Saturday, May 25, 2013

Teaching during a day of clinical general practice

There are many reasons I love my work. One of the reasons is that it is impossible to be bored! We see a whole range of people who believe they have or might have a problem and want to discuss it. Sometimes, that might be a significant medical emergency. Sometimes it might be a significant chronic disease. Sometimes it might be a significant mental illness, or a self limiting condition, or a request for information or support to get housing. Sometimes it might be loneliness. Often these occur together in the same person. This list could be endless - the only limit is the world population and imagination. And there is almost nothing where we can say "That's not our business."

So how do you teach that? In essence, we need a safe approach for anything that can come through the door. And that means there is no learning off limits, nothing we can learn that can have no application. But we can't know everything.

I thought it might be interesting just to post the variety of topics that Michael and I covered in one day, Admittedly it was a day where we had more chance to chat than usual. But the range covered would not be unusual. I'll describe what we did, and reflect a bit on why this might be relevant to General Practice. (Some of the info might be a bit vague - I don't want to run the risk of any patients being identified! Confidentiality is a cornerstone of our work!)

As you'd expect, we do talk about medical conditions and treatments.

COPD and inhalers

A quick discussion in the corridor on the use of Salmeterol/Fluticasone combination (you all know it by another name: "The Purple Inhaler!") in COPD. The evidence shows that people are more likely to have a serious pneumonia on a steroid inhaler. The long acting beta agonist is probably helpful, but we should be cautious about the combination. This wasn't the information we were often taught about this combination, and we have both felt a bit duped by drug companies!

A Rash!

There probably isn't a day in General Practice where you can't use a rash as a teaching opportunity. We're usually taught rashes as if pattern recognition is the only game in town, but it's always always always worth sitting on your hands before looking at the rash and taking a history. It's true for any set of symptoms, and it's true for rashes. And diagnosis isn't the only game in town. You need to be able to form a management plan acceptable to the patient (or their parents) and explain it and understand and alleviate any particular concerns.

 Rare Diseases

Every GP has a few people they know well with a rare disease. The care of a patient with a rare disease can't really be discussed online, because the person is all too readily identifiable. As GPs we are so unlikely to see any one particular rare disease, so we don't usually know about them until we see them. But as GPs, we also know that these are people, and the diagnosis of a rare condition isn't what defines them as  person - though it often has  huge impact. We thought about whether the symptoms my patient had might be related to their rare condition, or whether they might be something else more common, perhaps unrelated. After all, people with rare diseases need the rest of their medical care, too, including preventive care. And I had one of those frisoons of pleasure as Michael quoted back at me the paper I'd co-written. (I think he knew this!) (I'm biased, but I think it's worth a read - it sets out the common problems faced by people with a rare disease, and also an approach GPs might take)

Childhood Obesity

Michael and I have discussed the problem of obesity and food security quite often (and I have drawn on these thoughts blogging here and here) and we have shared Michael Pollan's books which take a cultural view of healthy food, rather than a nutritional approach. On Tuesday, we listened to this podcast from Freakonomics, which highlighted discussions from a range of experts across different fields. It was interesting to see the personal responsibility versus social policy play out again, as well as a search for technical solutions. If you're thinking aboout setting up a tapeworm company, there might well be an opening for you...

Over to you
The day finished with me (Tim) learning 2 things. I learnt what Takotsubo syndrome was. And I learnt that I was the only person in the world who'd never heard of it before!

We'd love to hear your thoughts on these topics - either using the #supertwision hashtag or in the comments below. What's the range of things you cover? What's the strangest resource you've used?


  1. I'd be really interested to see how patients can form a formal part of your teachings - in a role that is more that the case/subject in question!
    Great blog - makes me realise how much GPs have to know!

