DundeeChest 3.0

Archive for the ‘Medical Education’ Category

Patient outcome is not altered by longer shifts, but juniors’ training suffers overall:

The Japan earthquake and Tsunami has lead to critical incidents at nuclear power stations, and, understandably, concern over radiation levels throughout Japan. At the site of the incident, radiation levels soared to 400mSv per hour, but quickly fell to 0.6mSv per hour at the front gate of the plant hours later. Levels throughout Japan have been reported as 6uSv per hour this morning.

But what does these figures actually mean? And how do they relate to the doses of radiation we expose our patients to in clinical practice?

A CXR is about 0.02 mSv

Background radiation for a year in Dundee is 2.5 mSv

A helical CT scan of the Chest, Abdomen and Pelvis is about 12 mSv

Radiation sickness usually occurs at 1 Sv

Louis Slotin received 5.1 Sv during the criticality accident in 1946 that lead to his death

Radical radiotherapy is usually of the order of 50 Sv, in a number of fractions

If you want to learn more about the risks of ionising radiation associated with common radiological investigations, you can visit the Radiation Tutorial that Smithy devised last year.

This message is for group B2.

Due to a massive cock-up in ward staff communication, I seem to have lost you. I was timetabled to teach you on the ward today at 2. I was called away urgently to see a CF patient in the clinic, so ‘phoned ahead to the ward to ask the ward staff to allocate patients for you to see. Then some 3rd years turned up for a different teaching session, were allocated your patients, and the junior doctors sent you away.

The juniors told me you were coming back at 3, so I taught the 3rd years, and waited for you. By 3:45 you had not turned up again, so I’ve given up and come back to my office.

Most unfortunate, all in all. I suspect you got the weekend itch, which is fair enough.

So, we should try to reschedule for next week.

Let me know when you’re free.

TCF

Whilst Jamie Oliver concentrates on getting school dinners back on the government’s agenda, I’ve been slaving away on some formative assessments for the upcoming second year respiratory block. There’s only three of them there just now, but it’s a start, and there’ll be more once I get around to writing them. Currently there are EMI questions, but we’ll expand that into MCQ, short answers, best of 5, that sort of thing. Hopefully this will become a useful bank of questions for you all. I know that one of the new 3rd year students is setting up a website dedicated to collating past paper questions, I’ll link to her site once she has it up and running.

Teaching the 5th years in the final gasp of their medical school career, the APART course last week ran them through some scenarios of acutely unwell patients. This was quite literally their last two hours of medical school before starting work in August and I was surprised at the sea of blank faces when they were faced with a COPD patient in type two respiratory failure.  The progressive (simulated) decline of the patient (accompanied by my now legendary impressions of “elderly confused woman” and “obstructed airway”) did little to trigger the request for non invasive ventilation. Comments like “ask ITU to keep an eye on them” did little to quell the rising panic in my little respiratory educationalist heart.  Once the topic of NIV was broached there remained an air of mild confusion and the whiff of misunderstood acronyms in the air. What is BiPAP, CPAP, NIPPV? Can’t you just tube them all?  I find myself relieved that the new and improved respiratory teaching for the second years will go some way to exposing our students to this most oft used and useful of therapies, but what of the students in the more senior years? DundeeChest 3.0 to the rescue….? When I find some useful web resources in this area I will post them, but I have to admit I’ve come up short so far.

Cross posted from my Doc-2-Doc blog.

I did a post take ward round on Monday. The usual mixture of general medicine, with little to excite the respiratory physician. A student commented that I had reviewed a whole bay of patients without the need for a stethoscope. This got me thinking – has the ancient art of auscultation died with my generation of physicians?

Does it matter if we can tell the difference between various murmurs when a portable echo can give us not only qualitative, but quantitative information with one bedside test. We hear fine crackles, an echo an an HRCT tell us what we need to know. 25 years ago our cardiologists taught us how to determine reverse splitting of the second heart sound, and to judge the severity of mitral stenosis from the delay before the opening snap. When was the last time you relied on that kind of clinical finding? Last month I saw a patient with a 5 cm pericardial effusion; there was no clinical indication of that diagnosis at all.
So what’s the point of all this? A senior colleague of mine has long said we should stop teaching our students auscultation, and teach them all bedside ultrasound rom an early stage. I have to agree with him about the ultrasound: we should be definitely be teaching these skills, and I have started teaching all our registrars, and ST grades the basics of thoracic ultrasound. But should we throw away our ‘tubes’? I don’t think so.
Rene Laennec invented the stethoscope on 1816, and it has served us well for nearly 200 years. Although the echocardiogram may have made listening to heard sounds “so last century”, there’s no test to detect bronchospasm, no scan to detect a pleural rub. So as chest physicians, we still need the ‘scope.

A non-physician friend of mine worked with HEMS in the 90’s – he tells me that the real reason we carry stethoscopes is for photo opportunities. What would Laennec say?

Thanks to everyone who made the effort to come along to the revision lecture on Wednesday – I appreciate that the week before the exams is a precious time, and two hours of me waving my arms about at the front of the class, being grumpy about hypoxic drive might not be your first choice of entertainment for Wednesday.

I have been told I was a little bit *too* grumpy, which is probably a fair piece of feedback – I was disappointed that the issues of Respiratory Failure, CO2 retention, and oxygen therapy remain the biggest stumbling blocks for you all, despite me having put in a lot of personal effort to explain these concepts to you all during the respiratory block.

After the lecture I taught a small group of 4th years on arterial blood gas analysis and respiratory failure. A small number of 2nd years tagged along (This is hugely rewarding for me, that 2nd years want to join in with 4th year teaching, so thanks) and it was during this session that I think I’m expecting too much regarding the respiratory failure, hypoxic drive issues: the 4th years have no more grasp of the concepts than the 2nd years. These *are* difficult concepts, and it is likely that the lack of understanding is due to poor teaching, rather than a global misunderstanding on the students part.

This has made me think about how I have been teaching these concepts. i have posted on DC1 and DC3.0 the definitions and explanations of the concepts of both CO2 retention in hypoventilatory states, the concepts of V/Q mismatch, and respiratory failure a couple of times, and each time I’ve tried to make them more understandable, and more straightfoward. I have had little feedback from the students regarding these posts. The videos are helpful, I’m sure, but the students are not getting it.

We have opportunities for students to do fellowships, SSCs, 4th year projects, and extra curricular work developing new learning materials, if anyone is interested.

So the revision lecture on Wednesday? My initial thoughts were of disappointment, and a small amount of despair. When I heard the feedback from a student that I was grumpy during the session, it has made me think more about not just the lecture, but how we teach these difficult concepts. Now? I’m hopeful that someone out there is encouraged enough to come to see me with an idea for a way to teach these topics in a more engaging way.

And I’m allowed to be grumpy occasionally – 365 days a year of manic enthusiasm takes it out on a person, even me!

After my recent careers focus talks, many people have asked me about the possibility of doing some research or audit within the chest department, and some are even interested enough to want to do an SSC or 4th year project with us! So I’ve started a page on the site to put all our current research interests together in one place. It’s in the student resources section, here.

Case of the week 4 is now up. A 66 year old man is referred to the psychiatry clinic for assessment of memory loss. If you want to know how this relates to respiratory medicine click here, or head over to the cases of the week section.

The Scottish Thoracic Society webpages have recently received a comprehensive overhaul. The new site should be easier to navigate, and give a more clear idea of what’s going on in the society.

The latest entry is the training program for the March 2010 session, on Lung Cancer in Stobhill.

Visit the STS site to learn more