Colin's Medical Education Blog

Do Doctors really need to know the Krebs cycle?

2009-10-12T17:57:00.004+01:00

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

2009-10-04T20:50:00.003+01:00

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

2009-09-30T07:40:00.003+01:00

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...

2009-09-03T18:04:00.004+01:00

...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

2009-08-04T17:17:00.004+01:00

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...

2009-07-23T15:58:00.009+01:00

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

2009-07-13T16:43:00.002+01:00

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

2009-07-13T14:15:00.006+01:00

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'

2009-07-01T18:30:00.003+01:00

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?

2009-06-21T10:52:00.010+01:00

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.

Personal Case Report: Visual Hallucinations post-op

2009-06-12T15:13:00.004+01:00

Interesting case last week - post-op Mr C was told by his surgeon that he'd had a myocardial infarction during recovery. A week or so later, his memory has turned this MI into a stroke. On a medical review of the frail surgical patients, Mr C happily told me he was getting over his stroke OK, but was troubled by odd hallucinations.

It's not uncommon for the elderly to experience confusion, fluctuating consciousness and hallucinations during acute illness - this usually represents delirium, a global, reversible brain phenomenon usually caused by infection, metabolic disturbance, drugs (prescribed, illicit and socially-acceptable) or drug withdrawal.

But my patient didn't quite fit the pattern. His memory wasn't great, but this doesn't appear to have changed recently. He was quite alert. And his hallucinations were, when he went into them in more depth, almost exclusively appearing to the left of his bed, usually seeming to be fleeting images of people, disappearing beyond the field of view as soon as they appear. To his left was a window, through which was the nurses station. Such fleeting mirages on a hospital ward are usually called 'nurses'. Ha ha.

This kind of hallucination sounded a little like the hallucinations often described in Parkinson's Disease - patients will often describe feeling like there is someone standing just outside their visual field ('presence' hallucinations), or seeing animals or dark shapes flitting out of their sight. But the left-sided phenomenon was odd.

A screeening neurological examination - tone and power in the limbs, a brief check of facial power and eye movements - was normal. Crude checking of visual fields however was grossly abnormal. This man had no vision to the left of midline.

More accurate visual field examination followed - demonstrating a left homonymous hemianopia - the loss of the left half of each eye's visual field.

For med students / junior doctors - Where do you think this man's stroke was? Bamford classification (TACS, PACS, PoCS or LacS) or anatomically. Or both.

Then look at the CT images:

The CT scan demonstrates a right-sided infarct in the occipital lobe - a stroke at the back of the brain on the right, which fits with the clinical picture of left-sided visual loss (the nerves from the eyes cross over in the middle of the brain). There is a small amount of haemmorhage within the infarct, but outside the acute period (first few hours) this doesn't affect management significantly.

Learning points? Clinical examination is still useful. Listen to your patient to guide your examination. Don't assume an elderly patient is confused just because they're describing odd phenomena.

Further, I'm now wondering if the visual hallucinations are similar to the Charles-Bonnet syndrome, or whether this is some kind of excitatory effect from the small amount of haemorrhage into the infarct.

SpR GIM Training Day

2009-06-10T11:42:00.000+01:00

Sort of experimental one, this, especially since I sent it from my iPhone. It turns out I'm trying to do several different things with this blog (but then it is my blog). I think that's ok since I can use posts such as this both as my personal reflection, and as examples of different ways to use a blog. Anyway, today was regional GIM SpR teaching on cardiology. Over all, lots of knowledge and expertise but most speakers too keen to show that rather than educate effectively. Take home messages required some distillation...

AF - Ablation? main indication is symptoms (and drug failure). Amiodarone little use for rate control, for rhythm control ok but poisonous.

Cardiac MR - Cost in Manchester only 3x echo. ?Now should be 1st line for myocardial perfusion.

Interventions for LVF:
Medical Rx
Beta blockers most important, some data that early (acute) beta blockade is lifesaving. (observational data). Optimal rx may soon include adding ivabradine to B-blocker.

