What is a disease flare in RA? A medical student’s perspective

Introduction: This guest article was written by Anca Smyth, who is currently a fourth year medical student at Queen’s University Belfast. She wrote an essay during her ‘special study component’ three week attachment in Altnagelvin hospital and later submitted it to the Irish Society for Rheumatology. Anca not only won the prestigious Bernard Connor Prize at the 2016 conference, but she was invited to present her paper to the Society. So congratulations to Anca and best wishes for the future! – Philip Gardiner

“When it comes to our health most of us are guilty of thinking that we are invincible. Imagine waking up one morning with excruciating pain, having stiff, swollen joints and weakness which markedly interfere with your ability to carry out the normal activities of daily living. To a rheumatoid arthritis (RA) sufferer such debilitating symptoms may constitute ‘a significant disease flare’, an episodic exacerbation of this chronic, symmetrical, small joint inflammatory condition. Or does it?

Unlike the ACR/EULAR classification criteria for RA [1] which is based on objective measurements of serological parameters, acute phase reactants, numbers and sites of swollen or tender joints and symptom duration, there has been no standard definition of what constitutes a RA flare or how it can be objectively assessed and classified according to severity. Apart from measuring the efficacy and safety of novel pharmacological agents used in the treatment of RA by means of randomised controlled clinical trials, a valid definition and classification of a flare would prove to be an invaluable tool in guiding clinical care and monitoring disease outcome.

When a patient is experiencing a flare, a significant increase in the disease activity so that it requires a change of treatment [2], there is often discrepancy in the interpretation of the severity of signs and symptoms between the doctor and the patient [3]. This may lead to inappropriate treatment, patient dissatisfaction and non-adherence to therapeutic interventions [4, 5]. Such discordance is due to the heterogeneous nature of the patient experience during this acute episode, which not only affects objectively measured clinical parameters but also generates self-reported symptoms such as pain, weakness, sleeplessness or fatigue [6, 7]. From the patient’s perspective the experience of a flare is also about functional impairment, disability and social participation [8, 9] which interfere with the patient’s quality of life and psychological well-being.

There is also variation between RA sufferers regarding what constitutes a significant disease flare. Reasons for this include the fact that patients report the severity of a flare according to their baseline disease activity and previous experiences with the disease [10], thus what seems a severe flare to an early RA patient may be classified as a normal fluctuation of disease activity by someone who has been living with this disease for an extended period of time. Additional factors in defining a significant flare include the level of a patient’s tolerance to worsening of signs and symptoms, health beliefs and coping skills [11, 12].

Current methods of assessing RA patients include measuring the disease activity in 28 joints using the DAS28 score and evaluating physical disability by means of a Health Assessment Questionnaire (HAQ28) and patient’s global health status by employing a 10cm Visual Analogue Scale (VAS).  However, none of these approaches are without flaws. Two of the main determinants of the patient’s global health are pain and fatigue [13], subjective symptoms which cannot be measured accurately and which are influenced by many factors including mental health status and co-morbidities [14]. Considering the ACR/EULAR disease remission criteria of a score of 1 or less on the patient’s global assessment scale of 0-10 such targets may be difficult to achieve accounting for the fact that many RA patients suffer from depression [15] or chronic pain syndrome [16].

The HAQ tool, limited by its ‘ceiling effect’ due to lack of adequate sensitivity in detecting a worsening of disability towards its upper limits or assessing lower limb function [17] does not accurately evaluate the severity of a RA flare. The DAS 28 score, a weighted composite of the number of swollen joints, level of the inflammatory marker ESR (erythrocyte sedimentation rate) and patient global assessment score is currently employed in clinical practice to classify disease activity, guide therapeutic treatment and function as an outcome measure in the treat-to-target approach [18]. Limitations of this approach include a misleadingly low DAS28 score if the flare predominantly affects the patient’s feet, which are not included in the DAS28 joint count, or if it is concentrated on a single joint, causing debilitating pain and rendering the patient unable to work. Conversely, a high DAS28 score based on a large number of swollen joints in the absence of pain or elevated ESR may initiate an unnecessary escalation in therapeutic treatment [19]. Some studies have used the inverse of the improvement criteria based on the DAS28 score to assess the severity of a flare but such a correlation seems inappropriate [20].

