Category Archives: Medical Education

Blogs and Posts related to Medical Education

FOAM, Medical Education

EM isn’t child’s play when it’s Emergency Maths

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New starters to paediatric wards, emergency departments and general practices around the country are faced with a huge array of formulas and equations to navigate. Most are relatively simple and require only a basic revision of multiplication tables. However some calculations are required in a time critical manner and anyone experienced in treating children knows how easy it is to make mistakes. In resucitation situations there may be many drug doses to calculate using some medications which may not be frequently used by the person prescribing them.

Given paediatric pharmacy is a very ‘mass’ based subject prompt calculation of weight is an essential first step. The traditional approach taken is that advised by APLS courses:

Weight 0 -1 = (Age/2)+4

Weight 1 -5 = (Age x2)+8

Weight 6 -12 = (Age x3)+7

There is a great blog from Simon Carley on the introduction of three equations rather than just one and the problems this may cause. The key point being does having three forumula increase complexity, and therefore risk of error, especially given we aren’t really sure what amount of difference in weight is clinically significant?  Other mechanisms of calcuating weight do exist, the broselow tape for example, but I especially like this one via Dilshad Marikar

(2010 APLS weight estimation) – Talking to the hand from Paediatric Tools on Vimeo.

The Leicester Hospitals Emergency Department have been working for sometime on a drug calculator for use in Emergency Situations. I’m very grateful to Dr. Mike Pearce, Dr. Mark Williams and Dr. Steve Corry for their hard work on bringing this to fruition. In the spirit of ‘FOAM’ we are sharing our efforts, not because we think it is any better than other systems out there, but because we are sure improvements can be made.

Drug Calculator

It can be downloaded by clicking LRI Paeds Drug Calculator v1.4. It’s been extensively tested and has the approval of our senior paediatric pharmacist. As with all such calculators we can not accept responsibility for its accuracy or ensure its currency.

Please let us know what you think via comments, @damian_roland or @em3foamed

FOAM, Medical Education

Leading an Emergency Department

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August is changeover time for junior doctors in the United Kingdom and hospitals of all sizes are welcoming new staff into their departments. In Emergency Medicine it is especially important that new staff are given support and supervision as the hectic nature of our specialty can be challenging. One of the most daunting aspects for junior doctors who have progressed through training far enough to start adopting more senior roles is the task of leading the Emergency Department.

Challenges Ahead

Being doctor-in-charge requires a skill set far greater than clinical knowledge. You must be also be a good communicator, negotiator, and arbitrator. There is a neat little summary of the managerial skills required here by Rick Body from St.Emyln’s. In order to help some of our new registrars Prof. Tim Coats has discussed some of the things he does while doctor-in-charge which we thought we would share:

There is also a podcast 

Please do feedback any additions or suggestions!

FOAM, Medical Education

Listen – Look – Locate: An approach to the febrile child #tipsfornewdocs

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The first Wednesday of August in the UK represents an exciting time for a cohort of newly qualified junior doctors who start their medical careers. For those commencing in Paediatrics and Emergency Medicine, or starting these specialties for the first time, the prospect of managing young potentially unwell children can be daunting.

Having to assess the “febrile’ child often results in a drain of colour from even the most confident of junior doctors. This quick presentation is centred specifically around assessing the febrile child and contains a few experiential and evidence based tips.  It is not a comprehensive guide to history taking or examination – please watch #Paedstips you won’t find in books , How to examine children, and look at the resources via Seeing kids is child’s play at St.Emlyn’s  for further detail.

If you need a framework to start with though – go no further than Listen, Look and Locate:

 

FOAM, Medical Education

Evaluating Education

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Many thanks to the SMACC team for releasing my #SMACCGold talk: Evaluating Education. The background story can be found here

The publication related to the 7I Framework can be found here

Video

Damian Roland – Evaluating Education from Social Media and Critical Care on Vimeo.

