Category Archives: Teaching and training

Keeping up to date

Generic, Teaching and training

Years ago it was already pointed out that there is way too much published research for the average doctor to keep up to date. Even to just be aware of all the guidelines that summarize research into best practice means reading hundreds of pages for the conditions that you might only infrequently see.

Of course you don’t always know if the patient in front of you is typical of the condition being discussed – research often excludes complicated cases (or children, or pregnant women).

Even then – “most published research findings are false” [Ioannidis, Plos 2005].  Lots of findings are never confirmed by further studies, and “knowledge” is based on a p value of <0.05. Actually depends on pre-test probability… Are certain things already known? Or is there just a lot of data without established relationships? Even if research design is perfect, bias eg selective reporting or manipulation of analysis. Different studies may use different end points or definitions, which increases the chance findings are false. True findings can be lost in noise or concealed by conflict of interest. Fixed beliefs may be as prejudicial as financial conflict of interest… Expert opinion often differs from outcomes of metanalysis. Small studies and small effects mean any significant result is more likely to be false.

In the model discussed in this study, an underpowered early phase clinical trial that produces a positive finding is likely to be misleading 75% of the time, even before you consider bias. If you are talking about a field where there probably isn’t actually any relationship between the things being studied, then large effects with high significance may just reflect the degree of bias, and should be seen potentially as a warning rather than something exciting!

Authors don’t check primary sources so misconceptions promulgate. Peer review is inefficient, inconsistent and insufficient. Post publication retractions are messy and difficult. See the problem of citations, below.

Systematic reviews are not kept up to date – in fact, they are usually already out of date when published… 

Authors of guidelines have a particular duty to ensure rigorous analysis. 

The average 10 min consultation will produce at least 1 unanswered question. 

[Richard Smith BMJ 2010]

The problem of citations

Citation error rate is estimated at 11-15% in biomedical literature. Propagates mistakes (even academic urban legends eg iron in spinach, due to a misplaced decimal point in a 1930s paper, which I have not verified) and undermines respect for literature review. 

Can be non-existent findings, incorrect interpretations of findings, or (20% of errors) chains of errors. Sometimes a hypothesis becomes a fact. 

1 surgical study was found to be misquoted by 40% of articles that cited it!

AI can help or make this worse. CONSENSUS.app is AI powered search engine for academics. 

Best would be a declaration, that the authors have read the original papers and checked for accuracy and relevance.

Oratory

Communication, Generic, Teaching and training

We quickly get used to doing case presentations, and talking with colleagues and patients, but we don’t really learn the skills of speaking with conviction, which Winston Churchill called the most precious gift of all the talents bestowed upon men.

Important for career development, advocacy and leadership.

At the age of 22yr Winston Churchill said the essential components of oratory were diction, rhythm, accumulation of argument, analogy and emotion.

Presentation skills

It’s pretty obvious when a presentation is done badly – and so it is obvious what you need to do to give a good presentation.

  • Unprepared
  • Technical issues, esp poor sound
  • Overly busy slides, or slides that don’t seem to correspond with what is being discussed
  • Simply reading slides
  • Glaring bright slide backgrounds
  • Spelling mistakes or inconsistent formatting
  • Lack of a pointer
  • Not really understanding what a table/chart is actually showing
  • Rushing at the end, not leaving time for questions

The best presentations convey the importance of the topic, discuss real life issues, are funny (some of the time – otherwise risk of sounding callous). The speaker looks at (speaks to) you.

Media interviews

  • Consider the interviewer someone with their own agenda – know yours.
  • Reframe any questions you see as misleading.
  • Avoid patronising or over-explaining.
  • Patient confidentiality above all.
  • Know your message(s)
[https://doi.org/10.20935/AL2219.1]

Gaming technology in healthcare

Generic, Teaching and training

Humans, and children in particular, learn through play. Play is how we develop new models to understand the world around us.

Expert game designers are well-versed in sociology, psychology, and the cognitive sciences that underlie motivation and behavior. They know how to achieve the perfect balance between challenge and mastery – too hard is off putting, too easy is uninvolving – and they build reward-driven experiences that capture attention.

Games are ultimately how we work out rules, and hence strategy.

All these things are essential components of learning, and indeed life.

A good game requires intense concentration, and this is where maximally efficient learning occurs, which contributes to better knowledge retention and skill development. And with a game this is almost an unintended consequence.

[Eric Gantwerker]

Confidence as a doctor

Generic, Management, Teaching and training

As a doctor, you want to feel confident in your abilities and your diagnosis, you certainly don’t want to question yourself constantly. Equally, your patients want to feel confident that you know what you are talking about, and will probably get better more quickly if they do (placebo effect).

Most people can smell bullsh*t from a mile off if you try to say something you don’t actually think or believe. Typically, your words (vague) and body language (evasive) will give you away.

At the same time, the over confident doctor is dangerous. Arrogance is also very unattractive. So there is a balance.

What do we mean by confident?

Confidence is a sense of belief in one’s own abilities. But of course you can have a strong belief in your own ability when you have no talent at all. So the kind of confidence we want to have is probably the sense of certainty that you can do something reasonably well, even that you can then do it without really needing to think too much about it at all.

