Why do we call it ‘Teaching’?

A Reflection on Teaching and Learning Culture in UK Emergency Medicine

 

One of the things that most amuses my school teacher friends is my insistence on referring to postgraduate educational opportunities as ‘teaching sessions’, e.g. ’I’ve got regional teaching this afternoon’. I’m not alone here in referring to ‘teaching’ – it’s common amongst doctors and medical students alike.

And an all too commonly heard moan for doctors, (I’ve done it myself, many times), is that they aren’t getting enough ‘teaching.’ At the recent College of Emergency Medicine and British Medical Association joint seminar held as part of the Emergency Medicine Trainees Association 2014 conference a recurring theme was a perceived need for more shop-floor teaching.

This is all anecdotal of course, but there is very little evidence out there regarding trainees views on this topic. The GMC National Training Survey[i] is a good place to start, but when you look at the actual questions and how the scores are calculated, it becomes clear that a score of 70-ish for local teaching (which it has been steadily since 2012) means very little, being calculated as it is from a combination of questions like ‘How many hours a week do you receive local specialty specific training?’ (What does this mean? Shop floor supervision? Small group seminars?), and ‘Who carries out local specialty specific training?’ (Senior doctors scores highly here but is that a true marker of quality? Does being a Consultant automatically make you an excellent teacher?) We are also asked to rate the quality of our teaching sessions, but against what standard? In summary, this survey is not an especially valid way of evaluating the quality of a teaching programme.

What do we actually mean when we say ‘teaching’? As postgraduate learners, we have a wealth of opportunities available to us, from organised lecture programmes and seminars, to shop-floor supervision to simulation courses.

Calling these varied learning opportunities ‘teaching’ turns them into passive activities and implies the spoon feeding of facts and transfer of knowledge direct from our teachers to our brains. It absolves us of our responsibility as learners to make the most of them.

The complaint of ‘not enough teaching’ is generally used to refer to shop floor learning, where a trainee is directly supervised doing something by a senior, (for example leading a team or performing a procedure), hence the regular comparisons with the one-to-one training that junior anaesthetists receive. That juniors in emergency medicine have senior supervision available for absolutely every single patient that they see seems to pass us by. That senior anaesthetic trainees practice independently for much of the time without constant one-to-one supervision also seems to escape us.

In actual fact, we do receive a significant amount of this kind of teaching. In the departments I have worked in, there has been consultant presence on the shop-floor for the vast majority of time in-hours. My current department has consultants on the floor for 16 hours a day. Supervision is therefore available to me for the vast majority of my working hours. Are we counting those ‘Can I just ask you about?’ and ‘What do you think of this?’ as being ‘teaching’?

As well as this, the College of Emergency Medicine has an exhaustive list of workplace based assessments that we are all required to complete. They are near universally despised, yet they represent direct hands on supervision opportunities, or to put it another way; ‘teaching’. Why then do we hate these assessments? Rather than seeing them as irritating tick box forms, can we reframe them as empowering us to request direct training and feedback on our performance?

And what exactly do we want ‘teaching’ on/about? If you’re a surgeon, then understandably you want to spend lots of time performing surgery, learning the craft of each procedure. If you’re a gastroenterologist, then the hours spent as a general medical registrar probably seem less relevant to your career compared to the endoscopy lists and clinics. This just doesn’t apply in emergency medicine. As an EM doctor, every single patient that we see on every single shift is a potential learning opportunity. We cannot just see the critically ill – our speciality is far broader than this. We need to be happy with the bread and butter of our specialty, not just the jam. Head injuries, elderly patients with falls, acute confusion, intoxicated patients both drugs and alcohol, febrile children, vague chest pain, dizziness, non-specific abdominal pain, deliberate self-harm, red eyes…It’s all on our curriculum and forms the vast majority of our workload[ii],[iii].

As senior emergency medicine doctors, we do not need to be directly supervised seeing these patients, but we should not dismiss them as non-learning or pure service provision events. There is no substitute for seeing large volumes of real patients and building up a bank of experience. Experience is what tells you that the ‘drunk’ patient with confusion has a subdural haematoma, or that the ‘back pain’ is an abdominal aortic aneurysm beginning to rupture (but experience is not everything – see below!) And sending a patient home reassured, happy and without what they thought came for (scan, antibiotics, xray) is as much an art as running a really slick arrest call.