Given the complexity of patient experiences and heterogeneity of assessment tools that affect the interpretation of a significant disease flare, there is no ‘one size fits all’ approach to monitoring a flare. In an era of demedicalisation, there is an emphasis on treating the individual in the community, with medical care providers offering evidence based patient education and counselling regarding management of flares or side-effects of medication in the form of leaflets, telephone consultation with various members of the multi-disciplinary team or telecare services for people to report and be advised on their flares [21]. Such a model of care not only promotes self-efficacy and helps achieve an internal locus of control but it also increases accessibility and reduces travelling time for patients in the rural communities.

Since RA is a chronic condition, the patient may be the expert in monitoring their condition and self-management of a flare by means of non-pharmacological (such as exercise, bed rests, applying ice or heat packs or via complementary and alternative therapies) or pharmacological interventions (by increasing the dose of glucocorticoids, analgesics or non steroidal anti-inflammatory medication alongside a fixed-dose of disease modifying anti-rheumatic drugs) seems to be the approach employed by most RA sufferers [22]. There are times, however, when self-management of a flare is ineffective and the patient decides to seek medical help. Although the threshold at which such a decision is made is unknown, the doctor must adopt a holistic approach in assessing the patient and based on shared-decision making determine an appropriate change in treatment.

In conclusion, the concept of a significant disease flare in RA is complex, non-standardised and its interpretation depends on interplay between a patient’s physical and psychological parameters, previous disease experience and health beliefs. Monitoring of this acute episode should occur in the community, with health professionals providing ongoing patient education and counselling and facilitating timely review by the clinician when the patient seeks medical help.”

References

[1]. Aletaha D, Neogi T, Silman AJ, Funovits J, Felson DT, Bingham CO, Birnbaum NS, Burnester GR et al. 2010 Rheumatoid Arthritis classification criteria: an American College of Rheumatology/European League Against Rheumatism collaborative initiative. Arthritis and Rheumatism 2010; 62(9): 2569-2581.

[2]. Alten R, Pohl C, Choy EH, Christensen R, Furst DE, Hewlett SE, Leong A, May JE, Sanderson TC, Strand V, Woodworth TG and Bingham CO. Developing a Construct to Evaluate Flares in Rheumatoid Arthritis: A Conceptual Report of the OMERACT RA Flare Definition Working Group

[3]. Studenic P, Radner H, Smolen JS and Aletaha D. Discrepancies Between Patients and Physicians in Their Perceptions of Rheumatoid Arthritis Disease Activity. Arthritis and Rheumatism 2012; 64(9): 2814-2823.

[4]. Van den Bemt BJF, van den Hoogen FHJ, Benraad B, Hekster YA, van Riel PLC, van Lankveld W. Adherence Rates and Associations with Nonadherence in Patients with Rheumatoid Arthritis Using Disease Modifying Antirheumatic Drugs. The journal of Rheumatology 2009; 36: 2164-2170.

[5]. Matteo MR. Variations in patients’ adherence to medical recommendations: a quantitative review of 50 years of research. Medical Care 2004; 42: 200-209.

[6]. van Tuyl LHD and Boers M. Patient’s Global Assessment of Disease Activity: What Are We Measuring? Arthritis and Rheumatism 2012; 64(9): 2811–2813.

[7]. Kalyoncu U, Dougados M, Daures JP, Gossec L. Reporting of patient-reported outcomes in recent trials in rheumatoid arthritis: a systematic literature review. Annals of the Rheumatic Diseases 2009; 68: 183–190.

[8]. Benka J, Nagyova I, Rosenberger J, Marcejova Z, Lazurova I, van der Klink JL, Groothoff JW and van DijkJP. Social participation in early and established rheumatoid arthritis patients. Disability and Rehabilitation 2015; 19: 1-8.
[9]. Sverker A, Ostlund G, Thyberg I, Valtersson E and Bjork M. Dilemmas of participation in everyday life in early rheumatoid arthritis: a qualitative interview study. Disability and Rehabilitation 2015; 37(14): 1251-1259.
[10]. Seror R, Tubach F, Baron G, Guillemin F, Ravaud P. Measure of function in rheumatoid arthritis: individualised or classical scales? Annals of the Rheumatic Diseases. 2010; 69(1): 97–101.

