understanding the flow of energy in metabolism makes a great deal else a medical student must understand coherent, although I have big problems with how the Krebs cycle and a lot of biochemistry is taught. If instructors felt they could use the field of reference of physics and general chemistry in a sophisticated way to animate the presentation of the Krebs cycle, it would mean a lot more to students.

You mentioned the greater emphasis on clinical experience and communication in recent educational trends, at the expense of basic science. There is a lot of similar talk in the United States. Maybe medical educators are giving up on making medical school an experiment in finding the maximum possible amount of information a human mind can hold. It may be that there is good cost benefit to teaching doctors to be better communicators because it leads to better outcomes for patients without too much trouble. Convincing people to quit smoking has done more against cancer than understanding the mechanism of histone acetyl transferase, at least so far.

However, the proposition that animates my own work is that a more effective curriculum at the earlier stage would prepare entering students significantly better for the challenges of understanding and retention they face in medical school, whether the A-levels in the UK or the undergraduate level in the United States. I mean the fundamental level of physics, chemistry, organic chemistry and biology. Medical school would be more vivid. I think it is ridiculous that undergraduate students in the United States do not learn the fundamental physical and biological sciences within a combined curriculum that builds on itself, but within disconnected modular courses. How can a person understand free energy change in chemistry without mechanics, electrodynamics, and thermodynamics from physics? How can you understand oxidative metabolism without oxidation reduction? Being a person who has worked very closely with many small groups of premedical students, taking them through the basic sciences in review more times than I want to admit, I'm burdened with knowing how little conceptual fluency students actually possess after their undergraduate years that would help them unify the enormous encyclopedia already in their heads, and what is coming, which would make the facts coherent and memorable.

So I made the WikiPremed MCAT Course at www.wikipremed.com because I hoped it would benefit people as part of the whole movement to make education more accessible and I hoped it would be a way to share some ideas I had about rearranging the basic science curriculum for future doctors at the undergraduate level. The sequence of topics and goals in the course represents my best effort at what a unified, interdisciplinary, spiraling curriculum for basic science would look like (without lab component). I think medical school would be more interesting and enjoyable if students were prepared by a science program that followed a sequence like this one I have come up with, where chemistry comes out of physics and the biological sciences out of the physical sciences. If anyone is interested, they can go visit, if at least to see what a person is capable of who gets so deep in a project they can only double down. I'm too close to the work to see it's many problems clearly, so please make criticisms, as long as they are fixable.

Personally I'd love to know more about molecular chemistry and thermodynamics, for my own interest and general education. Perhaps one day I will. But do I think it will make me a better doctor? Maybe, but not much. I studied for the USMLE exams a couple of years back, covering biochemistry topics I hadn't looked at for nearly 10 years. It was painful. I remember being 19 and wondering "Will I really need to know how many ATP molecules are produced from each stage of this reaction when I'm a doctor?" At the time, I guessed I wouldn't. 10 years later I knew it wasn't any use.

Clearly there are significant differences between US and UK medical education. I don't think ours is anywhere near as much of a 'hazing' ritual as it is in the States, as the longer time period (5-6 years), lower expectations of students, and longer post-graduate 'apprenticeship' training make the whole experience much less intensive. And I think UK medical education has already moved focus away from basic science more than in the USA, which probably makes it easier too...

So the focus in the two systems is different, but I think both could be criticized for not stressing the more clinically useful basic sciences - physiology and pharmacology especially. I'd go back to my medical school lectures on those topics if I could. I'd probably get more out of them now, too.

So there you are. Medical school - wasted on medical students.

Comments & Medical Advice

I just rejected a comment on my hallucinations case report - an anonymous commenter posted a short description of their mother's unfortunate situation with confusion / hallucinations. I assume this is a way of discussing that situation and looking for help. Understandable, as it sounds very upsetting, but this really isn't the forum for giving healthcare advice.

