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How would you completely restructure medical education?

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    I was on a ward round with some 3rd years the other day and they were absolutely smashing all the renal physiology questions the consultant was throwing at them, but didn't have the first clue on how to read a chest x-ray

    I know I'm not the only one struck by how ass-backwards medical education can be. But I can never think about the right way to fix it.

    So, what would do? Change as much or as little as you like - how would you fix the system?
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    (Original post by Ghotay)
    I was on a ward round with some 3rd years the other day and they were absolutely smashing all the renal physiology questions the consultant was throwing at them, but didn't have the first clue on how to read a chest x-ray

    I know I'm not the only one struck by how ass-backwards medical education can be. But I can never think about the right way to fix it.

    So, what would do? Change as much or as little as you like - how would you fix the system?
    Make the practical stuff like reading x-rays compulsory experience. In biology A-level, this may be why they have the practical assessment, acknowledging how important it is.

    But if I could change the entire structure, hoo-boy, I wouldn't even know where to begin... One thing I'd do is make sure there are more opportunities for people wanting to become doctors - but I'm not sure how to do that. Currently, a lot of people want to become doctors, or so they think, yet demand is high for them. Obviously, it's the financial factor that's a problem. I wouldn't argue from the perspective of "imagine if there wasn't a financial factor" - cause when would that ever happen, right? Anyway, I would keep costs low, somehow, and provide more opportunities for these vital skills. Knowledge itself isn't going to save a patient who needs some serious surgery.
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    They're third years. Renal physiology is academic and their education thus far has been academic. Reading a CXR is largely clinical experience, of which they've only just started.

    Seems unsurprising to me.
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    (Original post by Ghotay)
    I was on a ward round with some 3rd years the other day and they were absolutely smashing all the renal physiology questions the consultant was throwing at them, but didn't have the first clue on how to read a chest x-ray
    Yeah, they're third years, what's the problem? If they'd been final years then sure...

    I think I've ranted incoherently on this topic many a time on other threads... which obviously won't stop me this time.

    a) Less memorisation. We live in the era of the internet - its not needed in all bar arrest calls pretty much. I'd even include use of the internet e.g. performing a simple literature search, as part of assessment criteria.
    b) Less BS portfolios. I never actually experienced this but I gather others spend ages on it. Pointless.
    c) More emphasis on presentations in clinical school and post-graduation. I think they're an excellent way to make clinical teaching evidence-based yet accessible and beneficial to the whole team including the consultants. Much better than the 'just do what the consultant does' approach that is still disappointingly prevalent currently, especially once you've graduated.
    d) Specialisation straight out of med school and graduation->consultant time of 4-5 years, like basically every other country in the world. Final year would need to be more internship-like but that's achievable.
    e) Stop the stupid practice of making doctors move every year or more. Training programs to be in a maximum of 2 centres unless there's an exceptional reason, or unless a doctor waives that right.
    f) Surgeons to no longer be medically trained, replaced with ward-based surgical doctors who decide when and when not to do surgery and specialist surgical technicians who actually perform said surgery.
    g) More emphasis on research in general, in training and beyond. Ths NHS setup and its huge information-gathering systems (for purposes of funding) are the ideal setting for loads of large-scale studies. Yet all the data gets wasted and even many simple questions don't seem to have an evidence base e.g. patient X has a PE but is on fragmin and fine. When do we send him home? Straight away? Two days? Longer? So easy to do a study yet the evidence out there is so flimsy.
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    (Original post by nexttime)
    Yeah, they're third years, what's the problem? If they'd been final years then sure...

    I think I've ranted incoherently on this topic many a time on other threads... which obviously won't stop me this time.

    a) Less memorisation. We live in the era of the internet - its not needed in all bar arrest calls pretty much. I'd even include use of the internet e.g. performing a simple literature search, as part of assessment criteria.
    b) Less BS portfolios. I never actually experienced this but I gather others spend ages on it. Pointless.
    c) More emphasis on presentations in clinical school and post-graduation. I think they're an excellent way to make clinical teaching evidence-based yet accessible and beneficial to the whole team including the consultants. Much better than the 'just do what the consultant does' approach that is still disappointingly prevalent currently, especially once you've graduated.
    d) Specialisation straight out of med school and graduation->consultant time of 4-5 years, like basically every other country in the world. Final year would need to be more internship-like but that's achievable.
    e) Stop the stupid practice of making doctors move every year or more. Training programs to be in a maximum of 2 centres unless there's an exceptional reason, or unless a doctor waives that right.
    f) Surgeons to no longer be medically trained, replaced with ward-based surgical doctors who decide when and when not to do surgery and specialist surgical technicians who actually perform said surgery.
    g) More emphasis on research in general, in training and beyond. Ths NHS setup and its huge information-gathering systems (for purposes of funding) are the ideal setting for loads of large-scale studies. Yet all the data gets wasted and even many simple questions don't seem to have an evidence base e.g. patient X has a PE but is on fragmin and fine. When do we send him home? Straight away? Two days? Longer? So easy to do a study yet the evidence out there is so flimsy.
    PRSOM. Agree so much with this
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    (Original post by Etomidate)
    They're third years. Renal physiology is academic and their education thus far has been academic. Reading a CXR is largely clinical experience, of which they've only just started.

