Undergraduate Medicine at the University of Edinburgh

A Toolkit for Clinical Teachers A Practical Guide to Integrating CSPPD themes into Clinical Teaching

EEMeC is the online ‘virtual learning environment’ for the Edinburgh MBChB and as such contains a large amount of information, resources, tools and services for both students and teachers. Further information on all of the themes described in this booklet can be accessed via the CSPPD home page on EEMEC: https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcs0000 A list of individual CSPPD theme links is given in the back of this publication.

EEMeC is username and password protected and you can apply for access by contacting the EEMeC team at [email protected]

2

Contents The Clinical Skills Personal and Professional Development Course

3

The Consultation

4

Clinical Communication

6

Clinical Procedures

8

First Aid & Resuscitation

10

Evidence-based Medicine and Research

12

Informatics

14

Personal Professional Development

15

Medical Ethics, Legal and Professional Responsibilities

16

Theme Leaders

18

EEMeC Links

19

3

4

It’s hard to define the features of a good doctor but a range of skills and a set of values and attitudes are needed, in addition to a knowledge and understanding of disease and ill-health. The CSPPD course aims to transmit these skills and values to our medical students. Some parts of this training are timetabled and taught separately, but we hope that most learning will relate to clinical events, giving the learning context, adding motivation and improving understanding of the relevance of these values. CSPPD teaching has been split into eight themes. However clinical problems rarely fall neatly into one of these eight categories, although it often helps students to put together their experience from different places in this way. The Eight Themes • The Consultation • Clinical Communication • Clinical Procedures • First Aid & Resuscitation • Evidence Based Medicine and Research • Informatics • Personal Professional Development • Medical Ethics and Legal & Professional Responsibilities This booklet explains each theme, and suggests where you may find chances to teach these medical skills and attitudes. Your clinical teaching is the best place to do this in the appropriate context.

Foundation Doctor Vertical Themes Biomedical & Clinical Sciences Clinical Skills, Personal and Professional Development (CSPPD) Social Sciences & Public Health Clinical Presentation, Diagnosis & Management Pharmacology and Therapeutics Psychological Aspects of Clinical Practice Student Selected Components Key Clinical Topics e.g.disability, lifecycle, nutrition, pain, alcohol, diabetes, infectious diseases, cancer

5

Introduction

The Clinical Skills, Personal & Professional Development Course (CSPPD)

What you can do

Overview

The Consultation The consultation is central to all clinical practice. It can be thought of as a structured sequence of tasks, most of which occur in all patient encounters whether face-to-face, by telephone or by e-mail. These tasks are… • OPENING (create appropriate environment, welcome patient) • GATHER INFORMATION History (including ideas, concerns & expectations) Clinical examination Investigation (previous results & data) • DIAGNOSIS (summarise probable bio-psycho-social diagnoses) • ADDRESS THE PROBLEM(S) Consider treatment options Explanation (problem, options) & Advice Negotiate & agree plan (includes treatment, lifestyle changes, further investigation & referral) Reassurance & Support (as appropriate) • CLOSE (confirm plan / follow-up) & DOCUMENT This theme focuses on acquiring and practicing skills in consultation, whilst learning some of the theory behind these skills and developing appropriate attitudes towards patients. Some useful strategies to facilitate this learning are: • Observe students performing these skills in the workplace and provide constructive feedback. • Ask students to clerk patients and present them. • Encourage students to take histories or examine patients in pairs and give each other feedback. • Involve students in explanations to patients, and in treatment planning.