Also on our curriculum are a whole range of managerial and leadership skills. Whether we like it or not, managing patient flow, supervising juniors and maintaining an overview of the department will form part of our job as ED Consultants. While we might prefer to be in resus seeing that interesting trauma, learning how to run the floor is essential, and can only be learned through practice. Maybe it’s not such a bad thing to be asked to run the show while the boss is in resus doing the fun stuff sometimes? It all depends on whether you see doing that as a key part of your role and important for you to practice or not.

And practice is the key word here. ‘Practicing’ medicine is what we are licensed to do. We cannot learn our craft solely through our computer screens, high fidelity simulators or textbooks. It is widely believed that to become expert in something, approximately 10 years of practice is required[iv]. Yet many people play sports or musical instruments for years without achieving mastery. Experience alone is not enough:

‘You have not had thirty years’ experience, Mrs Grindle-Jones,’ he says witheringly. ‘You have had one year’s experience 30 times.’[v]

Deliberate practice is required in order to become expert[vi]. Deliberate practice means thinking about what we are doing with each and every patient. It’s about seeking out feedback, following up cases, reading around. About thinking ‘Next time, I’ll do that a bit differently’. The responsibility for this lies with us. Our teachers are there to assist us in this process, not to do it for us.

I believe it is time for us to take control of our own learning. Complaining that we’re not getting enough ‘teaching’ isn’t good enough. We are surrounded by learning opportunities and it is up to us to make the most of them. What do you think?

 

 

Sarah Payne

Newcastle

 

 

[i] GMC National Training Survey, General Medical Council; 2014

http://www.gmc-uk.org/education/national_summary_reports.asp (accessed 30/7/14)

[ii] The Older Person in the Accident and Emergency Department, British Geriatrics Society; 2008

[iii] Health and Social Care Information Centre, Focus on Accident and Emergency, UK Government Statistical Service; 2013

[iv] Ericsson, KA. The Road to Excellence, Lawrence Erlbaum Associates;1996:10

[v] Carr, JL. The Harpole Report, Quince Tree Press ; 1972: 128

[vi] Ericsson, KA. The Road to Excellence, Lawrence Erlbaum Associates;1996: 21, 33

The Science Behind Telling “Sick” From “Not Sick”

Jeff Kline contributed a very interesting article to the Emergency Medicine Journal last week – offering up a bit of a potential science behind the “gestalt” in medicine. We’ve seen multiple examples where clinician gestalt performance is very similar to carefully-derived, evidence-based, risk-stratification criteria. Specifically, the diagnoses of “acute coronary syndrome” and “pulmonary embolism” have been evaluated in the past – and only the newest attribute-matching tools have offered any promise regarding improving upon simple clinician judgement.

This newest study from Kline, et al, evaluated 50 patients in the Emergency Department and their facial reactions to visual cues. It turned out, the 18 patients from this cohort ultimately diagnosed with significant cardiovascular syndromes displayed significantly decreased expressive variability when prompted with multiple stimuli. The reasonable conclusion, therefore, is patients with serious diagnoses may exhibit measurable, reproducible behavior changes. A small study, to be sure, but hence the idea – there is something encoded in our emotional intelligence helping us evaluate “sick” from “not sick” in the Emergency Department.

Supposing this observation holds up to further scrutiny, the results do not surprise me at all. Part of clinical training in Emergency Medicine involves simple voluminous exposure to as many patients as feasible. The behaviors of each different patient, their clinical features, and their outcomes become encoded in this entity, the clinician “gestalt”. And, what this study reflects is something we all recognize – a patient is not simply a collection of risk factors, or a Revised Geneva Score – the physicality associated with how a patient exists in the examination room provides additional information. The intuition of the experienced clinician, then, may be based as much in reading patients’ faces as it is synthesizing clinical knowledge.

