Education for Primary Care (2013) 24: 206 18 2013 Radcliffe Publishing Limited Teaching exchange We start this time with the last of Paul Silverston s articles about undergraduate teaching in primary care. This article aims to bring everything together and describe a programme of teaching for students attachment to general practice though the details will obviously vary between different medical schools. We hope you will find Paul s practical approach helpful. For our second contribution we move to nurse education and a short piece from the USA about a type of problem-based learning. We then continue with a fascinating account of a visit to the Wellcome Gallery by a group of foundation doctors. Their reflections on what they saw in the gallery showed just how much art can inform clinical practice. Finally we have an article aimed particularly at GP trainers, though it may well have resonances for other educators. How many trainers despair at their trainee s minimalistic approach to the e-portfolio? Mike Tomson and Ramesh Mehay suggest that this is a symptom and it needs to be investigated and then treated. Their description of how the investigation might be carried out makes interesting reading and no doubt applies to may similar situations. * * * * Consultation skills teaching in primary care Paul Silverston BA Jt Hons MBChB Visiting Fellow in Medical Education in Primary Care at University Campus Suffolk; Hon. Visiting Senior Lecturer in Pre-Hospital Care at the Postgraduate Medical Institute, Anglia Ruskin University Keywords: apprenticeship learning, consultation skills, general practice, patient safety, undergraduate education INTRODUCTION There has been a significant increase in the amount of time that medical students spend in primary care attached to general practitioners (GPs). However, the role that the GP plays in undergraduate medical education seems to vary considerably between medical schools, with some involving GPs in teaching large parts of the general curriculum, whilst others simply offer students the opportunity to experience general practice. This paper describes how GPs can assist medical students in their consultation skills training and provides GP teachers with a number of visual models to facilitate this teaching. TEACHING CONSULTING SKILLS The complexity of the modern models of consulting and the emphasis placed on teaching communication skills does run the risk that the student can lose sight of what the fundamental principles of a consultation are and how to conduct a safe, efficient and effective consultation. GPs, however, are in an excellent position to be able to show medical students how a highly time-constrained consultation can be conducted safely and effectively and also how the same principles can be applied to each consultation, regardless of the symptom presented by the patient. Whatever else the GP teaches during the student s attachment to the practice in terms of the medical school curriculum, it should be recognised that the GP has a unique role in teaching this type of symptom-sorting, problemsolving consulting method and that time needs to be set aside for the student to experience this. GP consultations are often complex, multifaceted phenomena, involving patients with different personalities, symptomatology, disease processes, attitudes to medicine and pathologies, all mixed together. For the inexperienced medical student trying to learn about the pathological processes of diseases, often artificially boxed into specialty areas, a GP consultation can be difficult to follow and may involve disease processes which have yet to be learned about. In particular, for a student sitting behind the GP, observing the consultation being conducted, it may be almost impossible to follow the GP s thought processes, as the standard model of medical interviewing simply does not apply. It is essential, therefore, that the GP introduces the student to the model of consultation that is being used in primary care, which may be very different from the one that the student has been taught in medical school, or observed being used within the hospital. In order to help the student understand and appreciate what is happening in a GP consultation, it may be helpful for the GP to reflect upon the way that they consult themselves, following the principle that if we do not know what we are doing, how can we explain it to others? The GP can then select a few
Teaching exchange 207 components from within the consultation process, relevant to the stage in the medical student s training, and concentrate on teaching these well. In particular, the GP can teach the student about the dynamic nature of illness; the safe consultation; managing diagnostic uncertainty and the mechanics of consulting, along with the role of communication skills in consulting. There are, of course, many other components but it is important to concentrate on the key components that the student may not experience anywhere else during their training. The concept of diagnostic uncertainty is an important one, as it contains within it the risks of misdiagnosis, treatment failure and the need always to safety-net for the risk that a diagnosis that has been made on a single point in time assessment may change over time, as the illness progresses. All of these points can be discussed with the student and the way in which GPs do this in every consultation highlighted. In addition to this the GP can explain how different parts of the consultation are used to help reduce diagnostic uncertainty and aid in the making of a diagnosis. TEACHING STUDENTS ABOUT ILLNESS One of the most useful learning experiences for students coming out to general practice is to see ways in which illnesses present in their early stages and the difficulties of making a diagnosis under such circumstances. In secondary care, students are often sent to clerk patients in whom the disease is already well-established and in whom the diagnosis has already been made. On the other hand, many of the patients whom the students see in primary care are presenting with symptoms rather than a diagnosis and this makes general practice the best place for students to learn about the nature of illness and its dynamic process. A visual model of this is shown in Figure 1. The GP can discuss the difficulties of making a diagnosis when patients present to the left on this model, along with the concept of diagnostic uncertainty that arises as a consequence. 