Slides:

Audio: link here

FOAM, General, Medical Education

Just who or what am I evaluating? Learning from #SMACCGold

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Many thanks to the St.Emlyn’s team for the idea for blogging on the background to SMACCGold talks..

Very rarely do I get an e-mail that makes me instantly smile but receiving a request from Chris Nickson to speak at #SMACCGold was one of those occasions. I felt in someways like an imposter but also, if I am honest, some degree of validation. The input and impact of the smacc team into the #FOAMed community is something I am hugely respectful of. Surely, whatever the reasons for my invite, it must have meant some of the things I had been blogging/publishing on were being well received? (If I lack insight in this regard please be kind with feedback….!)

Regardless of my initial surprise though, how to go about constructing a SMACCesque talk that could possibly come even close to Victoria Brazil’s or Cliff Reid’s? I’d like to share a mistake I made early in the development of my talk. I do this firstly because I try to be a reflective learner but also because it has had quite a profound effect on me. The big mistake was that I spent far too long thinking the talk was about me rather than a talk about evaluating education. Obviously the talk wasn’t about ‘me‘ but I had noticed from the previous SMACC that people talked about Levitan’s “airway” or Weingart’s “resuscitation”. What could I bring to the talk that would encapsulate the essence of me? I was partly relieved to hear both Victoria Brail and Simon Carley say they had had weeks of sleepless nights before their talks due to their own internal pressures to perform well. This I suspect was a measure of anxiety to maintain high standards not because they were interested in showing off prowess of their subject. Ultimately once I realised the material could speak for itself, and I just needed to be an effective conduit, things started falling into shape.

To be clear that I don’t think I only made one mistake (!) other errors I made were embarrassingly predictable:

Changing material at the eleventh hour – don’t do this. None of the last minute changes I made in the conference centre lobby on the day of may talk added anything useful. In fact they just resulted in me forgetting to say things that would have been beneficial information!

Not practicing what you preach – specifically to practice, practice and practice and then practice again (preferably in front of someone else)

The talk itself was based on my PhD work and my experiences with trying to bridge the chasm between educational theory and the clinician with an interest but no such background. I am a firm believer in the power of face validity – therefore educational models need creating which are well researched but also easy to explain to those not interested in complex theorem. Given one of my research interests is validity in medical education this all starts to get a bit ‘meta’. I wrestled for some time with putting a run of slides in explaining different types of validity. I went for this in the end, also choosing to deliberately include a ‘bad slide’. I had been emboldened to do this  after trying the same in the education workshop (particularly Chris Nickson mouthing ‘so glad he said that!’ when I explained that the slide I was showing was intentionally dreadful)

One of the challenges in medical education is the interplay between the educator and the subject of the ‘education’. What is the impact of a great speaker in terms of knowledge acquisition? Knowing the importance of this effect weighed heavily on me. Reflections after the event have resulted in a very critical evaluation of myself as a speaker but if I have learnt anything from the experience it is this self-evaluation is a useful process. Fascinating this didn’t occur to me at the time…

 

FOAM, Medical Education

#FOAMed and #SMACC : Revealing the Camouflaged Curriculum

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“Assessment drives learning” raises wry smiles (and occasional heckles) whenever it is mentioned. However it’s unfortunately the case that ‘encouragement’ to understand and learn comes from the need to demonstrate that new knowledge in some form of test. In Post Graduate Medical Education these tests are specialist exams which are required in order to progress to more senior stages of training. The scope of information needed is huge (and often the exams split into various sections to make them manageable!). The curriculum describing the knowledge similarly large and there is great heart ache as you scroll through 50+ pages of bullet points each starting, “the trainee will be required to know…”.

By necessity curriculum are bland but what has become increasingly apparent to me is the large blocks of ‘grey’ knowledge that appear to be missing from them. I say ‘them’, I can only really speak for Paediatrics, but I am given confidence in this assertion by the ever increasing momentum of the #FOAMed movement. Chris Nickson has previously eloquently explained why #FOAMed itself doesn’t need a curriculum. However while assessment drives learning, so does experience. It’s quite clear from the huge amount of materials posted daily on a variety of clinical topics there is a thirst for information that is not readily available by common reference sources. I’ll use the #SMACCGold conference to demonstrate this point.