6

7

Locomotor system, including assessment of Opthalmology & ENT disability & X-rays systems

Psychiatric history and Mental State Examination

Clinical aspects of Molecules to Society modules

Intimate examination: examination of the breast

Clinical aspects of Molecules to Society modules

Health Needs of Older People

Year 5

Practice clerking patients for foundation year

Geriatric history, cognitive and functional assessments and planning

Paediatric history, examination, diagnosis & management

Breast / PR examination

Progression of Learning

O&G/Sexual history, Obstetric and Gynaecological examination, diagnosis & management

Tailoring/ developing skills for specialist situations such as GP, Haematology, Urology & Dermatology

Further training in Recognition & Psychiatry, Neurological management of patients & Urinary systems who are acutely ill or injured

Further training in Cardiovascular, Respiratory & Gastrointestinal systems with more emphasis on investigation and planning treatment

Introduction to Clinical Practice: history, clinical examination, diagnosis, explanation and advice in Cardiovascular, Respiratory, Gastrointestinal, Urinary & Neurological systems

Year 4

Talking With Families

Year 3

Year 2

Year 1

What you can do

Overview

Clinical Communication The Clinical Communication theme aims to teach graduates to communicate clearly, sensitively and effectively with patients, relatives and colleagues regardless of their social, cultural or ethnic backgrounds or any disabilities. Most of these skills and strategies are generic and can be used in many situations, some are more specific. The course has a ‘toolkit’ structure, providing a range of methods for use in different circumstances. In Year 1 students receive a theoretical and practical introduction to communicating as a health professional with patients and their relatives, and in Year 2 learn how to communicate in the consultation. In Years 3 to 5 history taking, information giving and negotiating skills are developed with more challenging situations (e.g. communication difficulties, embarrassing situations, teamworking) with specific teaching on managing anger and distress, breaking bad news and motivational interviewing. During clinical attachments, students should do the following (under supervision) • Take histories from patients and present these (informally and formally). • Give information to patients and answer questions. • Discuss and negotiate management plans. • Contribute to multidisciplinary team meetings. • Video-record consultations. • Talk to patients who have difficulty communicating, are distressed or use an interpreter. • Take a sexual history, get involved in discussions about incapacity, ‘do not resuscitate’ and organ donation decisions • Talk with children and their parents.

8

9

Patient centred interviewing

Core interview structure. Introduction to key skills and strategies

Health Needs of Older People in Primary Care

Talking with Families

CAL package

Workshop

Clinical communication in the consultation

Establishing good doctor-patient relationships

CAL package

Primary care-based modular teaching

Integrating structure, key communication skills, and clinical knowledge in history taking/ giving simple explanations & advice

Year 2

Year 1

Theme weeks

Workshops

Hospital-based modular teaching

Decision making

Working with interpreters

Handling anger and distress

Using well structured consultations

Giving information/ explanation followed by advice/ reassurance

History taking

Year 3

CAL package

Workshops

Primary & secondary care

Student-led GP surgeries.

Communicating as a teacher

Police/ Fiscal

• Post mortems

• Incapacity Act

• Treatment withdrawal

• Resuscitation

• Consent

• Confidentiality

Ethics in practice:-

Progression of Learning

Primary care & hospitalbased modular teaching

Report writing

Presentation skills

Motivational interviewing/ lifestyle advice

• Sexual health

• Physical disability

End of life decision making

Teamwork

• Bad news • Mental health problems or learning disability

Communication with children and families

Year 5

Communication challenges:-

Year 4

What you can do

Overview

Clinical Procedures With new work patterns and short clinical attachments, apprentice-style training is more difficult. By training in clinical procedures during their attachments, students should be able to help with the clinical workload and gain experience as well.

Much of this training is in simulated settings. However, this learning must be reinforced by supervised practice on real patients if students are to become competent before graduation. Here are a few ideas to help practical instruction: you may see others. • Encourage students to undertake simple clinical procedures that need to be done on the lists or in the clinics they attend. • Set up links with nurses and other practitioners who now undertake most procedural tasks on the ward. • Ask students to keep a log of procedures to chart their progress towards competence and inspect this log as part of the end of attachment assessment. • Encourage the junior doctors to involve medical students in the procedures needing done on the wards.