1 The temporal aspects of illness are important for the student to experience, in order to understand the varying presentations of diseases over time. TEACHING THE MECHANICS OF CONSULTING Consultations are highly complex phenomena but sometimes there is a need to return to what one might call the nuts and bolts of a consultation, the mechanics of consultation. 2 At its simplest level, a consultation involves four processes: informationgathering; information-processing; decision making; and decision implementation. In the complexity of the all-encompassing modern models of consulting and communication skills training, students can sometimes lose sight of these fundamentals and the GP has the opportunity to assist students in developing their consulting skills by helping them to grasp the basics. In addition, simple visual models can be used to lead students through the information-gathering and information-processing stages, before the GP discusses the problems that diagnostic uncertainty poses and the need to adopt a patient-safety-centred approach during the decision-making and decision-implementation phases of the consultation (Figures 2 and 3). TEACHING SAFE CONSULTING The World Health Organisation (WHO) Patient Safety Curriculum 2011 highlighted the need for a patientsafety-centred approach during consulting and for patient safety attitudes and behaviours to be taught during medical training. GPs have the opportunity to show how patient safety is incorporated into their consultations and to emphasise to students the importance of adopting such an approach. The first part of this teaching relates back to an understanding of the dynamic nature of illness, in that one has to learn about the early presentation of illness as well as how it presents in its established form. The presentation of two illnesses, one serious and one less so, can be identical in the early stages and the diagnosis may only become apparent over time (Figure 1). The need always to Exclude the worst, first is a fundamental principle in consulting and is essential in the training of safe doctors. Whatever else happens during a consultation, this is perhaps the most patient-centred behaviour that a doctor can adopt. SYMPTOM-BASED AND PROBLEM- BASED LEARNING In undergraduate medical education, there is a move away from teaching disease as a purely pathology- Symptoms A B C Time Figure 1 Relationship between symptoms and time
208 Teaching exchange Referral to hospital Far-patient Near-patient Patient Information gathering Physical examination History Clinical observation Figure 2 The information-gathering stage of the consultation normal resting state until something that is said by the patient, or discovered on clinical examination, causes the antennae to twitch, alerting us to the presence of a potentially serious illness and the need to exclude the worst, first. Good clinicians memorise normal and abnormal patterns of serious illness and develop an almost innate ability to recall and apply these patterns to the symptoms and signs presented by the patient. Teaching students about these patterns is essential and helping them to develop and hone their medical antennae to detect them is a fundamental part of teaching safe consulting. TEACHING COMMUNICATION SKILLS Referral to hospital Far-patient Near-patient Patient Information gathering Physical examination History Clinical observation Figure 3 The information-processing stage of the consultation based or disease-oriented science and towards teaching students using symptom-based, problembased and case-based learning. This approach has its merits, particularly for those students who will work in primary care, as most patients present with a symptom at their first consultation for a new illness in general practice. GP consultations involve the pattern-recognition of illnesses, along with hypothesis-testing to confirm or refute whether the symptoms match the patterns of illness that the GP is suspecting. Students learn question cascades relating to body systems or diseases but often find it difficult to move from the symptom that the patient is presenting with to those specific question cascades. GPs are in an excellent position to demonstrate how one moves from a symptom to a question cascade. Students find this extremely useful, along with advice on how to go about clinical problem-solving. Another useful concept for students to learn about is the use of medical antennae. When one is seeing large numbers of patients, most of whom do not have serious illnesses, it can be difficult to maintain a constant level of alertness for the presence of serious illness. One s medical antennae are in a Communicating well with patients is a key part of GP consultations, not just from the point of view of job satisfaction but also as a skill to assist GPs in information-gathering and information-imparting with a patient. One of the things that students always remark on is the good relationship that exists between a GP and most patients and this comes about usually through the GP s ability to communicate well with the patient, along with trust and a caring attitude. However, communication skills also have a place to play in the mechanics of consulting such as to elicit information from the patient or to explain a diagnosis or management plan. GP teachers can assist their students in learning these essential skills both in theory and by example. TEACHING MINOR ILLNESS Students learn much of their medicine in secondary care where little, if anything, is taught about the management of patients with minor illness. Yet most people (including friends and relatives!) would expect a newly qualified doctor to know about how to manage simple, common conditions. GPs are being asked to deliver more of the undergraduate medical curriculum within primary care, yet this key part of general practice (and a general medical education) can sometimes be overlooked. One of the roles of the GP teacher is to show students how to manage common minor medical conditions, which we are all going to experience at some time in our lives and which should perhaps be regarded as a medical life skill. THE STUDENT AS AN APPRENTICE There is, perhaps, a difference between calling someone who is studying medicine a medical student and a student doctor. The former implies