It was pretty painless to reject an anonymous comment (I think if there's any question over appropriateness / relevance and the poster can't be identified it's pretty reasonable not to publish it) but if the poster chose to give his/her name or identifier I reckon I'd let it stand, albeit with a comment similar to that which I'm currently writing.

Time for a disclaimer about medical advice online? I'm not sure they're worth anything in court but it's maybe just good practice anyway. It seems fairly obvious that it's difficult to give advice worth a damn without knowing the whole story first hand (ie looking after the patient).

Learning about Managing

In some ways I am a nostalgic soul, tragically yearning for a past that perhaps never existed as I imagine it. I wish I'd been a doctor when we didn't have to commission a service, we just provided one. Reading about SHAs, QOFs, WCC, PBC and CQUIN (good name though, sequin. Don't know what it is, but it sounds glamorous. Perhaps this is the body that will design our new Doctors'/workerdrone uniforms) leaves me cold.

But in the North West, and I assume the rest of the country is no different, the realisation that we have to know about this stuff is beginning to dawn. NHS management has a worldwide reputation for incompetence and mediocrity, so naturally British doctors have to know how to interact with it. I guess the hope is that one day we'll have doctors engaged at all levels of management, guiding the NHS in the right direction. After all, my management and business skills are what got me interested in practicing medicine in the first place.

To this end, there are now various efforts to involve doctors in training with management, in terms of additional training schemes and as special secondments... TO THE DARK SIDE!

I'm sorry, I don't know what came over me there.

In reading about such postings in the North West I came across this National guide to NHS strcuture and management, aimed at Junior Doctors. It's rather well put-together and clearly written, although it does have the smell of propaganda. I think it's important that junior doctors know about this stuff, at least so any critique of it is well-informed (and well targeted - it's often difficult to work out which agency is actually responsible for a particular gripe, although perhaps this is a feature rather than a bug)

But did you know that Sir Bruce Keogh, Medical Director at the DoH, has 2 junior doctors working with him? (An ST3 and an ST5). What a fascinating job that must be (Not for me, I think I'd rather be a Urologist, and that's saying something). I hope these trainees use the skills they develop to improve the NHS. It's terribly easy to be so impressed by the power and complexity within an organisation that you struggle to see its failings.

Tomorrow's Doctors...

...are going to be quite similar to yesterday's doctors, apparently. According to the GMC, Medical Schools should now be focussing on giving students meaningful clinical experience, making sure that medical students are ready to become junior doctors. Which is what we've always thought, right?

But it is encouraging to see the GMC trying to take the lead in guiding medical schools towards promoting useful clinical experience rather than increasing PBL, training sessions, communication skills and simulations (all of which are valuable educational tools as an adjunct to clinical teaching, but have perhaps been over-represented).

In my brief run-through the new Tomorrow's Doctors I can't say I found much to substantively address two related issues though:

1. It's all very well incorporating clinical experience into the first few years of medical school, but this experience is of limited value when basic knowledge is so poor (as you'd expect early in undergrad training). Students need a good grounding in relevant medical science (ie you don't need to know the Krebs cycle inside-out but a good knowledge of pharmacology is essential). For example, I spent 5 minutes teaching a medical student (not final year, but not 1st either) about a lumbar spine x-ray. It took longer than I thought because instead of concentrating on the osteoporotic crush fractures, we had to spend some time working out what the calcified tube-thing anterior to the spine was (hint, it sounds a bit like "Ray Liotta") I didn't use that clue, though.

2. Dumping groups of medical students on wards doesn't equal clinical experience. All the checkboxes, DOPS etc in the world will not ensure that the student isn't spending most of his/her time wandering round aimlessly behind a disinterested ward-round, chatting to the other students because no one has the time or interest to actively teach. My ward was short staffed earlier this week, leaving a house officer for one team and an SHO for the other. This situation is manageable, but not ideal. Enter 5 medical students. You can imagine what kind of educational experience they got that day. Perhaps the advent of Student Assistanships will make the students more responsible and useful on the ward, which would undoubtedly improve the educational yield from their 'ward time'.