10

11

Hand washing

Recording twelve-lead ECG

Demonstration of inhaler technique Examination male genitalia

Basic suturing

Pain control

IV therapy

SC + IM injections

Year 5

Progression of Learning

Taking cervical smear

Faecal occult blood testing

Pelvic examination

Safe use of blood products

Urethral catheterisation

Urinalysis

Moving & handling

Arterial blood gas sampling

Setting up a drip

Otoscopy

Ophthalmoscopy

Breast Exam 2

Year 4

Nutritional assessment Rectal examination

Breast Exam 1

Subcutaneous administration of insulin

Blood glucose testing

Peripheral IV cannulation

Taking blood cultures

Respiratory function testing

ECG interpretation

Venepuncture

Measuring pulse & blood pressure

Year 3

Year 2

Year 1

The current programme of formal training in clinical procedures.

What you can do

Overview

First Aid & Resuscitation (FA&R) Medical students are often expected to be able to cope with emergencies. Although this expectation might be unreasonable from the general public, it’s widespread! The First Aid & Resuscitation theme aims to equip students with the knowledge and skills to cope with emergencies, in and out of hospital. The training programme is shown in the table opposite. In Year 1 students train in basic life support and this is developed further each year. The emphasis shifts from managing collapse to preventing deterioration in a critically-ill patient. This follows the suggestions of the Resuscitation Council.

Emergencies are unpredictable and the chances of direct learning often limited and opportunistic. However, the ABCDE framework can be used in assessing and treating most patients needing acute hospital care. Basic resuscitation can be reinforced in this way. For example, students could be asked to explain the A and B of managing an asthmatic patient being reviewed on a ward round (it could be upper airway obstruction – it has been known!). C and D could be discussed in relation to a patient having a fracture reduced and fixed in theatre. The E of exposure can be seen in action as the A&E staff cut off the clothing from an acute admission. Many teachers already use these opportunities. These examples may be far less dynamic than others you may be able to think of.

12

13

Introduction to Advanced Life Support

Airway Management

Defibrillation

Rhythm recognition

Assessment of BLS

Basic Life Support

Year 3

Year 2

Year 1

Acute Medical Emergencies

Immediate Life Support Course

Paediatric Airway

Year 5

Progression of Learning

Support (Cardiac Arrest Simulation Teaching)

Advanced Life

Paediatric Resuscitation

Year 4

Overview

Evidence Based Medicine and Research Evidence Based Medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients. This means integrating individual clinical expertise with the best available clinical evidence from systematic research. Best available clinical evidence comes from clinically relevant research, often from basic science, but especially from patient-centred clinical research into the accuracy of diagnostic tests, the power of prognostic markers, and the efficacy and safety of medical treatments, rehabilitation, and preventive regimens. Students are given the following steps for an evidence-based approach to practice:

What you can do

Ask an answerable question

Search the literature

Apply Critical appraisal of evidence to patient care findings

Evaluate performance

During clinical attachments, encourage students to explore the practical applications of EBM by: • Discussing how you use clinical guidelines to inform your practice and keep up-to-date. • Describing how a departmental audit was used to highlight a problem and instigate change. • Requesting that a student conducts a literature search and finds the best available evidence on a condition they see in clinic or on the ward for the very first time. • Demonstrating how an integrated care pathway engenders the practice of evidence-based medicine.

14

15

Epidemiology, statistics and critical appraisal of published papers are covered in Public Health

PBL group work:

• Ask question

• Find information

• Assess for quality and relevance

Introduction to EBM

Introduction to the Library and using literature databases (Cochrane, Medline)

PBL group work:

• Ask question

• Find information

• Assess for quality and relevance

To be introduced: appraising quality of web pages

Year 2

Year 1

Portfolio essays

Portfolio essays

Clinical attachments

Year 5

Progression of Learning

Possible overview essay topic

Portfolio essays

Statistics for metaanalyses

Research design

SSC – optional tutorial for systematic literature searching

Year 4

Beyond basics of literature searching

Year 3

This is how EBM teaching is developed in the curriculum:

