Tomorrow's Doctors...

Tomorrow's Doctors...

...are going to be quite similar to yesterday's doctors, apparently. According to the GMC, Medical Schools should now be focussing on giving students meaningful clinical experience, making sure that medical students are ready to become junior doctors. Which is what we've always thought, right?

But it is encouraging to see the GMC trying to take the lead in guiding medical schools towards promoting useful clinical experience rather than increasing PBL, training sessions, communication skills and simulations (all of which are valuable educational tools as an adjunct to clinical teaching, but have perhaps been over-represented).

In my brief run-through the new Tomorrow's Doctors I can't say I found much to substantively address two related issues though:

1. It's all very well incorporating clinical experience into the first few years of medical school, but this experience is of limited value when basic knowledge is so poor (as you'd expect early in undergrad training). Students need a good grounding in relevant medical science (ie you don't need to know the Krebs cycle inside-out but a good knowledge of pharmacology is essential). For example, I spent 5 minutes teaching a medical student (not final year, but not 1st either) about a lumbar spine x-ray. It took longer than I thought because instead of concentrating on the osteoporotic crush fractures, we had to spend some time working out what the calcified tube-thing anterior to the spine was (hint, it sounds a bit like "Ray Liotta") I didn't use that clue, though.

2. Dumping groups of medical students on wards doesn't equal clinical experience. All the checkboxes, DOPS etc in the world will not ensure that the student isn't spending most of his/her time wandering round aimlessly behind a disinterested ward-round, chatting to the other students because no one has the time or interest to actively teach. My ward was short staffed earlier this week, leaving a house officer for one team and an SHO for the other. This situation is manageable, but not ideal. Enter 5 medical students. You can imagine what kind of educational experience they got that day. Perhaps the advent of Student Assistanships will make the students more responsible and useful on the ward, which would undoubtedly improve the educational yield from their 'ward time'.

Once I've had a chance to have a proper read I may need to eat those words. We'll see.

The 11th Reason Doctors order unnecessary tests

The 11th Reason Doctors order unnecessary tests

I liked this list of reasons why doctors order tests. It's based on medical practice in the US but most apply to doctors in the UK too. I'd go so far as to add another - temporizing. It's really an extension of reason 1, with a bit of 2,3 and to some extent 5 as well.

Time can be an excellent way of finding out what the natural history of a disease process is, of gaining new information, etc, so ordering a few tests while watchfully observing your patient is often reasonable or even very good practice. However there's definitely a trap that many doctors fall into where they have a patient in want of a diagnosis or definitive plan, who doesn't readily fit into a disease paradigm, and they'll keep on ordering tests until they get bored. The problem with this sequential over-testing is it allows the doctor to stop thinking. All you need to do is fire off a few tests, then you don't need to think until they all come back negative. What to do? Order another test that takes a few days! And again, and again…

Although this could result in the diagnosis coming to light, either by eventually finding the 'right' test, or by the disease revealing itself more clearly (or just resolving), the unfortunate side effect of the process is that instead of being watchful and considering possible diagnoses for a time, the doctor disengages brain for all but the 30 seconds it takes to think up another few tests - thus while thinking he's exemplifying the considerate, watchful doctor, he becomes the exact opposite of that, sometimes for weeks on end.

However, I'd add just a tiny critique of Dr Rangel's underlying rationale for critiquing over-testing. Not that I disagree with him, because the behaviours he describes are absolutely not good medicine and should all be avoided. But why are they not good? In criticizing the lazy physician who can't be bothered to formulate a diagnosis using clinical skills, he says:

"It takes time to listen to and sort through a patient’s symptoms and to do a proper and directed physical exam. But if you have 55 patients to see today and you want to make it home on time then you can just order a GIANT MRI SCAN of EVERYTHING that’s all but guaranteed to detect any and every abnormality. Wrong. That’s not practicing medicine. That’s the cookie cutter approach. My dog can do that."