Once I've had a chance to have a proper read I may need to eat those words. We'll see.

(HT: Cambridge Medical Library)

The 11th Reason Doctors order unnecessary tests

I liked this list of reasons why doctors order tests. It's based on medical practice in the US but most apply to doctors in the UK too. I'd go so far as to add another - temporizing. It's really an extension of reason 1, with a bit of 2,3 and to some extent 5 as well.

Time can be an excellent way of finding out what the natural history of a disease process is, of gaining new information, etc, so ordering a few tests while watchfully observing your patient is often reasonable or even very good practice. However there's definitely a trap that many doctors fall into where they have a patient in want of a diagnosis or definitive plan, who doesn't readily fit into a disease paradigm, and they'll keep on ordering tests until they get bored. The problem with this sequential over-testing is it allows the doctor to stop thinking. All you need to do is fire off a few tests, then you don't need to think until they all come back negative. What to do? Order another test that takes a few days! And again, and again…

Although this could result in the diagnosis coming to light, either by eventually finding the 'right' test, or by the disease revealing itself more clearly (or just resolving), the unfortunate side effect of the process is that instead of being watchful and considering possible diagnoses for a time, the doctor disengages brain for all but the 30 seconds it takes to think up another few tests - thus while thinking he's exemplifying the considerate, watchful doctor, he becomes the exact opposite of that, sometimes for weeks on end.

However, I'd add just a tiny critique of Dr Rangel's underlying rationale for critiquing over-testing. Not that I disagree with him, because the behaviours he describes are absolutely not good medicine and should all be avoided. But why are they not good? In criticizing the lazy physician who can't be bothered to formulate a diagnosis using clinical skills, he says:

"It takes time to listen to and sort through a patient’s symptoms and to do a proper and directed physical exam. But if you have 55 patients to see today and you want to make it home on time then you can just order a GIANT MRI SCAN of EVERYTHING that’s all but guaranteed to detect any and every abnormality. Wrong. That’s not practicing medicine. That’s the cookie cutter approach. My dog can do that."

Yes, that's not very impressive doctoring. But the problem with the 'cookie cutter' approach is not that it's intellectually lazy, although it is. It's that it doesn't work - it has a terrible signal to noise ratio, and it results in patients being exposed to risks from the original investigation and from subsequent investigations or procedures relating to incidentalomas. However, if we had some amazing new body scan that could accurately predict the natural history and effects of every 'abnormality', at £1 per scan, then ordering a GIANT WIZZBANG SCAN of EVERYTHING might be very good for patients, even though any lazy idiot could order the scan. I'd be out of a job, but people would probably be healthier.

Despite what a few mail-order scanning companies would like to tell you, that scan doesn't exist, and is very unlikely to any time soon, so us good doctors who use clinical skill and judgement can rest safe in our paycheques. But it's important to remember what the point of our jobs is - being a 'good doctor' (which includes using investigations judiciously) improves the health and lives of our patients. It's not an end in itself.

As a medical teacher, I can't teach my students / juniors about every situation where they should or shouldn't order a particular test. But if I can teach them an underlying throught process or behaviour pattern relating to how to approach diagnostic situations - with the outcome for the patient paramount - then I shouldn't need to tell them how to avoid each of the 10 bad reasons for ordering tests. They should be able to work that out for themselves.

A Nursing student writes...

I recently received an email from a charming nursing student who read my blog, and wanted to know a little more about a presentation I'd uploaded to slideshare - on NICE and healthcare rationing. Primarily she wanted to reference it in an essay for her nursing degree on a similar topic. Now, of course I was very flattered, and yes, I do think my opinions are sensible and backed up by evidence, but I'm clearly not an expert on the ethics, law or economics of healthcare rationing. So I advised her to go to my references and look at the primary sources.