[11]. Rohekar G and Pope J. Test-Retest Reliability of Patient Global Assessment and Physician Global Assessment in Rheumatoid Arthritis. The Journal of Rheumatology 2015; 36(10): 2178-2182.

[12]. Sanderson TC, Hewlett SE, Flurey C, Dures E, Richards P and Kirwan JR. The impact triad (severity, importance, self-management) as a method of enhancing measurement of personal life impact of rheumatoid diseases. The Journal of Rheumatology 2011; 38: 191-194.

[13]. Bartlett SJ, Bykerk VP, Cooksey R, Choy EH, Alten R, Christensen R, Furst DE et al.  Feasibility and Domain Validation of Rheumatoid Arthritis Flare Core Domain Set: Report of the OMERACT 2014 RA Flare Group Plenary. The Journal of Rheumatology 2015; 42(11): 2185-2189.

[14]. Barton JL, Imboden J, Graf J, Glidden D, Yelin EH and Shillinger D. Patient-Physician Discordance in Assessments of Global Disease Severity in Rheumatoid Arthritis. Arthritis Care and Research 2010; 62(6): 857–864.

[15]. Khan NA, Spencer HJ, Abda E, Aggarwal A, Alten R and Ancuta C. Determinants of discordance in patients’ and physicians’ rating of rheumatoid arthritis disease activity. Arthritis Care Research 2012; 64: 206–14.

[16]. Wolfe F, Michaud K. Severe rheumatoid arthritis (RA), worse outcomes, comorbid illness, and sociodemographic disadvantage characterize RA patients with fibromyalgia. J Rheumatol 2004; 31: 695–700.

[17]. Gardiner PV, Sykes HR, Hassey GA and Walker DJ. An evaluation of the health assessment questionnaire in long term longitudinal follow-up of disability in Rheumatoid Arthritis. British Journal of Rheumatology 1993; 32: 724-728.
[18]. Ward MM, Guthrie LC and Alba MI. Clinically important changes in individual and composite measures of rheumatoid arthritis activity: thresholds applicable in clinical trials. Annals of the Rheumatic Diseases 2013; 1: 205079.
[19]. Pincus T, Yazici Y and Sokka T. Quantitative measures of rheumatic diseases for clinical research versus standard clinical care: differences, advances and limitations. Best Practice and Research Clinical Rheumatology 2007; 21(4): 601-628.

[20]. Leeb BF, Sautner J, Leeb BA, Fassl C, Rintelen B. Lack of agreement between patients’ and physicians’ perspectives of rheumatoid arthritis disease activity changes. Scandinavian Journal of Rheumatology 2006; 35: 441-446.

[21]. National Institute for Health and Care Excellence. Commissioning for people with rheumatoid arthritis. NICE commissioning guides [CMG51], 2013.

[22]. Hewlett S, Sanderson T, May J, Alten R, Bingham CO, Cross M, March L, Pohl C, Woodworth T and Bartlett SJ. ‘I’m hurting, I want to kill myself’: rheumatoid arthritis flare is more than a joint count- an international patient perspective on flare where medical help is sought. Rheumatology 2012; 51:69-76.

The Rheumatologist, The Student, and the ever so humble Hashtag

hashtagsMany doctors are still sceptical about whether or not using Twitter is a sensible use of their time. I have to confess that before I started using it I had regarded it as little more than a written form of gossiping. For some well established academics with narrow interests and a network of colleagues who shun social media it may indeed be an unhelpful distraction. For others it may seem frustrating that even if one day they happened across a nugget of insight it would disappear from their sight like catching a snowflake. Some early adopters have been put off by finding that even though they may know a hundred colleagues in their specialty, very few of them were using Twitter and even fewer were tweeting about the things that interest you most. But the humble Hashtag has changed all that. Hashtags on twitter are words beginning with the character # and are highlighted in blue. If you click on them you will see an up to date listing on that topic. For the enlightened (or optimistic) medic, hashtags are like Pubmed keywords on steroids. You aren’t limited to any official MESH list of headings and following topics of interest is simple enough for everyone to use. And it can allow us to really filter the stuff that we look at.