Yes, that's not very impressive doctoring. But the problem with the 'cookie cutter' approach is not that it's intellectually lazy, although it is. It's that it doesn't work - it has a terrible signal to noise ratio, and it results in patients being exposed to risks from the original investigation and from subsequent investigations or procedures relating to incidentalomas. However, if we had some amazing new body scan that could accurately predict the natural history and effects of every 'abnormality', at £1 per scan, then ordering a GIANT WIZZBANG SCAN of EVERYTHING might be very good for patients, even though any lazy idiot could order the scan. I'd be out of a job, but people would probably be healthier.

Despite what a few mail-order scanning companies would like to tell you, that scan doesn't exist, and is very unlikely to any time soon, so us good doctors who use clinical skill and judgement can rest safe in our paycheques. But it's important to remember what the point of our jobs is - being a 'good doctor' (which includes using investigations judiciously) improves the health and lives of our patients. It's not an end in itself.

As a medical teacher, I can't teach my students / juniors about every situation where they should or shouldn't order a particular test. But if I can teach them an underlying throught process or behaviour pattern relating to how to approach diagnostic situations - with the outcome for the patient paramount - then I shouldn't need to tell them how to avoid each of the 10 bad reasons for ordering tests. They should be able to work that out for themselves.

A Nursing student writes...

A Nursing student writes...

I recently received an email from a charming nursing student who read my blog, and wanted to know a little more about a presentation I'd uploaded to slideshare - on NICE and healthcare rationing. Primarily she wanted to reference it in an essay for her nursing degree on a similar topic. Now, of course I was very flattered, and yes, I do think my opinions are sensible and backed up by evidence, but I'm clearly not an expert on the ethics, law or economics of healthcare rationing. So I advised her to go to my references and look at the primary sources.

Because I'm a doctor I'm contractually obliged to unthinkingly underestimate nurses, and in fact she'd already done that. But she still thought it was appropriate to reference my presentation since she felt it had influenced her thinking:

"In some ways it's a grey area as I could solely reference primary sources and the Tutor would be unlikely to question it. But I am definitely borrowing the odd point from your presentation, so best to do the right thing"

TBH I don't think I would have been quite so honourable. I read a lot in articles, blogs, twitter feeds, on the TV, and from friends and colleagues. Sometimes I hear ideas or opinions I like or that persuade me to change my thinking. Some of it is conscious, much unconscious. So, when it comes to writing scholarly work, I tend to reference the primary sources that are at least published if not peer-reviewed too. Even if a blog article or online presentation influenced my thinking, I think I wouldn't reference it unless I was quoting it.

Is this reasonable, or am I being a snob about referencing sources that I don't think of as traditionally 'authoritative'? Would I feel better about referencing an article or book chapter by someone rather than the same person's blog? I think I probably would. And what about sites like wikipedia, which has the advantage of being 'peer reviewed' in some sense?

The debate about referencing wikipedia in scholarly work still has some distance to run, I think. For now, the rule seems to be that you can use wikipedia to learn but shouldn't rely on it as authoritative - and therefore shouldn't reference it directly. I think there's a lot to be said for wikipedia generally, especially if you understand how it works and how to look at the evolution of the article and its related discussions. But no matter how good wikipedia / my slideshare presentations / my blog waffling is, if I'm still sceptical about sticking them in the reference section of my essays, I think it'll be some time before these kinds of resources are widely accepted as reasonable reference points for academic work.

Perhaps this is a shame, but perhaps a conservative attitude to this new medium is wise until theres a widespread and deeper appreciation of how it works, how it can be used and what it adds.

Finally, my web-savvy nursing-student reader signed off with another interesting point. Having reviewed many of the primary sources I'd mentioned in my talk, she did pause for thought at the end of the assignment, reflecting...

"Oh well, I still can't give a patient a urinary catheter, but I read Aristotle today..."

What hath I wrought?