This has interesting implications for other developments in medicine, as well. The time pressures in Emergency Medicine, or in other outpatient settings, that simply cut down on time spent with each patient, may detract from the quality of the evaluation. Telemedicine, another technological advance aimed at diluting and expanding coverage, may suffer as a result of diminished communication of these critical nonverbal cues.

Regardless, this study is quite unique in the spectrum of Emergency Medicine research, and hopefully inspires a follow-up generation of research.  Or, alternatively, what would you say forms the basis of our “gestalt”?

Link: “Decreased facial expression variability in patients with serious cardiopulmonary disease in the emergency care setting

 

vb

 

Ryan

 

Ryan Radecki

What’s your target BP for ruptured abdominal aortic aneurysm?

Untitled design(5) copy 2

 

A couple of years ago I was very (very, very) peripherally involved in an RCT investigating the management of ruptured abdominal aortic aneurysm. The IMPROVE trial was well designed and reported it’s results in 2014. The abstract is shown below, and I must admit that to my surprise there did not appear to be a definable advantage to endovascular repair.

Anyway, this post is not about the trials results per se, rather we received a comment from Prof. Janet Powell on behalf of the trial investigators that may have relevance for those of us in emergency and critical care medicine. One of the great advantages of large trials is the ability to look through data to see whether other themes and associations become apparent and this is what the trial team have done. Such data analysis has risks, but it can be an excellent way of generating hypotheses for future research, and observational data can also help us stop and think about current practice.

I digress. Read the letter from Janet below and then share your thoughts. As an emergency physician this observation raises a myriad of questions about data, analysis, resuscitation targets, association vs causality etc. and whenever I start thinking I know I’m getting better. So please, read, think, learn and please debate. Janet asks how we can work together to resolve and explore these results and surely that’s an offer that the EM and surgical communities should grasp.

vb

S

 

Blood pressure targets for the elderly with bleeding and vascular emergencies

The IMPROVE trial is the largest randomised trial of a strategy of endovascular repair versus open repair for ruptured abdominal aortic aneurysm, with over 600 patients [1]. Nearly all these patients started their care pathway in the emergency department and detailed evaluation of this large cohort of patients has raised some discussion points relevant for those in emergency care.

When we started this trial, we recommended that patients were managed with fluid restriction and hypotensive haemostasis, with systolic blood pressure targets of 70-80 mm Hg, to prevent further bleeding and optimise outcomes. These recommendations were based on emergency care guidelines for patients with abdominal trauma and the opinions of some leading vascular surgeons [2,3]. Hindsight is a wonderful thing. The patients we enrolled had an average age of 76.7 years: were these blood pressure targets far too low for this age group who were likely to have other cardiovascular disease and high cardiovascular resistance?

Cohort analysis has shown that there was a linear relationship between lowest systolic blood pressure and mortality (Table 1) and suggests that in these patients a blood pressure target of 100 mm Hg might save more lives. Lowest systolic blood pressure was directly related to outcome in a linear fashion, with each 10 mm Hg increase translating into a 13% relative improvement in the odds of survival to 30-days [4]. 30-day mortality rates of <30% were only achieved in those in whom the lowest blood pressure was 100 mm Hg or more.

Screenshot 2014-06-29 07.25.24

Management of other aortic conditions, particularly aortic dissection, may similarly be disadvantaged by unrealistic blood pressure targets. For aortic dissection the rapid blood pressure lowering to <100mm Hg, which is recommended [5], comes mainly from evidence in turkeys.

How can we work together to get the evidence for appropriate blood pressure targets for the elderly population with bleeding and other vascular emergencies? The current observational evidence is not sufficient and the question needs to be addressed in one or more randomised trials.

Janet Powell for the IMPROVE trial investigators

 

References
1 Endovascular or open repair strategy for ruptured abdominal aortic aneurysm: 30 day outcomes from IMPROVE randomised trial IMPROVE trial investigators BMJ 2014;348:f6771
2 Joint Royal colleges Ambulance Liaison Committee. Ambulance Service Clinical Practice Guidelines; 2006. www.jrcalc.org.uk/guidelines.html‎ [accessed 1 September 2013].
3 Mayer D, Pfammatter T, Rancic Z, Hechelhammer L, Wilhelm M, Veith FJ et al. 10 years of emergency endovascular aneurysm repair for ruptured abdominal aortoiliac aneurysms: lessons learned. Ann Surg 2009; 249: 510–515
4 Observations from the IMPROVE trial concerning the clinical care of patients with ruptured abdominal aortic aneurysm. IMPROVE trial investigators Br J Surg 2014
5 The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 report. Accessed March, 2014 at www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.pdf

 

So you have your invitation. Get in touch with the IMPROVE team to discuss, share and explore this observation.