Because I'm a doctor I'm contractually obliged to unthinkingly underestimate nurses, and in fact she'd already done that. But she still thought it was appropriate to reference my presentation since she felt it had influenced her thinking:

"In some ways it's a grey area as I could solely reference primary sources and the Tutor would be unlikely to question it. But I am definitely borrowing the odd point from your presentation, so best to do the right thing"

TBH I don't think I would have been quite so honourable. I read a lot in articles, blogs, twitter feeds, on the TV, and from friends and colleagues. Sometimes I hear ideas or opinions I like or that persuade me to change my thinking. Some of it is conscious, much unconscious. So, when it comes to writing scholarly work, I tend to reference the primary sources that are at least published if not peer-reviewed too. Even if a blog article or online presentation influenced my thinking, I think I wouldn't reference it unless I was quoting it.

Is this reasonable, or am I being a snob about referencing sources that I don't think of as traditionally 'authoritative'? Would I feel better about referencing an article or book chapter by someone rather than the same person's blog? I think I probably would. And what about sites like wikipedia, which has the advantage of being 'peer reviewed' in some sense?

The debate about referencing wikipedia in scholarly work still has some distance to run, I think. For now, the rule seems to be that you can use wikipedia to learn but shouldn't rely on it as authoritative - and therefore shouldn't reference it directly. I think there's a lot to be said for wikipedia generally, especially if you understand how it works and how to look at the evolution of the article and its related discussions. But no matter how good wikipedia / my slideshare presentations / my blog waffling is, if I'm still sceptical about sticking them in the reference section of my essays, I think it'll be some time before these kinds of resources are widely accepted as reasonable reference points for academic work.

Perhaps this is a shame, but perhaps a conservative attitude to this new medium is wise until theres a widespread and deeper appreciation of how it works, how it can be used and what it adds.

Finally, my web-savvy nursing-student reader signed off with another interesting point. Having reviewed many of the primary sources I'd mentioned in my talk, she did pause for thought at the end of the assignment, reflecting...

"Oh well, I still can't give a patient a urinary catheter, but I read Aristotle today..."

What hath I wrought?

Blog Branding

IMG_0980.JPG
Originally uploaded by myglesias

Time for a minor update to the 'About me' blurb. It's clear I need more brand identity, or something like that, so I'm lifting this amazing bit of corporate missionwaffle from Nestle. Here's where I got it (via Matt Yglesias)

Bait for the MedWeb2Skeptic

Gah, @amcunningham beat me to a proper look at this paper on web2 use in medical education. To be fair, I was on night shift at the time, so wasn't really in the right frame of mind to write anything longer than 140chars. Still, feeling quite chuffed that I got in there early with the critique, even if it was a little... concise.

Anyway, there isn't a massive amount to add to Anne-Marie's skewering of this survey-based paper on use of Web2 tools in medical/nursing education - she rightly critiques the low response rate, confusion & conflation of web2 / social media tools, and the authors' rather bold conclusions (subsequently echoed around the twittersphere).

The authors do acknowledge one of the paper's weaknesses when they state:

"...given the small sample size, it is difficult to predict whether the use of Web 2.0 tools portends a growing trend in education or merely represents a passing fad"

But although they note the small sample size, they still accept their findings as significant, albeit perhaps transient. To be honest, in this paper, the future of web2 use in medical education is not 'difficult to predict', it's completely outwith any of the conclusions that could possibly be drawn from the data.

But just a few more points...

1. A survey of web2 usage by medical/nursing institutions by a fairly open-access survey, with a very poor response rate means that any conclusions must be interpreted with a degree of caution. But it's not just the low response rate that sounds a note of caution. One also has to question why those particular people bothered to respond (selection bias). It's easy to hypothesize that survey recipients who'd never heard of Moodle etc would just delete the email, while those who were evangelical about using wikis and youtube would reply in their droves. So the sample biases itself.

2. I think there's two other ways to do this kind of research - either spend some time identifying IT/education leads at medical schools and send them a better-designed survey asking questions about overall web2 tool use in medical school, or survey a large number of medical students from several medical schools with a very short survey to ask what tools they actually use on a regular basis.