Lets take the section on statistics in Royal College of Paediatrics and Child Health (RCPCH) emergency medicine curriculum.

RCPCH Curriculum

To be fair this is clear, practical knowledge that is needed by clinicians. How does this translate into actual practice though? How will we use this to provide better patient care? What will convert these concepts into something clinicians can practically deliver? I think the answer comes from Prof. Simon Carley’s two excellent lectures at #SMACCgold. One on what to believe and when to change  and one on risk factors in ED

 

As another example Paediatricians are involved in extremely challenging situations in resuscitating seriously ill children and sometimes need to make decisions about when that resuscitation should end. Is there a curriculum that defines and aids this process? It appears not but certainly Cliff Reid’s talk at SMACC is a great example of how this topic could be approached.

Finally I scanned through the College of Emergency Medicine curriculum for “chronic pain” and struggled to find anything. However with over 1000 views so far this probably fits the bill:

 

It would be harsh to say that those writing curricula have been lax in their tasks, it’s more that some topics are not easily encapsulated. They are often hidden, or camouflaged, in between more clear cut points.

 

Camouflage

 

This is where #FOAMed has come to the rescue. A variety of brilliant minds around the world have been able to recognise knowledge they needed to know but just wasn’t currently available ( a recent talk is entitled #paedstips you won’t find in books!). Ultimately #SMACCgold stands as a testament to revealing this camouflaged curriculum content (and I am sure more will be revealed at #SMACC2015). It may well be the case that assessment drives learning, but perhaps those in charge of medical education may want to use #FOAMed to drive curricula…

FOAM, Medical Education

n=1 isn’t anecdote when it is your child

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At #SMACCGold in 2014 one particular lecture that really caught my attention. Cliff Reid talking on “When  should resuscitation stop”.

It is brilliant talk with a well pitched narrative, evidence based insights and a constant return to the human side of clinical practice that is all too often forgotten. As a Paediatrician with a special interest in Emergency Medicine the child presenting in asystole (no movement or electrical activity of the heart) is one of the hardest aspects of my job and the decision on when to stop CPR often a challenging one. It is vital that anyone who works in Emergency Medicine listens to Cliff’s talk and takes home some of his key points:

Never make decisions in isolation of each other and a blood gas should never make your decision for you

(my interpretation and not Cliff’s actual words)

The talk uses two examples, both of children, to demonstrate the huge human factors element to decision making in halting CPR. In one of the cases the child made a full recovery despite nearly being in situation where attempts to resuscitate were stopped. The cases certainly were unique  – one involving cold water immersion and the other a complex congenital heart defect. What of a potentially more common scenario – sudden infant death syndrome. These are still unique events, there is no other child in the parents’ eyes, like the child you are trying to restore a circulation to. What evidence or anecdote will you use in these situations?  Does the knowledge that one child, in one place, at one time, survived after a heroic resuscitative effort lead you to do the same? What if the parents knew that there are reported cases of children surviving after hours of down time. Could you convince them why you are stopping after 20 minutes if you think the child has never shown any signs of life? Only the clinicians in these unique situations will know the real circumstances of what made them go that extra minute or seek that extra intervention. Encapsulating their gestalt will be nearly impossible – so we are left trying to do the best we can with the information we have available. As Cliff says:

“The important thing about human life is that its about other people – it’s about connection and it’s about love. It’s about our love for other people that motivates us to do everything we can.”  

For these most complex and emotional decisions the chance to reflect before these tragic events can only be of benefit in my opinion. Cliff Reid’s talk is certainly an excellent chance to do that.