What you can do

Overview

Informatics The Informatics theme has two main components: • Medical informatics: the use of informatics to improve patient care and clinical effectiveness, to enable students to appreciate the role of informatics in day-today patient care and in medical science in general. • General informatics: developing computing and study skills in the early years of the course. Much of the Informatics teaching is embedded in other parts of the course such as CSPPD themes like Evidence Based Medicine and Research or Clinical Communication, whilst other topics such as record taking, statistics, imaging and electronic patient records are addressed in a number of different years and rotations. Informatics teaching also draws on a range of online tutorials and study materials on EEMeC, the MBChB’s web-based virtual learning environment: see the EEMeC Informatics area at https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcsmi00 Although informatics technologies are transforming healthcare across the UK their presence ‘on the ground’ is so far quite patchy. As a result our students may miss out and fail to experience and appreciate how important medical informatics can be. You can help by addressing informatics issues that affect daily clinical practice, for instance: • Explore the advantages and disadvantages of electronic patient records when reviewing the notes or kardex of a patient • Discuss the benefits and drawbacks of an online Picture Archiving System (PACs) when teaching radiology and other imaging techniques • Ask students to search the SIGN guidelines for guidance on how to manage particular clinical issues such as diabetes, cancer or stroke • Discuss the issues of form design and use in clerking patients, checking test results or reviewing other kinds of clinical data

16

17

Key Informatics Themes

The following key Informatics themes should be born in mind and where possible pointed out and discussed with your students: Data Protection and Confidentiality: the 1998 UK Data Protection Act requires that all personal data must be: 1. Fairly and lawfully processed 2. Processed for limited purposes 3. Adequate, relevant and not excessive 4. Accurate and, where necessary, kept up to date 5. Not kept longer than necessary 6. Processed in accordance with the data subject’s rights. 7. Securely protected against unlawful processing and against accidental loss, destruction, or damage 8. Not be transferred to a country or territory outside the European Economic Area Information Flow: the patient journey depends on many forms of information flow and exchange. You could for instance explore how information is managed and how it flows between the different people and organisations involved with managing your patients Information Handling: this includes developing good writing and computer skills, accurate, clear and timely recording and coding of clinical data and an awareness of its importance in clinical care. Information Quality: critical awareness of the limitations of the information available to the doctor is also important. Students should be encouraged to consider the clarity, accuracy, completeness and representativeness of the information available to them and how this reflects on the way they are able to function in a contemporary healthcare environment.

What you can do

Overview

Personal Professional Development (PPD) The Personal Professional Development theme aims to help students to grow personally and professionally. PPD seeks to maximise students’ usefulness, personal satisfaction and self -awareness throughout their professional life by encouraging self-directed learning and reflective practice. Medical students need to: • Appreciate the attributes of a good medical practitioner • Increase their personal and professional self awareness • Develop a reflective approach to their work • Develop professional competence through experiential learning • Develop a better understanding of career options Medical students look to qualified doctors as role models, observing behaviour and attitudes to decide what is acceptable. You can also help medical students develop personally and professionally, for example: • Ask what they hope to learn or have learned during the clinical session • Ask students what further studying they plan to do after the session – follow up afterwards to see if it increased their understanding. • Give students feedback on their strengths and weaknesses. • Encourage students to present oral case reports • Discuss any significant events – recall actions and feelings • Encourage students to observe and critique other students’ clinical skills • Discuss the clinical team – members, how it works, what can go wrong • Discuss stressful professional situations & how you coped • Talk about your speciality– training aspects of job