3. As Anne-Marie mentioned, the qualitative data isn't mentioned. My guess is that there wasn't very much of it. The question is too broad and vague "please briefly describe how these tools are used in your institution". This makes it difficult to answer (therefore most respondents probably don't bother) and unlikely to identify any common themes, as the responses given are likely to be highly heterogenous. If you've ever tried to get useful qualitative responses from questionnaires, you learn this lesson pretty quickly. I did, and I was doing an MSF in my spare time.

So, having kicked the corpse a bit, what's the real issue here? I think it's this - apart from generating headlines, what use is this kind of research anyway? So 45% of medical/nursing schools use web2 tools. Big woop. Who uses them? What for? How? How often? And most importantly, why? If a web2 tool can deliver a better educational outcome (or an equivalent one more cheaply / easily / quickly) than a conventional teaching method, that's a good thing. But just using web2 education tools isn't important - it's what you do with them that counts.

Ref: Lemley T, & Burnham, J (2009). Web 2.0 tools in medical and nursing school curricula Journal of the Medical Library Association : JMLA, 97 (1), 50-52

Teaching Feedback - 'The Intimidator'

In 7 years as a doctor I think I've filled in a bazillion (approx) work-based assessments for junior doctors (most with contemporaneous structured feedback, some rather pointlessly a week or so later via email). I've handed in a few multi-source-feedback questionairres, and I've probably completed 0.3 bazillion post-lecture feedback forms. Feedback is everywhere in medicine now, and if it's done well it's incredibly useful. If it's done poorly, it's a total waste of time.

In terms of feedback I've received, most of it relates to my skills as a doctor, and very little has been comment on my skills as an educator. And if you don't count the aggregated scores from near-useless lecture feedback forms, I've received almost no feedback about my teaching. In fact, I really don't count those forms - the quantitative questions are so vague they're only useful for comparing yourself to the other speakers in a putative best-speaker competition. There is no specific information from this that can inform self-improvement.

Recently for the MSc in Geriatric Medicine (Teaching/Communication Module) I'm working towards, I completed an assigment on devising a multi-source feedback survey on one aspect of my teaching skills. The process, results and reflection was delivered by means of PowerPoint slides. This is it...

Appraising my Teaching Skills using MSF

View more documents from Colin Mitchell.

Notes:
1. Now, for those of you who don't know me, I'm not the kind of person that thinks of himself as intimidating. I'm a 5'7" geriatrics reg, ex-computer game reviewer, briefly a stand-up comedian. Not that these things define me or negate the possibility that I'm a scary, dastardly figure. But it's not something that's really come up very often, and frankly quite the opposite of my self-image, which is why I decided to explore the issue with my MSF. It seems I can be intimidating, to a few juniors. In fact this shouldn't be such a surprise, really. I've got just over 2 years until I'm a consultant, for many of them I'm 2-3 grades up in the professional hierarchy, I'm the teacher, I've (usually) got more knowledge than them... What do I do about it, though?

2. I don't actually think I'm Pete 'Maverick' Mitchell in Top Gun. But we do share a surname. And a nickname. Not really. But doing an MSF on yourself, about an aspect of your professional identity you're quite proud of is quite a challenge to self-image. That's what I was discussing with these slides.

3. Yes, the PPT slides are a bit wordy. But words mean points mean prizes (for the MSc markers).

4. HT to @nlafferty, who worked on the original DREEM, and pointed me towards the PHEEM (more relevant to F1s generally but less about teaching style, so I ended up using the DREEM as inspiration). The people you meet on Twitter...

Why are Junior Doctors no cleverer than I was?