#WILTW, Medical Education

What I learnt this week #WILTW

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The full list of #WILTW 

A few weeks ago I posted a blog with some thoughts on becoming a new consultant. I’d postulated that having insight into learning being a  life-long journey was an essential element to being a good healthcare professional. I’ve now been in post a couple of weeks: finding my feet, performing induction rituals and thinking about the goals I would like to achieve in my next year.

online-learning

What has hit me like a bomb has been my first clinical experiences on the shop floor. It’s been an amazing learning curve, far greater than I expected actually. The pure clinical component is not really an issue. I have been acting, in some respects, in a consultant capacity for the last three years as I performed locum shifts as part of my PhD. Making clinical decisions, practical skills and running a busy emergency department are almost second nature. What struck me was how little thought I’d previously put not into ‘what‘ I was doing but ‘how‘. I am now a consultant. Clearly I don’t want to create false hierarchies, I recognise I am part of a senior team of doctors and nurses and that the title does not make me lord of the manor. However I also recognise that I have  a responsibility to role model the best possible professional and clinical behaviours. In all situations the demeanor with which I speak to colleagues, the way I approach children, young people and their families and how I interact with staff sets a tone. It’s not until now that the importance of this has become crystal clear.

I thought I knew a bit about leadership. It transpires I have a great deal to learn. Reflecting on my approach to particular challenges (mainly difficult conversations about referrals or picking up staff on sub-optimal behaviours) has demonstrated how difficult being a consistent and strong ‘leader’ is. It is very easy to take a second-best option; that in order to avoid confrontation a compromise is reached which may not be your preferred choice. But when do you draw the line? Obviously always ensuring your way is the best way is no better than always accepting the other person’s point of view. However it’s all too easy to avoid the conversation about the tone that a junior has taken (potentially accidentally) with a parent or other member of staff, for example; but it’s these conversations I need to start having.

Tough Decisions Ahead Road Sign

(via http://www.advisoranalyst.com)

So what I have I learnt this week? Well, I’ve learnt that potentially I’m not as strong as I thought I was. That some of the things I thought I would be able to do in role will take a little more embedding. I am also sure that with the guidance of colleagues and passing of time I will get better. As I said previously – the learning has only just begun again….

So what have you learnt this week? #WILTW

Medical Education

13 years of training and tomorrow it all begins again…

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The art of medicine was to be properly learned only from its practice and its exercise.
Thomas Sydenham 

So after managing to prolong my training to its maximal extent, with two separate years in Perth, Australia and a PhD, tomorrow my medical ‘training’ in one sense comes to its end as I start work as a consultant. I’ve had a chance to reflect on what I have actually learnt since starting on the wards as a wet-behind-the-ears junior doctor back in 2001. Its funny, I don’t feel I am in any way, shape or form an expert now, even though I have probably done my obligatory 10000 hours. I certainly don’t feel as wise as the paediatric consultants I remember when I was a house officer. This might reflect an element of an impostor syndrome – or perhaps I have actually become unconsciously competent.

I’m not really sure how this all happened. I struggle to remember more than a handful of occasions when I specifically learnt anything from anyone, although there are some notable exceptions.

“Don’t listen for the murmur, listen for the absence of noise”

This brilliant advice has always stuck with me, especially as someone who has always struggled with the complexity of paediatric cardiology.

I remember being shown during my first neonatal attachment that babies often open their eyes when put over their mother’s shoulder (which makes identifying the red reflex much quicker).

One of my most powerful experiences occurred in Australia as I watched an Emergency Department Consultant at the resuscitation of an infant from an out-of-hospital cardiac arrest. After several of rounds of CPR it was clear the outcome was going to be devastating. I saw the mother realise this; she was inconsolable. And then the consultant handed leadership of the resuscitation to someone else and went over to her, putting his arm around her and bringing her to her child’s side. He spoke to her about loss and how no more could be done. I don’t remember exact words but I vividly emember him crying with her as we all took a step back. It was one of the most incredible things I have seen a consultant do.