  2. Thanks Anya,
    It's a really important point you make. In general, patients don't get to contribute enough to medical eeducation. Where Michael and I work, we do include the patients in our consultations. The setting is an Aboriginal COmmunity Controlled Health Service, which is similar to a co-operative, so the community (including most of our patients) actually own the practice. They see the health professioanl teaching as an important way of ensuring quality service for thie patients in the future. We've not managed to bring our own patients' contribution to the blog, becuase of confidentiality, and we are being quite careful on social media with this.
    However, it was also one of the reasons for having a go at #Supertwision - to broaden out the contribution to education of doctors - the more people comment and contribute the better.
    Thank you very much for your comment, and we'd love to hear from you and more patients. It's very easy for doctors to forget other perspectives, or even not o realise there may be other perspoectives that we've missed.

    1. I really like the idea of the community owning the practice - do they determine some of the training needed? Is the ownership emotional or purely practical? Has any of that training been delivered by/with patients? I understand the confidentiality issues regarding their involvement online, but lots of patients could contribute as patient leaders. In that role, patients are working beyond their own experience and therefore it becomes less of an issue.
      As someone having made the transition from medical student to patient, I believe that patients can contribute to the learning and development of healthcare professionals at the individual level through their own cases in the clinic, but also at a wider collective level by co-designing and co-delivering some of the training for healthcare professionals. When I was at medical school the patient stories are one of the only things I can still remember - and stories and experiences shared can add enormous value to medical training. But the scope for potential contributions extends beyond that to the design, philosophy, structure and focus of any teaching/learning/training.
      Although based in the UK, I'd be really interested in hearing your thoughts and exploring this further!

    2. Thanks, Anya, these re eally important points - and makesa me realise how much I take for granted here I work!
      The background is important - Aboriginal people and Torres Strait Islander people were the first inhabitants of Australia. 200 year sof dispossession have resulted in a background of non-indigenous services not being trusted automatically by Aboriginal an dTorres Strait Islander people. 40 years ago the first Aboriginal Community Controlled Health Service as set up, and now there are around 150 around Australia. Each of them are owned by the local Aboriginal community, who elect a local Aboriginal board. They determine the services operated from the service, which usually includes medical services. As a GP, I am employed by the service, on a salary - it is not mine (or Michael's) to own and run. Many of the staff, inlcuding the CEO are Aboriginal. It means there is both practical and emotional ownership. The community is proud of he service, and it has a different feel to a private General Practice. (Private GPs here are comparable ith NHS GPs, but we are a bit more corporatised here than in he UK).
      Many Aboriginal medical services are involved in health professioanl training (and it's essential that they are involved in teaching Aboriginal health to doctors and other health staff). However, there is much more that could be done to embed this more systematically into teaching. The service where I work has been involved in developing the Indigenous health curriculum at the medical school where I work, too. I think in Australia the Aboriginal community sector is at the forefront of patient and community involvement in medical education, but there is a long way to go for this to be embedded, and we bump up against capacity all the time.

    3. Wow that sounds like a really good system! I am very impressed! How do you overcome the hurdles of clinicians accepting the role of their patient communities in this set-up? Or do only people with this particular passion work in this area?
      I think this is a really good model! What would your top tip be for involving patient communities in the medical education process?

  3. Thanks Anya,
    We're often not very good at explaining to clinicians just how different the governance is and some clinicians do struggle with the reduced control. It does tend to attract people with a particular passion (and also some doctors who trained overseas and so have restrictions on where they are allowed to work). This post ( is about how many doctors work n this setting (it's a tiny number!) and this post ( explains why I do so.
    I've been thinking about top tips (and will post your query on Twitter, too) as it made me realise how much is dependent on good will at medical schools or medical colleges. I guess I'd start by saying to your local Med School, Hospital, GP that you're really keen to be involved, and find someone in the system with a passion - they are definitely there, and Social Media will help track them down. If you're seeing a doctor, ask if the students can come in, and then take over a teaching session!
    My ideas may not be the best! I've realised recently at the service I work in and the Medical school I do some work with that it does take institutional will power to support it happening, too.

  4. As a result of this conversation and some chat about it on Twitter, I've posted some thoughts about involving patients in medical education over on my other blog (because I've gone broader than strictly AMS or #Supertwision topics.