It’s been a while since I’ve written a blog but “informed decision” is the phrase I have been using with patients a lot recently. I’m working in Oncology where there aren’t a lot of clear answers. Why? Consenting for chemotherapy is about dialogue. What exactly does it mean for the patient? Some patients decline treatment. Why do they do this? Everyone has their own set of circumstances which we need to be informed of too.
Are any of the following scenarios about “informed decisions”? A patient self-discharging even though they may have bowel obstruction because they don’t have childcare is an unenviable position.
What about the young girl having seizures because of her brain metastases who doesn’t want to be admitted for a CT scan because her father has just died and she doesn’t want to leave her mother alone overnight?
I’ve had to ask them to sign self-discharge forms. We have to state the risks. The most severe one being death.
These are the scenarios that no classroom can absolutely prepare you for but where there is so much for the patient and junior medical professionals to learn. So what’s the key? Practise, practise, practise and de-brief after. The manner in which you handle these situations can be significant on impressionable junior doctors and can encourage them to develop their own communication skills further. That experience is irreplacable.
Sadly, I won’t have any juniors this year and I will remain at the bottom of the pile for teaching!
My teaching is now essentially health education for the public whenever they come into Accident and Emergency. One of the most recent criticisms of the NHS has been the over-medicalisation of patients when they come into hospital. See http://www.nhs.uk/news/2014/01january/pages/experts-say-sadness-is-wrongly-being-medicalised.aspx and more recently on Jeremy Vine’s radio 2 programme on 19th August 2014.
Just as we have been discussing expectations of medical students and theirs of us, I have to challenge the public’s expectations of us and mine of them. In the time that we have to talk to and examine our patients, guessing the agenda and expectation on their presentation in ED can take a lot of detective work, especially when the patients cannot talk or communicate for themselves.
My seniors have stressed the importance to us of promoting health and trying to prevent unnecessary re-attendances (it wastes our patients’ time too sitting in ED). As doctors, we are also trained to be doing something to save our patients. This has led to the term “treating the doctor more than the patient” in my local workforce.
I think there’s a link between the two. The ambulance sees an elderly gentleman found unresponsive in a care home, I see “urosepsis with end-stage parkinson’s disease in a resus bed and a blood pressure of 70/40” and then I see the DNACPR and the medical registrar and I see “should this poorly man have ever come into hospital or should he have been kept comfortable with his family?”. It is sad (and that’s not actually a medical illness, it’s a state of emotion) that we are so well trained to treat the “problem” that we do not allow behavioural economics to come into the equation and step back until we are too late and on the treadmill to treatment which may be uncomfortable and distressing to the patient.
People come to doctors because they don’t know what to do when someone is sick or poorly and 99% of the time that’s the right thing to do. However, in some circumstances we have to do what is right by the patient. Palliative care is heavily involved in well known diseases like cancer where there is a slow deterioration and often irreversible decline. However, where is the counselling and palliation for patients and their families with diabetes, COPD, dementia and parkinson’s? I often find that these patients have no idea where there illness will take them and how it will affect them in the future. Is ED the best place to educate people on this, probably not but maybe someday the patient will be grateful if I give them some advice for the future, even if it is just a few words or a leaflet from patient.co.uk.
We’ve taken a detour from styles of teaching to look at how to lead a teaching session. It is not often that we are “leading” a team though I can probably tell you the ward of all the team’s patients better than the consultant. However there may be a time, however short, that you are. Common examples are teaching, medical emergencies (until the other staff arrive) and when you have medical students.
The BMJ module below focuses on long-term leadership but I think that is worthwhile for the shorter sessions too and explains that you don’t have to lead by being the dominant member of the group.
Happy Easter to you all!
This week’s post comes in the form of a recommendation to a self-directed learning guide created by Dr Deborah Gill, an expert in medical education, on the challenges that each clinical learning environment takes and some further general advice. She makes some excellent points about the how teaching in the clinical environment is far better than the classroom alongside some worrying statistics about the percentage of medical student teaching time spent on the wards (5%).
There are also some excellent points which encourage one to reflect on their own development as a medical educator. This article is definitely worth a read and can be accessed at http://www.faculty.londondeanery.ac.uk/e-learning/explore-further/teaching_and_learning_at_the_bedside.pdf.
Why not read the article and reflect on it in your own e-portfolio?
In this new series, I am looking at the best way to deliver effective teaching. I’m starting with what is becoming the standard way to teach and asking if this is really the best….Microsoft Powerpoint
A good foundation to add in further media
Provides a form of focus
Good for large groups
Good in a formal environment
Can be too structured
Doesn’t enable the teacher or pupils to process newly acquired information
Is rather didactic
Not good for impromptu teaching or small groups
Whether you are for or against the powerpoint presentation, here’s a module on how to improve…
and a comment on content: http://www.bmj.com/rapid-response/2011/10/30/support-traditional-teaching-methods
Here is what’s happening in the BMJ on medical education http://www.bmj.com/specialties/undergraduate and if you’re feeling flush, this course comes highly recommended http://www.medicalinterviewsuk.co.uk/index.php/Teach-the-teacher/Teach-The-Teacher/View-category.html
I’ll be back next week with more insight into medical teaching.
Or have some advice on how to teach students? Please message me if you would like to blog for us. Jen
I have the classic male problem of no follow through
said Jude Law in The Holiday. We are over-saturated with resources and sometimes it can be difficult to know which are the best.
Teaching often highlights weaker areas of knowledge which you don’t always have time to cover. It’s easy to suggest that they read on the topic when they go home but if you can suggest a resource which covers the subject, they may be more likely to go home and actually read about it. Next time you see your students, make a friendly enquiry into whether or not they’ve read up on chest x-rays/post-partum haemorrhage or not.
Every student will have their own resources but if you need to encourage students to do some background reading then http://www.fastbleep.com and http://www.almostadoctor.com are excellent. Both started by medical students at the time, they provide undergraduate students with the essential information in a digestible fashion. Moreover, you can currently nominate yourself to write an article for them!
Tips to build up a teaching portfolio and filling in the gaps.
The GMC now requires us to develop teaching skills as a medical student. Catherine Gray and Patsy Stark give us some tips in the article above. Let the 4th years teach the third years and let the 5th years teach them both. If you’re at medical school, start a society that actively engages students from across the years to become involved in a speciality or an OSCE with help from junior and senior doctors at your teaching hospital. It is a great experience for everyone involved. At the University of Manchester, we set up OGSOC to engage students who were interested in learning more about and a career in Obstetrics and Gynaecology. You can find the link at https://www.facebook.com/groups/191529574253119/