The most obvious impact of hashtags among Rheumatologists has been their use to mark out the tweets from conferences e.g. adding #Rheum2014 somewhere in a tweet about the BSR Rheumatology meeting in 2014. If everyone is using the ‘official’ hashtag for the conference, then you will see all the tweets from the conference. This will help you to gain an insight into the sessions you aren’t able to attend and you can also use it to meet up with and get to know other doctors attending the conference (through face to face ‘tweet-ups’). tweetup2At the end of the conference you can collect up the interesting tweets using tools such as ‘Storify‘. But you need to be aware that tweets do ‘fall over the waterfall’ after a week and a general search will not be able to retrieve earlier tweets. This doesn’t matter too much for conferences where the hashtag becomes redundant a day or two after the event, but it can be an issue for tweets that arrive at an inconvenient time. Although the stream of tweets are only catching a tiny amount of what goes on at a conference, experienced users can often summarise the key points from presentations in three or four tweets.

In Rheumatology, we use a number of hashtags to filter content for different audiences/groups. For instance #rheum is mostly used by patients and is a popular general tag. I use it when sharing general information that the public might be interested in. Ronan Kavanagh nominated #rheumedu for more specialist tweets particularly for information that a specialist health professional/trainee specialist might want to view/keep. Keeping one eye on #rheumedu will allow you to quickly find out who is tweeting the sort of material you are interested in and build up the list of people you want to follow.

Why bother with a twitter hashtag for medical students learning musculoskeletal medicine?

I recently suggested that we should use #mskstu for collecting information of use to medical students. I hope that we can help our students by keeping this hashtag to help them track down the very best freely available teaching tips and resources on musculoskeletal medicine. I suppose it could be argued that even if Twitter is useful for professionals, it might still be a bad idea to encourage medical students to start using it. Students do need to maintain a tight focus on what they are learning throughout the course and may have been set a lot of background reading by their university. However, over the past year or two I’ve noticed that a lot more students are using Twitter and reading blogs – and at least part of the time they are using these sources for their studies. There are some great resources out there for students & if they want to use their initiative to learn in this way then I think we should encourage them. Hashtags are also useful for arranging online twitter ‘chats’, particularly if you want to engage with patient groups. You can combine a couple of hashtags in the same tweet e.g. #mskstu and #anatomy – but don’t overuse them!

Any app or program that you use to follow Twitter will have an option to search for a particular hashtag, usually listing results in a separate column. So if you have a column for #mskstu it will collect tweets using this hashtag. If you prefer a more visual presentation then Flipboard can be configured to have a section devoted to your favourite hashtag.


Storing the best tweets for posterity is currently not a straightforward task. One way to store your own personal tweets is to use IFTTT to set up a ‘recipe’ that automatically collects all of your tweets into Evernote. I’m still looking for a tool that would help to build up a teaching resource for students based on the #mskstu – something like ScoopIt can do for web pages, for instance. Your suggestions and ideas would be very welcome.

Other hashtag related resources you may find useful:

Twubs is a site that lets Twitter users form groups around popular hashtags. Hashtags are roughly categorised in a form of unofficial directory. This site could also be used to organise online chats.

Tagdef has columns of information about trending hashtags including “Top today,” “Top this week” and “All time high.” Click on any of the hashtags to learn more information, such as the user-provided definition and related tags.

The final arbiter of the usefulness of the #mskstu hashtag will be the students themselves. So please help get the word out there and contribute your own special teaching tips to help make it worthwhile!