 

vb

 

S

Predatory Journals – Enemies or Inspiration?

Science – unlike deranged, furious cursing – is not best cloistered behind closed doors, in the dark, with no audience. Dissemination of medical evidence is critical to refinement of practice and the generation of future research hypotheses. Yet, most evidence resides behind electronic publisher paywalls, accessible only for a fee, or to those with specific institutional access.

Those of us in academics take such access for granted – yet, the other 7 billion on Earth, many of whom toil in conditions with a lower standard of living, have a much higher barrier to entry. Many journals offer free access to visitors from certain countries, a generous, but incomplete, solution to the free flow of information. A growing alternative, however, to traditional publishing are “Open Access” journals. Such electronically published journals are free to access for all, and in lieu of the typical advertising + reprint business model used to support editorial and typesetting functions, the authors pay fees to support the costs of publication.

Some of these, such as PLOS ONE, have grown to become the largest journals in the world – publishing 31,000 articles in 2013 alone. At USD$1,350 per publication, the revenue associated with such a model is substantial. And therein lay the critical issue – the promise of such riches has attracted the usual unsavory crowd.

Now, we have the phenomenon of the “Predatory Publisher”, a faux journal whose primary function is profit. These publications, masquerading as legitimate science, have grown from 18 in 2011 to at least 477 in 2014. Most academics are likely familiar with the near-daily spam e-mails soliciting article submission, editorial positions, or conference speaking roles. In many cases, the journals are indistinguishable from reliable publishers, and well-meaning authors, hoping simply to increase the audience for an article, are sucked in.

Despite the shoddy or non-existent peer-review – in which nonsense articles by such renowned authors as Ocorrafoo Cobange pass through with nary a critical eye – these articles are entering the scientific ecosystem in ever-increasing numbers. One of the largest for-profit open-access publishers, MedKnow, from Mumbai, India, claimed over 2 million article downloads each month. In an academic professional reality where publication means promotion, and open-access publishing means unfettered distribution – it is no wonder such journals are thriving.

This phenomenon, of course, massively dilutes the scientific literature with a locust swarm of substandard evidence. Traditional journals, with strong reputations and robust Impact Factors, are holding strong for now. But, at the fringes – if funds are available, why would one risk rejection in a more rigorous, but low-impact journal, where the study would lay hidden behind a paywall?

While these journals are certainly the enemy of reliable evidence, and transitively, the public good, they represent an interesting lesson – and possible inspiration – for how traditional academic publishing might evolve.

What are we doing in EM?

Screenshot 2014-06-12 08.46.02It’s been a tough few months in UK Emergency Departments and has caused me recently to do a bit of thinking, as I knew I was losing a bit of my zeal and enthusiasm for our specialty. Yes, there’s the constant unrelenting pressure over targets and working under very trying circumstances with overcrowding and understaffing on an almost daily basis. It remains an enigma to me that for a lot of aspects of our work aviation is taken to be a shining example of how CRM should be done, yet a pilot would not take to the sky with 170% capacity and half the crew missing but we do, carrying on with a”Dunkirk spirit” to the best of our abilities.

So much appears to be put in our way, when trying to care for our patients.  We are drowning under the mass of bureaucracy and paperwork, it reduces time available for patient care. Common sense and practicality have gone out of the window, you can’t admit a patient to the short stay ward for a few hours without completing a host of paperwork required by outside agencies. Cannulation forms, an assessment of VTE risk, estimation of alcohol intake and smoking habit, consideration of hidden harm, a falls assessment, etc etc. A folder bulges with Standard Operating Procedures (SOPs), some about important clinical topics, but others seem appear to be bureaucratic ticks in boxes.  We even had to write an SOP  and subsequently approved in numerous places to allow a patient to sit on a chair in a clinical area rather than a trolley, but only after consulting the SOP on how to write SOPs!