Clearly I was taught things – lectures, seminars, ward rounds must have had an impact – but nothing tangible remains and many of the times I know I learnt the most were situations when I was on my own, sometimes inappropriately so.

I have no idea how I learnt to cannulate the septic ex-prem with tiny hands already scarred, little knowledge of when I gained the confidence to lead a group of people I have never met to deliver emergency care to an injured child, and certainly not a clue when I began to appreciate the subtle difference in the reaction of a parent who has not deliberately injured their child compared to one who has when asked how that bruise happened.

But what is more incredible is what I still have to learn. I am a mere ’13 years old’ – health permitting, I may be practicing medicine for double that time yet. It is inconceivable that I will not learn exponentially in that time. And it will be an exciting time, I think. I hope I continue to reflect on those learning experiences, painful or not, in this next phase of my life.

My training begins again  – it’s just that now I have a different title.

FOAM, Medical Education, Social Media

#SMACCGOLD – It hurts..

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Too often we enjoy the comfort of opinion without the discomfort of thought

The 2nd SMACC (social media and critical care conference) has just finished. A packed 4 days (including pre-conference) with over 1000 delegates developed by a few brilliant individuals who have envisioned a different way of learning and collaborating.

This is no ordinary conference, with fantastic topics discussed and innovative events. See Salim Rezaie’s great blog for the detail. There are few conferences where professionally executed simulation debriefings occur in front of an entire auditorium, speakers’ cry in a context that feels appropriate and delegates give standing ovations in some of the break out sessions.

I sit writing this approaching Doha on the second stage of my journey home. I am a SMACC virgin, utterly humbled by the invitation to speak in Brisbane. I have met and listened to some extraordinary people but my over-riding emotion at the moment is one of sadness. I am truly sad it has finished. Don’t get me wrong, my youngest developed chicken pox during my journey away, I do want to go home. I am sad though that I know I will be attending other conferences (unfortunately SMACC Chicago is over a year away!) where I will sit and listen, I may learn some additional clinical information, I may meet a future research collaborator, if I am really lucky something may inspire me to change practice.

What is unlikely to happen is that there will be a tangible excitement when the first speaker takes to the stage, that over coffee break all the delegates will be smiling, that I will witness carefully constructed slide sets that support (not deliver) the stories the speakers are telling.

The attention to detail in the narratives delivered at SMACC was brilliant. It’s likely those reading this who weren’t at SMACC will probably be a little sceptical of this hyperbole. Please, please, watch the video casts when they are released. Watch how Cliff Reid and Iain Beardsell bring their emotional talks together full circle. Natalie May delivers to a packed crowd on “paediatric tips you won’t find in a book” using slides with no text and Tamara Hills received a standing ovation for her PK presentation.  Listen to Victoria Brazil deliver a 20 minute presentation in exactly 20 minutes with no timing aids (ok – I admit this is only probably considered really cool by geeks like me).

The hierarchical nature of academic events is not present at SMACC. It was brilliant to see a mix of professionals, grades, and specialities mucking in. Medical students and junior doctors delivering lectures and being part of the panel discussions. And so I could go on….

If there was one thing that encapsulated SMACC it was the patient centered approach to challenging dogma. I am struck that although the patient should be at the heart of everything we do – I often don’t see that at conferences. I hear people ‘talk’ about it but during lectures on new treatments or methods it’s about stats and facts. It’s about why the speaker thinks something is wrong. What SMACC did was deliver lectures where the speakers understood the challenges of normal practice. That patients are humans, that the things we do in critical and emergency care have an impact on them. That if we do what we always did, we will get where we are going – and is some cases that is simply not acceptable. Challenging Dogmalyis, championed by Prof. Simon Carley is uncomfortable. It hurts sometimes to be challenged.

SMACC hurt.

But until SMACC Chicago this type of hurt is so much better than the pain of any other conference you will go to….

Post Blog note:

Have already started getting messages saying but what about…..? Will start adding 🙂