18

19

Revision of Academic writing & exam techniques

* extracurricular activities

Personal development profile

Peer assisted learning* sessions

Personal development profile

Peer assisted learning*

Issues of personal safety in psychiatry

Year 3

**Scottish Foundation Allocation Scheme

Academic writing & plagiarism Personal development profile Preparing for exams

Procrastination & Organisational skills

Coping at University

Collecting & processing information

Reflective practice

Career management*

Introduction to Personal Professional Development

Professional Codes of Practice

Year 2

Year 1

Personal development profile

Progression of Learning

Personal development profile

Writing referral letters

Peer assisted learning

Coping with a foundation job

CV writing*

SFAS** process & application*

Year 5

Managing aggression

Risk assessment

SFAS** process & application*

Career management Career Fair*

Year 4

PPD skills: self care, self awareness, self directed learning, reflective practice, motivation, commitment, reliability, time management, organisational skills, recognise own limitations, risk assessment, multidisciplinary teams, leadership, delegation and presentations are addressed and assessed throughout the curiculum including clinical attachments. In addition to the PPD opportunities highlighted in students’ general study guides, there are the following scheduled PPD sessions:

Overview What you can do

Medical Ethics and Legal & Professional Responsibilities Ethical, legal and professional responsibilities are at the heart of what a doctor is and what a doctor does. Few clinical decisions can made without considering them. This theme aims to equip students with the knowledge, skills and attitudes to make these decisions within an ethical and legal framework and with insight and compassion. A formal teaching programme covers core topics in Years 1 to 5. This programme is complemented by clinician-led teaching during hospital and GP attachments. This teaching sets the students’ learning in a real and memorable context and aids their professional growth. These are some suggestions for integrating ethical, legal and professional issues into your teaching: • If you are asked to place a patient under the provision of Adults with Incapacity Act, discuss the legal implications and limitations of doing so. • When reviewing a DNAR order on a ward round, question the student on their understanding of this concept. • Discuss the ethics of resource allocation having placed a patient on a long waiting list. • Speak about the moral tension between the duty of care to the individual and the interests of others when recruiting a patient into a clinical trial. • At a departmental M&M meeting, ask the students to think about the implications of responding inappropriately to clinical mistakes. • Discuss ways in which patient confidentiality can be broken unwittingly.

20

21

Principles & practice of medical ethics in clinical & community practice*

Integrated modular case-based discussions

Professional Conduct*

Confidentiality*

* topics addressed through formal teaching programme

Ethics of resource allocation*

End-of-life issues*

Ethics related to the lifecycle*

Research Ethics*

Consent*

Year 3

Year 1 & 2

Integrated modular case-based discussions

Do Not Attempt Resuscitation (DNAR) orders

Prioritisation of care

Ethics & Legislation governing treatment and care of children*

Ethical Issues in Geriatric Medicine*

Year 5

Progression of Learning

Integrated modular case-based discussions

Transplantation

Ethics & Legislation governing reproduction*

Mental Health Legislation*

Palliative Care, Advance Directives and Euthanasia*

Year 4

Contact

Theme Leaders The Consultation Dr. Donald Thomson [email protected] https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcscl00

Clinical Communication Dr. Kirsty Boyd [email protected] https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcscm00

Clinical Procedures Dr. Jeremy Morton [email protected] https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcsck00

First Aid & Resuscitation Dr. Gordon Drummond [email protected] https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcsfa00

Evidence-based Medicine and Research Dr. Andrew Tambyraja [email protected] https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcseb00

Informatics Dr. Rachel Ellaway [email protected] https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcsmi00

Personal Professional Development Mrs. Karen Simpson [email protected] https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcspr00

Medical Ethics, Legal & Professional Responsibilities Professor Kenneth Boyd [email protected] https://www.eemec.med.ed.ac.uk/node.asp?ID=vtcset00

22

23

Undergraduate Medicine at the University of Edinburgh CSPPD Toolkit for Clinical Teachers A Practical Guide to Integrating CSPPD themes into Clinical Teaching Published by the Medical Teaching Organisation, © The University of Edinburgh 2006, all rights reserved.

24