Biventric pacing (resync) for NYHA 3 or 4 despite medical mx, EF <35% + LBBB

ICDs for 2ndary prevention, primary prevention post-MI, CCF, VT on tape and stimulation.

VADs = mini bypass machines. Weak evidence base. Big stroke risk.
Used for:
1. Buy time before transplant (4-6/52)
2. Bridge to recovery (longer)
3. Long term (not on NHS) if not fit for transplant.

Transplant for the otherwise fit. 20% mortality at 1yr.

Aortic Stenosis: once symptomatic, survival is months and QoL poor.

Transcutaneous AV replacement:
For severe symptomatic AS with excessive surgical risk + survival > 1yr. No good survival data yet.

How to Fix British Undergrad Medical Education? Two suggestions: Copy the US, or use Google Wave.

2009-06-03T17:27:00.004+01:00

So, is Google Wave going to fix medical education in this country? Quick answer: of course not. Silly question. Of course, the question is really there to draw you in and make you think. What am I really asking? Something like... "How can we use advanced forms of Social Media to improve the undergraduate medical education experience?"

But why fix? Is it broken? Well, not really broken, but there are issues. And what's this got to do with the US? Well, foremost of the problems I see with current medical undergrads is the lack of time spent on wards / clinical responsibility. When I was working at MUSC in the US, I worked with some excellent medical students who were knowledgeable, personable and interested. Even though I was only there for 3 months, and some of their attachments were even shorter than that, I got to know them well and saw them improve noticeably in that short period.

I even friended some of them on facebook.

Back home, I can't tell you the names of any of the medical students that have been attached to my firm in the last 3 years. Is this because my memory is terminally shoddy? On this occasion, no. Because recently I've not seen a student often enough to really get any idea who they were, what they knew, or what they needed to learn.

Particularly in district general hospitals, students seem to spend one or two half-day sessions on the ward, following the consultant ward round, occasionally getting a grilling, then disappearing off to some unspecified teaching. At first I thought they were all just going home (I distinctly remember using the phrase 'studying in the library' as a euphemism for going straight home, possibly via the pub (it didn't look like this when I was at med school though)) but they really do have timetables with various educational commitments, all over the hospital.

Great that they're being exposed to so much, but dismal that they spend most of the time as hospital tourists, superficially glancing over a variety of procedures, clinics, rounds and lectures then forgetting all about most of it.

How do we get students to make the most of their time in a hospital?

So option 1: Get them on the ward, get to know them, give them some responsibility (the US model). I like it. But with so much to see and learn, are we depriving them of the huge variety of experience they currently have access to?

Option 2: Use social media. Google Wave is the hot topic right now (and it does looke pretty freaking cool), since it mashes up the best of email, blogging, IM, and wikis/online documents. Is this how we'll get students to actually reflect on and synthesize their experiences?

Perhaps a single session in the cath lab, or at a falls clinic will become substantially more meaningful if medical students can discuss, reflect, share relevant resources, and contribute to some kind of assessable group output on each of the types of experience they've had in their hospital attachment? (Because with British medical students, if there's no assessed end product, several would probably say f**k it and go to the pub. I know I would have) This does raise the question of how you assess collaborative work, of course.

Or why not do both? A bit of the old-school with some of the new wave? Sounds like a good idea to me.

Another challenge for EHRs

2009-05-04T17:06:00.002+01:00

I have more confidence in Google's attitude to Electronic Health Records than the current National Program for IT, and the major factor in this is openness. (NB this doesn't mean I don't have any worries about Google doing it, just that they appear to be doing it better than the DoH)

Google addresses an interesting problem with user access to EHRs. A US hospital was sending ICD-9 diagnoses direct into a patient's EHR. Guess what? The coded diagnoses were often nonsense, as they were either a 'best fit' or a rule-out diagnosis (eg the hospital codes and bills for Acute Coronary Syndrome when the patient is admitted with ?ACS, but turns out to be troponin negative)

The US is ahead of us with this because they've been relying on coding for payment for years (indeed coders can be found wandering the corridors of US hospitals scouring for billable events or diagnoses). But in this case, the user reviewed his own record, noted the appearance of some odd diagnoses, and took it up with Google. Now both google and the hospital have changed how they work.