Unlike colleagues in other specialties, where patients appear more grateful for their care, those attending the ED seem rather less so and referrals for inpatient admission are rarely greeted with thanks.  As much as we all try to persuade ourselves we don’t need external validation to feel valued I for one will openly admit I feel a whole lot better about myself and the job I do if just occasionally someone says thank you, well done or good job.

The final straw came when I did a brief online questionnaire which revealed I’m at very high risk of burnout. Whoa! I’ve only been an EM consultant for 6 years, part time at that. So the rethink began and I’ve come to the conclusion that what I personally, and I believe we as a speciality, need, as corny as it sounds, is  to get back to basics. To do the fundamentals really well as part of team working.

burnout

I’ve distilled this down to three areas: self; patients and environment. For myself I will try to always be a role model to others: to smile, think positively and value myself and others. My patients I will keep informed, take away their pain and encourage regular observations. The environment we work in should be professional, clean, tidy and quiet. Most importantly of all I will never forget that at the heart of all of this is care and compassion for our patients.

None of these are revolutionary requiring a policy or SOP, they are common sense, low cost, communication based basics that everyone, medical, nursing and support staff can fully participate in. So no-one can change my enthusiasm and zeal for the job except me, I’m trying to get the fundamentals spot on and encouraging others to do likewise, will you?

Dr Sarah Robinson

Consultant in Emergency Medicine

ROBINSONSarah

Patients, are they the silent contributor to case reports?

Seattle_physician_with_patient_1999

Patient participation (wikipedia CC)

We are in currently in the process of putting together a case report following a toxicological emergency in the ED. It’s an interesting case, deals with new street drugs and has some great lessons for emergency management…., well we would say that wouldn’t we, every case report author from the dawn of time has said the same…., but that’s not the point today.

Rather, as part of the writing process it is important to gain consent for publication. This is a routine requirement for any case report in the literature and here within the BMJ group you can visit the BMJ case reports website where the absolute and explicit requirement for patient consent is stated. The consent form is available in an impressive 13 languages so we obviously take this very seriously. Similarly there are explicit and clear(ish) instructions for authorship and contribution within the group as we clearly want those with their names at the top of the paper to have made a substantial and important contribution to the work. Authorship is defined differently to contributorship and it would be rare for patients to meet the following 4 criteria as lead out by ICMJE.

Screenshot 2014-05-02 07.06.39

Requirements for authorship.

I don’t think you need to be too clever to see where this is going. In a case report it is surely the patient who makes the most substantial contribution to the paper as without their involvement there is no case. Should we therefore offer patients the opportunity for acknowledgement on case reports?

Now you may argue that we need to protect patient confidentiality and that’s true so this could only ever function as an opt in rather than as an opt out, but should we at least offer the possibility of opting in? Those with paternalistic tendancies may argue that there are risks in patient identification. Coercion, willingness to please and the possibility that initial enthusiasm may subsequently turn in to a regret from sharing are clearly possible although the current trends in social media suggest that many patients share their injuries and illnesses in public forums already. My experience is that many patients are delighted to share their cases and some have expressed a wish to be acknowledged in publication, but as things currently stand it is unclear how to deliver this.

Patient involvement in publication is increasing. Examples exist such as the Patient Perspective series in journals such as the BMJ, but these are written contriubtions from patients with the time, talent and inclination to write. That is not typical of patients in case reports and in some cases it may not be possible for them to do so.

The ICMJE defines contributorship as non-authorship listing a number characteristics and ways of defining what constitutes authorship. Interestingly and perhaps disappointingly the contribution of the patient (the case of the case report) is missing. Examples include ‘caring for the patient’ but not ‘being the patient’ which I find a little strange and again somewhat paternalistic.

So, I ask the question of the readers, the editors and any patients who might be out there. If a patient wishes to be acknowledged as a contributor to the education of clinicians, should we make it happen, and if so how?

vb

S

Screen Shot 2013-10-22 at 08.04.20