 

 

What are we doing to make our service safer?

scaffold safetyI was speaking to a man recently who had worked all his life as a scaffolder. I asked him about advances in safety since the early days. He told me the story of when he worked on scaffolding 23 stories up on a building site in London many years ago. He seemed proud of the raw bravery you had to have in those days, but in hindsight he can’t believe the risks they took at work every single day. One day his foreman called him to join him on some work on the next floor. For some reason he didn’t go immediately and just a few minutes later his shocked workmate informed him that tragically the foreman had just walked over some loose boards and fallen 24 stories to his death. The scaffolder spoke about the incident as if it was yesterday and he still wonders why he hadn’t died that day. Safety regulations on building sites have dramatically reduced deaths and workmen these days wouldn’t dream of taking those risks. In the case of the health service, we as health professionals are not taking risks with our own safety but with that of our patients. So reducing risk – ‘first do no harm’ – should always be at the core of our professional integrity. In today’s uneasy climate it doesn’t take much to bring the great weight of ‘quality inspectors’ and intense media attention to bear on a hospital and its services. At the moment this level of scrutiny is still quite infrequent, and people may get the impression that patient safety is not embedded into routine practice. It is high time that we all started to reflect on what we are doing to improve patient safety and let people know what we’re doing. High risk specialties involving high risk surgery or obstetrics are well used to reporting deaths to confidential enquiry programmes such as ‘CEPOD’. In some cases, particularly in the U.S., these statistics are available to the public and not anonymised. In lower risk specialties such as Rheumatology the measures of safety and quality are harder to measure. The safety measures listed below are gradually being incorporated into routine practice. Here is a provisional list of some of the measures we currently use in our Rheumatology unit to promote patient safety:

  • We report serious drug adverse effects using the ‘Yellow card’ post marketing surveillance run by MRHA. This is a voluntary reporting scheme: some report more than others, but it can help to pick up problems that haven’t surfaced in the drug’s development. We also contribute to a national ‘risk registry’ for the newer biologic drugs (BSRBR).
  • Morbidity reporting for infusion reactions. In the past year we noticed quite a high incidence of allergic reactions in our unit to Iron Dextran infusions: following discussions with specialists and pharmacists we have changed to another preparation with a lower risk of reaction. None of the reactions were serious, but it is still a patient safety issue.
  • Clinical Incident reports – actual harm or near misses. Our hospital has a database for this and the risk management team rate incidents as green/yellow/red by risk level. We contribute to this, mainly for the more serious incidents. These incident reports are looked at centrally and there isn’t normally much discussion at a local level. It is therefore difficult sometimes to see whether anything changes when problems are identified.
  • In our unit, we have started holding regular ‘Mortality and Morbidity’ multidisciplinary meetings – using a clear unambiguous format. These meetings take place once a month and take a few hours to prepare and write up.
  • Multidisciplinary clinical discussions about unusual imaging reports or difficult diagnostic or treatment decisions. We have a good meeting with radiologists to discuss x-rays and scans, but we could probably do better in discussing difficult cases with our peers. It is very difficult to find a time when all clinicians are free.
  • We use (and helped to develop) agreed regional shared care guidelines for ‘disease modifying drugs’ which used to be thought of as drugs with a lot of side effects. We record in the notes that these have been issued with every prescription and we check that monitoring is carried out when patients attend clinics. In our system the General Practitioner or Family doctor has responsibility for monitoring blood tests. We try to record telephone calls for advice, but this is an area we can improve on, perhaps by using email more often. We also standardise patient information about these drugs – we give out booklets but make sure that the patient understands the most important issues.
  • We are responsible for monitoring blood tests for patients on biologics drugs – our pharmacist and specialist nurses take responsibility for this and use an agreed protocol.
  • When we conduct research, we adhere to ‘good clinical practice’ standards and the international statement of Helsinki. We are also regularly monitored by the Trust’s R&D department and have to provide annual reports. Each study has to have prior approval by a regional (and very detailed) ethics review body.
  • We have a discussion of major drug safety alerts or other safety alerts at our monthly multidisciplinary meeting.
  • We carry out regular audits – for instance, this year we looked at the accuracy of Methotrexate prescriptions in patients admitted to hospital. This has led to several proposals to help ensure that mistakes are reduced/identified before a patient can come to harm.
  • Each doctor who works in the unit has to undergo an annual appraisal. For consultants, this includes a review of statistics including mortality & a comparison with peers. There is also a discussion about any complaints, incidents or legal cases. Each doctor has to sign a probity and health statement. Every five years a doctor in the UK now has to undergo revalidation. This assessment has to include two confidential surveys about the performance of that particular doctor – one from patients  and the other from health professionals with whom they work.