Teaching exchange 209 that the student is studying medicine as a science, whilst the former infers vocational training, an apprenticeship. Students attached to a practice have an opportunity to work as an apprentice to the GP, which, for some students, is a way of learning that they thrive upon and do not experience anywhere else in their training. However, for students to gain the most from this apprenticeship, they need to have this role explained to them. In other words, they need a teaching session on how GPs consult, followed by a period of observing the GP consulting, with the GP signposting and explaining how what has been taught in the tutorial is being applied during the consultation or afterwards. Traditionally, this is where GP teaching finished, with the student simply observing consultations, often to no-one s satisfaction. However, the GP has a unique opportunity to assist students in developing their consulting skills by observing the student consulting. This is likely to be the only time in the student s training that their consulting with real patients (rather than actors) is observed. This is where the master observes the apprentice and guides students through their consultations, helping them to develop their consulting skills, and gently correcting them where necessary. Taking the student through the four processes of the consultation along with emphasising the need to adopt a patient-safetycentred approach is something that GPs can help their students with. Finally, students can be sent to see patients alone and then to present the patient to the GP along with a proposed management plan. This the ability of the student to summarise and present their findings. Students often spend several weeks at a time (continuously or intermittently) in a practice. This enables the GP to develop a good working relationship with the student. Teaching consulting can be done progressively, with students on their first attachment being taught information-gathering skills and on subsequent attachments learning the other three components of the consultation, so that they become competent consulters and safe doctors by the time that they qualify. Students who arrive in the practice only to spend all their time either sitting behind a GP, observing consultations, or who are sent off to clerk patients tend to express negative views of their experience of GP attachments, as compared with those who have active teaching and an apprentice-based approach. GP teachers are now well remunerated and the expectation is that Schedule (for a whole surgery, or part of a surgery) Time Patient Student A Student B 9 1 Consults Observes 9.20 1 Observes Consults 9.40 1 Consults Observes 10 1 Observes Consults Figure 4 A teaching surgery Schedule Time Patient Student A Student B 9.00 2 arrive Consults alone* Observes GP 9.10 1 arrives Still consulting Observes GP 9.20 0 Presents patient Observes 9.30 2 arrive Observes GP Consults alone 9.40 1 arrives Observes GP Consults alone 9.50 0 Observes Presents patient *Asked to treat consultation as a 20 minute OSCE Figure 5 A working surgery students will receive some form of active teaching which can be achieved without major disruption to the smooth-running of the practice. (Templates for running a teaching surgery and a working surgery are shown in Figures 4 and 5. These were developed by a former student in the practice and have been well received by generations of students since then.) CONCLUSION Medical students are spending an increasing amount of time attached to GP practices during their course, although the content of the teaching curriculum for this time varies considerably between different medical schools. At the same time consultation skills training has become a large part of the undergraduate medical curriculum. GPs are in an excellent position to assist medical schools with this type of teaching, given the nature of the GP consultation and the amount of exposure to consulting that is given to students whilst they are attached to a practice. However, there is a need to develop a formal programme for teaching general practice within the undergraduate medical curriculum which emphasises the way in which consultations differ in primary and secondary care, along with the need to consider the differing presentations of the same illness, referring to the Model of Illness described above. The four components of consulting can be discussed, along with pattern-recognition and hypothesis-testing. The fundamental principles of safe consulting can be taught through allowing the student to be an apprentice within the practice, especially during the time that the GP observes the student consulting. In this way, GPs can help produce doctors who consult safely, effectively and efficiently in the future and who are also good communicators. Acknowledgement The author would like to thank Dr Juliet Usher-Smith for her help and support during the preparation of this paper.
210 Teaching exchange References 1 Silverston P (2012) Using a model of illness to aid symptom-based learning in primary care. Education for Primary Care 23: 443 5. 2 Silverston P (2013) Teaching the mechanics of consulting in primary care. Education for Primary Care (in press). Correspondence to: Dr Paul Silverston, The Mill Barn, Mill Lane, Exning, Suffolk CB8 7JY, UK. Tel: +44 (0)1638 577729; email: paul.silverston@ btinternet.com