Amongst doctors in training there seems to be little appreciation for the benefits of on-line learning. As a source of information (primarily via google and wikipedia) all but the most luddite seem to appreciate some of the benefits, although the benefits that are most often praised seem to be immediacy and accessibility. Accuracy less so, and not because most doctors know how accurate the information sources they're accessing are, thus give them less weight or learn how to assess, compare and cross reference relevant data - but because unfortunately many don't seem to care. That's fine when you need a two-line summary of a condition in a patient's medical history, but not good enough when on-line information is the backbone of your learning & referencing. Confession - I can't remember the last time I opened a traditional medical textbook to look something up.

The old-fashioned method of trusting a few reputable names (Davidson's, Harrison's, The Lancet, NEJM, Cochrane, the AHA, or even specialized online efforts such as Medscape or Up-to-date etc) isn't going to fly when there is such a huge amount of information available, going far beyond the scope of any of these august institutions. Frankly, appealing to authority rather than assessing sources, data and methodology yourself has never really been good enough either, even before the intertubes. Not to devalue these organs (all worthy in their own right, and still regularly form the backbone of my referencing) but their depth and breadth are already dwarfed by the rest of what's out there on the tubes.

So, we need to teach young doctors how to obtain, interpret, and evaluate data sources from more sources than can ever be pre-emptively approved. They also need to know how to integrate this new learning into their pre-existing knowledge to form new understanding and improve practice. That is, in order to learn and improve practice, they need to self-apply a constructive hierarchy of learning, from finding new information and understanding it, through using and evaluating that knowledge academically, and then applying it to their patients (creativity).


(Simplified version of the Revised Bloom's taxonomy (Anderson & Krathwohl, 2001))

I've talked before about how medical students are exposed to a huge volume of experience but seem to lack the skills or opportunity to assimilate it usefully. The same can be said of junior doctors, only substituting 'teaching' for 'experience'. When I was a junior doctor I got one hour of organized teaching a week at lunchtime, and the occasional attendace at grand round. I was often too busy to make either. Currently, the juniors in my hospital get an afternoon of teaching (An hour of Grand Round and 2.5-3h of specific F1/F2/CMT tutorials). It's bleep free and their wards are covered by on-call staff. So, 2-4x the amount of teaching, and they usually get to it. But knowledge and practice don't seem to be any better (and I am aware of the 'when I was a house officer' fallacy - I don't think they're any worse than I was). But why no better?

Often the methods used in hospital teaching programs try to jump over the intervening stages of learning, firing knowledge at the bemused faces of junior doctors via PowerPoint and expecting that to magically enhance their practice. I've even heard consultants bemoaning the fact that "They were taught this last week!". Not well enough, it would seem. Further, doing this kind of thing for 3 hours is utterly pointless. Even if they remember a few points from the first PowerPoint, they've forgotten them by the end of the third one, and are also apocalyptically bored.

The Plan

So, junior doctors have access to a huge amount of information, but don't know how to use it. They're also given a large amount of teaching time, a lot of which is wasted. I think there's an opportunity here, and I'm currently planning to change some of the junior doctor training at my next Manchester hospital placement to demonstrate it. Details a bit sketchy at the minute, but if things work out, I'll be setting up a (probably Wetpaint-based) VLE / Wiki to assist with the delivery of either the CMT or Foundation curriculum.

Face-to-face teaching will remain the backbone of the program, but with a 30 min introductory lecture rather than 3 hours of PPT-punishment. Then, case discussions (PBL style), followed by wiki-based knowledge sharing, evaluation and synthesis. I'm aware that contributions outside of class time are substantially lower than during, so I'd plan for them to do the majority of the work straight away. Also, since I'm a believer in evaluation-driven learning (but sceptical of how accurately exam scores reflect real skills) I'd expect to use their contributions as a marker of the learning process. So instead of just checking at an appraisal that the doctor has signed in to 70% of teaching sessions, I'd be able to give an indication of exactly how much the doctor has participated - this could even be used as a official learning objective by the educational supervisor.

So, that's the idea. I expect it will change, due to practical constraints, and also because I'm learning about the process of delivering this kind of connectivist program. But for me to be learning alongside those that I'm teaching is really exciting.