This is not an exhaustive list, and it doesn’t mean that there aren’t areas in which we need to improve. For instance, we don’t yet use a clinical database, and we don’t have any link to the patient’s prescription list held by their GP. We don’t participate in a peer review programme – this doesn’t yet exist in our region. These are significant developments that may contribute to patient safety – but they have to be properly resourced and supported by our hospital’s management.

A Focus on Patient Safety: time to sharpen up our act!

There seems to be no end to medical scandals in the media. In the UK, the focus recently has been on the Francis Report into care at the Mid-Staffordhire NHS Foundation Trust. The report found that there had been a focus on targets rather than on patient safety and quality of care. A real concern was expressed about the apparent silence of medical staff in raising concerns about the problems. The recommendations of the Francis report are wide ranging, but it is a wake up call for health professionals to take ownership and responsibility for the safety of patients under their care. We need to ask serious questions about quality of care and be prepared to speak out to expose problems – even when we do not have a ‘managerial’ responsibility.

If you can spare an hour of your time, why not have a look at this video from the patient safety congress. Thanks to Anne Marie Cunningham (@amcunningham) for sharing it. The first talk is by Jeff Skiles, an experienced airline captain who recently had to ditch his plane into the Hudson river – the second is by a doctor who is trying to apply some of the lessons learned in aviation in the health care situation. Note that his co-captain Sully Sullenberger also lectures on aviation safety (@CaptScully).

At the recent NI Confederation conference in Londonderry (#NICON13 on Twitter) one of the speakers from the Southern Health Trust Hugh McCaughey gave us six safety questions every service should be asking of themselves.

  1. How can we prove that our service is safe?
  2. What are our team’s objectives?
  3. What would success look like to our team?
  4. Can you provide evidence that we are learning lessons as we go along?
  5. What do users think of our service?
  6. What outcomes are we achieving?

These are tough questions, but I think that it is a useful exercise. In the next series of posts I am going to look at each safety question in turn for our own service. I will be asking other members of the team to contribute to this discussion so that our final statement will be agreed by the team.

Why not teach ultrasound in medical school?

As a rheumatologist working in Northern Ireland, it is more or less expected that you should have developed some competency in performing ultrasound of the joints. Ultrasound training is now well embedded in the training programme for our Rheumatology SpRs, and this has perhaps been reflected in the very high ratings for trainee satisfaction in our region compared to the rest of the UK. Although most of us have embraced this new technology with enthusiasm and ‘gone back to school’ relearning anatomy and going on ultrasound courses, I can’t help feeling that the learning process would have been far easier had it been taught at medical school along with anatomy teaching. Using ultrasound not only challenges our in-depth knowledge of anatomy, but it can also help sharpen up our clinical examination skills. I often encourage students in clinic to examine a joint, declare exactly what they have found, and then I can test their findings using ultrasound and give them instant feedback.

Creative Destruction of Medicine
Creative Destruction of Medicine

Experience and clinical skill can help us a great deal, but even an experienced rheumatologist will get caught out from time to time!

Of course, Rheumatology isn’t the only application for ultrasound. Cardiologists were the first to embrace ultrasound and develop specific training courses. In emergency medicine, there is now a recognition that ultrasound can be invaluable for detecting a wide range of acute pathology e.g. intra-abdominal bleeding in a trauma situation. And quite apart from diagnostic use, ultrasound can help with gaining intravascular access, guiding liver biopsies and performing chest drains.

When I was trained in medical school, I was taught how to use a stethoscope in the same way as doctors had been for almost 200 years before me. I recognised that I couldn’t use this tool quite as well as a trained cardiologist, but as a screening tool it was still valuable. Now that portable and relatively affordable ultrasound is becoming available, should we not accept that in the near future most doctors will find some use for skills in ultrasound medicine? Out of hours in emergency situations when specialist ultrasonographers are not available, there are still many simple diagnoses that can be made by those with basic training. And what about screening for aortic aneurysm? At the moment this is patchy at best and many are still dying from ruptured aneurysms that could have been prevented. If we are to believe Eric Topol’s ‘Creative Destruction of Medicine’, we physicians are at risk of losing our ‘mastery’ of healthcare if we do not stay ahead of the game and adopt new technologies to make the most of our expertise. Topol describes how he, a well respected cardiologist, has set aside his stethoscope in favour of a smartphone sized ultrasound that allows him to diagnose simple valvular disorders. You can watch a YouTube video of the Vscan to see what he is referring to.