It isn’t a character trait! And of course there isn’t such a thing as a “confident person”, because it depends on the skill being considered. Great athletes can be terrible public speakers, for example.

How do get more confident?

It’s cultivated by early childhood experiences of course. How were you encouraged to think about your own efforts and abilities? But no reason you can’t gain in confidence, or at least make your confidence commensurate with your competency. Some people may have more baggage to deal with, of course.

So first step must be to gain competency – which means understanding the basics, practising the skills, and recognizing when things fall outside what you have seen so far. Repetition is key, clearly.

Secondly – if you feel you are straying outside your comfort zone, is there any way to get more information? Do you have notes you can check? Do you know which are the best resources? Do you have a person you can ask safely?

Thirdly – can you see what factors are hindering you from performing at your best? Tiredness? Distraction?

The story you tell yourself

Of course you are not perfect. You will make mistakes. You will forget something. You cannot know everything. But is there anyone other than yourself who expects otherwise?

So rather than concentrating on the negatives (which is probably natural, given that in the evolutionary survival game, you really don’t want to end up wounded, poisoned, lost or dead as often as you get lucky), can you tell yourself that you are ready for this, that you are trained for this, you have worked for this, you work reasonably well in almost all conditions?

That mistakes do not cancel out everything you get right the rest of the time?

Although there is a time to be self critical, there are definitely just as many times if not more to be self friendly, and this can be hard for us if never modelled.

You need to practice positive self affirmations, if you want them to count when under stress. Confidence is like a bank balance that needs constant deposits. List the things you have done well in the past. Spend time each day reflecting on what went well. Spend time looking ahead and envisioning where you want to be. This should be the movie playing in your head.

The “shooter’s mentality” – any missed shot is a temporary slip, and just means the next shot will be successful. Any successful shot confirms that you are on a roll of consistent success.

And how do you think of other people’s success? Do you always equate confidence with arrogance, laziness, complacency?

Stand up straight with your shoulders back

Rule 1 of Jordan B Peterson’s 12 Rules for living.

“Standing up straight with your shoulders back is not something that is only physical, because you’re not only a body. Standing up means voluntarily accepting the burden of Being. You see the gold the dragon hoards, instead of shrinking in terror from the Dragon. It means deciding to transform the chaos of potential into the realities of habitable order. It means willingly undertaking the sacrifices necessary to generate a productive and meaningful reality.

“People, including yourself, will start to assume that you are competent (or at least they will not immediately conclude the reverse). Strengthened and emboldened, you may be able to stand, even during the illness of a loved one, even during the death of a parent, and allow others to find strength alongside you when they would otherwise be overwhelmed by despair.

“Then you may be able to accept the terrible burden of the world, and find joy. Look to the victorious lobster.”

See also the benefits of the Superman pose.

The cherry on top

Put in the work – the studying, the practice, the questioning, the reflection.

Then decide to tell yourself – “I’ve done the work. I know what I need to know. I’m going to deliver now. I am enough for this time and this place.”

History of Medical Failures

Ethics, General paediatrics, Generic, Medical, Teaching and training

Where to start!? Leaches, blood letting, pretty much everything doctors did in the pre-modern period…

Thalidomide and birth defects, of course. But unforeseen.

X-rays for pregnancy monitoring. Took years before people paid attention to the alarms. X-rays were also used for tinea capitis – not just brain tumours, strokes and ischaemic heart disease about 30% higher too.

Ribavirin (via SPAG machines) for RSV. Not harmful, just useless and expensive.

Iron supplements for preterm babies – increased sepsis.

Clinical teaching techniques

Generic, Teaching and training

Teachers generally believe they give regular and sufficient feedback, but this is often not how it is perceived by learners!

Set expectations – that most learning happens during daily patient care as part of the team. That teachers expect and welcome feedback themselves, and that feedback is normal everyday component of teacher-student relationship – else can generate defensiveness.

Feedback is a conversation about performance, rather than a 1 way lecture.

Modelling – think aloud, to externalize reasoning (in short spells!)

1-2 minutes direct observation.  Feedback perhaps after a number of episodes – one thing done well, one thing that could be done differently? Beware a list of demoralising fails. Avoid using the word “but” between the two, which seems to diminish the positive praise.

Balance feedback by asking for student’s own perceptions of their performance, and their ideas for improvement.

Send student ahead (“scouting“).

Self- explanation – without any instructions, student finds own explanations for results, obs, management plan etc.

SNAPPS – summarize case, narrow differential, analyse differential, probe [ask questions] where uncertain, plan, select an issue related to case for self directed learning.  1-2 mins only.

Tell me story backwards – Diagnosis, then supporting evidence, then why other diagnoses excluded.  Only then plan.

Contrastive example – ask student to give alternative diagnosis and balance probabilities.

Post it Pearls – record thoughts (not just pearls!) during clinic/ward round, review at end.

Diagnostic challenge – one person/team defends working diagnosis. Other asks about worse case scenario, or alternative diagnosis, investigations done or not done, and checks with patient themselves!

[Operation Colleague, from University of Glasgow; HPE Bytes]