Teaching Feedback - 'The Intimidator'

Teaching Feedback - 'The Intimidator'

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

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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?

Why are Junior Doctors no cleverer than I was?

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

Personal Case Report: Visual Hallucinations post-op

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.