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Archive for November, 2013

See one… go on a course… do one…

17 Nov, 13 | by Toby Hillman

The apprentice model of medical education is ingrained in the traditional lore of medical practice, and heuristics like ‘see one, do one, teach one’ are still commonplace.

As with all skills – medical procedures have a learning curve. Some learning curves are longer than others – a hernia repair is not the same in terms of complexity as a coronary artery bypass graft. But all procedures do have a learning curve.

The current editor’s choice in the PMJ (free) – analyses the results of a relatively new technique for assessing hepatic fibrosis in light of the operators experience.  Unsurprisingly it shows that there is a learning curve to the technique; accuracy and concordance with a gold standard improves with experience.

The way in which the initial experience of using this technique is gained is through a course developed and delivered by the manufacturers of the product.  This course involves theoretical, and practical aspects of the technique, and the opportunity to practice obtaining readings on 3 healthy subjects.

There were a couple of points from the paper which struck me as important for the wider training of clinicians, and medical education as a whole.

The first was that there is a disconnect between the number of scans performed during the course of training supplied by the manufacturer, and the number noted in the study to confer a degree of certainty about the reliability of the result.  The difference may not be huge – but the defining of learning curves for practical procedures is an important one in the days of competency based curricula.

However the paper raised my hackles a little bit with regards to another staple feature of modern medical education: the course…

Nowadays it seems impossible to learn any new skill without going on a course – be that a bronchoscopic technique, a surgical knot, or how to perform a fibroscan.  Clinical practice with appropriate supervision, it seems is no longer the best way to acquire skills and knowledge, and the separation of training from service which has been lobbied for over time may have come to pass.

But, what this paper shows is that going on ‘the course’ is not the end of the learning curve. As with most skills, learning continues in practice. The manufacturer of the equipment provide a reasonable grounding in how to perform the technique, but not enough, according to this paper, to produce reliable results.

Perhaps this is seen as stating the obvious, but we would do well to remember that knowledge and skills acquired in a classroom do not always confer competence. And for trainers who are responsible for patient safety, and patient care – perhaps a more robust test of confidence is the test of trust – would you trust this person to perform this procedure without supervision on your patient, or your family member (the grandma test)

The separation of clinical practice and training in the minds of trainees is a dangerous road to stroll down. Indeed, if we do not see our wards and clinics as the active training environments that they are, and fail to maximise the educational opportunities which reside there, we do a disservice to our patients.

The increasing reliance on ‘the course’ to provide education can be a convenient way to accelerate learning in a particular field, but if courses are being used to cover core competencies of medical practice, because training posts cannot cover that ground, or provide that supervision – we need to reflect deeply on how educating our juniors and developing their clinical skills and acumen has fallen so far down the agenda that service is now seen as completely divorced from education.

Scribes and scribbles

3 Nov, 13 | by Toby Hillman

Poor communication is often at the root of complaints about clinical care (see here and here)

Poor communication with patients is concentrated on in a number of spheres of medical education – the CSA exam from the Royal College of General Practitioners is an example where consultation style and communication is assessed as a key outcome for career progression.  Medical schools deliver communication skills training, and postgraduate training (especially for General Practitioners) sets a premium on communication between healthcare professionals and their patients.

In the background is communication between healthcare professionals within a team, or on different teams.  Acute situations are often covered well, and the ALS training system is a good example of creating a common language which enables swift understanding and communication in a time critical situation. Work within simulation labs in particular is bringing communication tools from other industries to bear on emergencies, and ‘crisis resource management‘ – with an emphasis on team communication is very much part of the current vogue in anaesthetic training (among other specialties)

But what about that staple of the medical world – the notes? Are we all trained as well in communicating in the written form?
As electronic notes loom on the horizon, perhaps it is understandable that note writing is becoming a lost art, and flourishes with a fountain pen becoming a rarity.

However, until we reach the nirvana (?) of a fully electronic patient record, we still have the task of communicating the complexities of a clinical examination in the notes.

An organ close to my (and your) hearts – is the lungs.  Examination of the lungs with a stethoscope has fallen out of favour in some quarters  but remains a key procedure in investigating the acutely unwell, or recuperating patient.

In the PMJ this month is a great paper on the use of different symbols used in medical notes to ‘describe’ findings in the chest examination – and the conclusions make a lot of sense. I was surprised to see foreign symbols which would make no sense to me at all, but reassured by the simple advice to make these hieroglyphics more understandable.  Below is one of my standard examination pictograms. I seem to have a different dialect from the studied population for wheeze, but agree with them in general for crackles…


My depiction of the study clinical description

A set of lungs with wheeze in the lower zones, and crepitations at the right base.


A common language would be the ideal, and this paper shows how we can improve this small but vital part of our communication in the notes.

When thinking about how to tackle this on a wider scale, it is tempting to think that to improve the accuracy, relevance and quality of note-making, the most senior member of the team during that consultation makes the note.  This is not the usual experience on ward rounds – where the most junior member of the team often scribbles down their interpretation of a consultation and then defines the actions taken by the team thereafter.

To enhance educational opportunities on the ward round, improve team understanding of the case, and the patient’s understanding of what is happening to them, Dr Caldwell in Worthing uses a technique which is discussed on this thread

The PMJ paper sets out the variation possible in understanding a ‘set-piece’ of clinical examination when written in the notes; we need to take the lessons from this and apply them more widely – to improve communication – which will in turn enhance patient safety, and potentially experience and engagement too.

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