Web2 may be about the power of crowds but it's nice to see a single person's issues being dealt with by the Google behemoth.

If the NPfIT wasn't a political football, a privacy concern, grossly overbudget and poorly designed from the ground up, maybe there wouldn't be so much secrecy about how it's going to work, and more user involvement to iron out its creases.

Ethics and UK Law in Healthcare Rationing

2009-05-01T17:49:00.002+01:00

NICE & Alzheimer's Drugs

View more presentations from Colin Mitchell.

That F2 Health2 Workshop in full

2009-05-01T17:46:00.001+01:00

Health 2 F2 Workshop

View more presentations from Colin Mitchell.

See below for Scribd workshop materials, also available on my slideshare site.

F2 teaching on Medicine 2.0

2009-04-08T22:56:00.005+01:00

As requested following today's F2 teaching - tasksheets on blogs, RSS and connectivism.

FYI, the embedded document below uses scribd.com's document sharing facilities. Once you upload a document to scribd you can share it by emailing a link, or you can actually embed a bit of code in a blogpost to show the document within the post, viz:

Health 2 F2 Workshop

Publish at Scribd or explore others: How-to-Guides & Manu blogs connectivism

The Best Medicine

2009-03-30T23:57:00.001+01:00

As house officers, my friend Tom and I had a discussion about which was the best medicine. I said laughter, he maintained it was frusemide.

Turns out laughter is quite effective medicine. I suspect the pharmaceutical industry will not be funding comparative trials though, so our previous debate remains unresolved.

I'm not sure how you'd do an RCT on laughter. Blinding would be pretty difficult. Placebo?

How to blog

2009-02-10T18:16:00.001Z

Well, I don't really know yet. But I do know how to start one up - it took about 5 minutes. Takes a bit longer to add some fancy stuff, but it's really about the content, innit.

Anyway, should the bug hit you, this is a google video on how to do it (using Blogger - other options are available):

(hat tip: clinical cases and images)

Mo' slidesharing - Dizziness and Socialized Medicine

2009-01-31T14:33:00.001Z

I'm uploading a few more of my old presentations to slideshare, trying to be a bit more open-source.

So I've covered:

Benign Paroxysmal Positional Vertigo and the Epley Maneouvre

Dizziness, Falls and Immobility for CMTs

Socialized Medicine - a personal US / UK comparison

The last one isn't so much educational as opinionated, but it is based on my time working in the NHS and a brief stint at the Medical University of South Carolina. Which was excellent, by the way.

Privacy And Electronic Records by NO2ID's Phil Booth

2009-01-26T21:51:00.001Z

Phil Booth, National Coordinator of NO2ID, spoke to the North-West's general medicine SpRs last week about the dark side of health informatics - particularly relating to the government's track record on privacy and data protection. No doubt that health records should take advantage of new technology, but NO2ID and their offshoot, thebigoptout, are convinced that the entire NHS CfH 'spine' needs to be redesigned to make health data genuinely secure.

Phil's talk from 19/1/09:

Electronic Health Records - Privacy Concerns, by Phil Booth (National Coordinator - NO2ID)

View more presentations or upload your own. (tags: electronic health)

Health 2.0 Presentation - A New Way

2009-01-26T20:58:00.001Z

I've definitely got plenty to learn about the blogosphere, and I definitely learn by doing. So let's see if I can post my Health 2.0 for UK SpRs presentation via a slideshare widget...

Health 2.0 for UK SpRs

View more presentations or upload your own. (tags: health 2.0)

Delicious

2009-01-25T15:25:00.001Z

Social bookmarking is one way of sharing useful resources. There are various options, I'm using del.icio.us.

The Connected Student

2009-01-25T12:44:00.002Z

If you like those videos with bits of paper being shuffled around to exaplin how stuff works, there's lots of them at CommonCraft. Borrowing the same style, but made by someone else, is this excellent video on how someone can use Web 2.0 tools to enhance their learning and work collaboratively on an educational project.