    Seems unsurprising to me.
    It's unsurprising, but my point is that I think it's dumb. 99% of medicine requires no knowledge of renal physiology at all, but reading a CXR is a pretty basic and useful skill in any specialty. Why do we do it that way?
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    I certainly think clinical relevance of things should be taught alongside physiology a lot more, although I can only work from my own experience regarding how it was done where I studied. I spent a lot of time in clinical years going 'oh so THAT is why we learnt about XYZ', especially anatomy and physiology. Mostly I think I'd forgotten it all. I think knowing the relevance helps you retain and apply the knowledge to practical situations much better.

    The main big change I'd like to make would be to clinical placements. Hundreds of hours spent in a kind of suspended animation limbo sat at the back of clinic rooms, 'shadowing' endless ward rounds, generally lurking... and you're mandated to turn up to be signed off, unless you're bold enough to slack off and go on holiday, which certainly happened. It's like medical education is the greatest and most elaborate commitment to belief in the principle of osmosis.

    I spent most of my placements staring out of windows wondering what on earth I was doing with my life. There HAS to be some kind of drive to make clinical learning relevant and engaging, and perhaps an acknowledgement that just 'being' somewhere doesn't equal learning. Even if you try to engage yourself and force some benefit out of the hours of passive placement by asking questions, trying to be involved etc., the 'yield' of such learning is mostly miniscule and the effort required feels pretty endless.

    If the medical school are going to pay all these £££ to departments, the teaching organised should be dedicated time specifically for active teaching. In an ideal world. Certainly in places it happens! An hour of bedside teaching is worth days and days of randomly showing up to the wards to be a peripheral feature of some ward round, in terms of your education. Especially earlier on in clinics where there's more emphasis on learning the material and less on pretending to be an F1. That's what I think anyway! Clinical years sometimes felt interminable and whilst I learnt things, most of what I learnt I did in my own time or came from just a few hours in a whole week of showing up every single day.
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    (Original post by seaholme)
    I spent most of my placements staring out of windows wondering what on earth I was doing with my life.
    Definitely agree with this. Just shadowing on wards is very low yield.

    HOWEVER, there is a certain amount of IRL this is what its like kind of learning you need. My solution is more shadowing of juniors specifically when they are on call specifically, as this is when you get that kind of stuff the most. It seems to me that this is the time you're least likely to see students, when in reality (especially final year and as you're approaching FY1) its probably the best time to do this observing?
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    (Original post by nexttime)
    Definitely agree with this. Just shadowing on wards is very low yield.

    HOWEVER, there is a certain amount of IRL this is what its like kind of learning you need. My solution is more shadowing of juniors specifically when they are on call specifically, as this is when you get that kind of stuff the most. It seems to me that this is the time you're least likely to see students, when in reality (especially final year and as you're approaching FY1) its probably the best time to do this observing?
    Agreed!

    I have a theory that by final year you've sort-of reached ward placement burn out, largely because the previous years have felt like so much wasted time in places. So you try to use your time more productively and take more control of your own learning, which based on previous experience of poor learning outcomes from the wards does not equal spending time there.

    I think it comes back again to being actively pointed toward things which are known to provide high educational and experiential value. I agree if you got allocated some time to follow the on-call doctor instead of instructed to turn up and waft around with the ward round every day (although at least in final year you can get a bit more involved in the WR & probably should), that would make so much more sense on every level.
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    (Original post by seaholme)
    I have a theory that by final year you've sort-of reached ward placement burn out, largely because the previous years have felt like so much wasted time in places. So you try to use your time more productively and take more control of your own learning, which based on previous experience of poor learning outcomes from the wards does not equal spending time there.
    You have somehow managed to articulate everything I am feeling right now
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    Just to play Devil's advocate...

    Medical students will all learn to read chest x-rays, whether at medical school or shortly afterwards. In fact, some people might argue that the only way to interpret chest x-rays effectively* is to see lots and to actually need them as an adjunct when making decisions about a patient. This is difficult to do from the relatively detached position of a student. If students don't learn the fundamentals of renal physiology at medical school, they will probably never do so again. Although I've forgotten much/most of the physiology I learned at medical school, I do think that it has left me with a conceptual understanding of how the body works that I think we take for granted but is often missing from our patients.*Clearly there is a balance to be struck and I'm sure some medical schools fall too far one side or the other. *

    I absolutely recall the point at which I took charge of my own learning as a clinical student and realised that sitting through the same sleep apnoea clinic for eight weeks was not the most effective use of time...

    **A radiology SpR friend tells me that that more he learns about chest x-rays, the less confident he is about reporting them.
 
 
 
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