Some light relief - Teach yourself how to make the best paper aeroplane... ever

2009-01-25T12:28:00.003Z

Digital Rights - the Coroners and Justice Bill

2009-01-25T12:22:00.005Z

A contentious topic, no doubt. But if you're happy to put your personal, taxation, health and immigration/travel records into one big file and let anyone in government/civil service put it on a flash drive, you won't be interested in this.

If you do care, you might like to go to contact your MP via Write To Them.

Missive from the SHA

2009-01-25T12:14:00.003Z

A few people asked questions about PACS on Monday. Courtesy of Rhidian Bramley - the PACS lead in the SHA, here is their reply... woah...

PACS is a COTS product and the method of searching for patients is the standard GE Centricity web user interface. Centricity PACS is Trust based and is interfaced to the Trust PAS. It receives, stores and updates both the Hospital number and NHS number through standard HL7 ADTs. I suspect the question has arisen because the user interface only displays one patient ID by default (i.e. either the local patient ID or the NHS number), although this can be toggled by the user through the user preferences. Users can only search on the NHS number if the NHS number is set as the default. The system administrator can also set which number is displayed by default (for each user). Following the recent DSCN we will be advising Trusts that they should be changing all accounts to display the NHS number by default. The timing of this will remain a local decision though, as it will need to be aligned with the rest of their trust implementation plan (I suspect this is a challenge we will face with a number of hospital systems).

We are promoting use of the NHS number through the Northwest NHS PACS Web Portal. This is a NWSHA innovation, (not delivered through of CFH), to support data sharing between NHS organisations. It has been a great success and all 29 acute Trusts are now connected with ~ 70,000 remote web accesses per year. The service is also available to PCTs. We include guidance to Trusts and users that they should be using the NHS number for all portal access, and there are instructions on how users can change their preferences in the FAQ help section of the portal. http://pacsportal.northwest.nhs.uk/PWportalhelpFAQ.asp#Can_I_search_for_patients_using_the_NHS_number
[N.B. It is planned that the LSPs will deliver a central data sharing solution under central CFH contracts but the scope and constraints of the project mean it unlikely we will have a solution for some time. To date the SHA has had minimal opportunity to input into this (PACS contracts are not formally part of NLOP). There are no plans in the CFH contract to support dual display of local and NHS number, as it is planned we will all move to the NHS number.]

PACS Training is provided through cascade. Each trust has a number of master trainers that have been trained by the PACS supplier, and each trust was supported in developing its training plan to cascade training to all PACS users. The SHA provides training and system administrator updates through the NWWM clinical reference group meetings, which are attended by all Trusts. The centricity web product also includes a self assessment training package that users can complete. The SHA is supporting Trusts in assessing the success and benefits of their PACS implementation through an online user survey. This includes a question on training, and this has helped Trusts direct additional training to those in need of it. http://pacsportal/PACSsurvey1TrustAvgResp.asp

There is an established SHA governance structure for PACS. We have a reporting process through the PACS leads in each Trust, and we have worked up a number of safety issues that have resulted in changes to system design and configuration. The structure has developed links between the NWSHA and CFH safety/help desk processes.

Umm... did you get that?

NHS Connecting for Health

2009-01-25T11:47:00.003Z

Those fellas from NHS CfH are very keen to get their message out. Dr Hannan has asked me to post a few links:

First, his PowerPoints:

NHS CfH - now and the future (5.3MB)

Making Records Accessible - eMPOWERing patients (13.59MB)

And he also has a blog on his practice website:

Dr Hannan on The Map of Medicine

Health 2.0

2009-01-25T11:44:00.004Z

I've uploaded my recent talk on IT, Web 2.0 and medicine onto Slideshare, a useful resource for distributing PowerPoint slides.

There's a link to my slideshare page to the right, where I should shortly have a few of my previous talks uploaded. Or you can access the Health 2.0 talk directly.

An end to hypocrisy

2009-01-25T11:39:00.003Z

It does seem a little ridiculous to spend an hour convincing 140 medical registrars that blogs, web 2.0 and interactivity are the future of medicine and medical education, but not to have a blog myself. So, now I do.

I hope the items I post here, as well as the links on the right prove useful and/or enlightening. Now, to business...