So it was with some excitement that I learnt that a medical school in South Carolina is actually incorporating ultrasound training into the medical school curriculum. Have you ever wished you could check your patient for an abdominal aortic aneurysm? Do you have twenty minutes to learn the basics about how to check for an abdominal aneurysm? Why not have a go and try the excellent basic course available online? It is currently available without charge and I think this is a great example of a clear and practical online course. Your scanning efforts probably won’t match those of a trained radiologist or vascular surgeon, but it will surely beat trying to diagnose an abdominal aneurysm using your fingers and a stethoscope! This course is provided by the ‘Society of Ultrasound in Medical Education’ who are trying to promote education in ultrasound among medical schools. There is also an enterprising group who have developed a series of online training courses in ultrasound for emergency medicine. You might argue that there is more than enough in the medical curriculum already. I would think that learning key skills should take priority over factual learning. Modern anatomy learning should surely now be based on the use of 3D imaging apps such as those from 3D 4 Medical, alongside dynamic ultrasound images and MR/CT images to supplement or replace the traditional textbook. This should help the student develop a better three dimensional and dynamic understanding of anatomy. A report on the four year experience of an ultrasound training programme for medical students in Carolina has recently been published – and the feedback from students was very encouraging. If they can achieve that in a four year programme, what is to stop our universities with five year medical courses from doing the same? app

The mark of a good doctor: The Caring Quotient (CQ)

What is the essence of a good doctor and how can we choose the right applicants at medical school?

The traditional way to choose doctors was mostly based on knowledge/memory tests. Choose the brightest students and you will get the best doctors, or so the theory went. However, there is a problem. Some very clever people have ended up as very poor doctors. Whilst it is likely that it will always be necessary to have and maintain a high level of learning in order to be a competent doctor, this is clearly not the whole picture. The general theory that IQ is the key to success has been undermined in recent years, and it has been clearly shown that there are other important aspects of intelligence that are not measured by IQ tests or tests of memory recall. Some would argue that today’s easy availability of vast data banks of knowledge will further erode the preeminent position of the learned doctor.

One area of active development has been to look at ways of testing for ’emotional intelligence’ or EQ. These theories are based on the work of a several psychologists over the past 50 years or so, particularly that of Daniel Goleman’s 1995 Book called ‘Emotional Intelligence’. His domains of EQ may be summarized as follows:

  • Knowing your emotions.
  • Managing your own emotions.
  • Motivating yourself.
  • Recognizing and understanding other people’s emotions.
  • Managing relationships, i.e., managing the emotions of others.

This does seem to make a lot of sense, but some have expanded the concepts to encompass such a broad sweep of ’emotional competencies’ that the term seems to lose all validity. To my way of thinking, desirable characteristics such as fairness or trustworthiness cannot be considered as subtypes of intelligence. Studies have shown a poor correlation between the EQ scores of employers and their employees’ assessments of their employer. A person with a high EQ will not always act with empathy/respect/fairness to the people around them although they should be in a good position to understand and practice these positive behaviours.

The media coverage of medicine in the UK over the past decade has been coloured by the dark shadow of Harold Shipman. A clever doctor who knew how to get patients to trust him (high IQ and EQ) but one who fundamentally lacked compassion for his patients. There has been a growing recognition that we need to take more care to recognize and weed out doctors like this but nobody seems to have any clear idea as to how this could be achieved. Appraisal, revalidation and multi-source feedback have been introduced but many feel that as currently set up it is not able to identify the next ‘Shipman’. Reflective practice is a good thing to encourage, but for many doctors their reflection relates mainly to their professional educational activities.

How can we encourage doctors to reflect more on the things that influence their quality of caring? I propose that it would help if we introduced the concept of a ‘caring quotient‘ to complement the IQ/EQ domains. We all recognize that doctors should be caring, but how much and in which situations? This could be tested by proposing challenging clinical situations and getting the opinions of a number of physicians as to what they would do in the same situation.

Is it possible to be TOO caring so that professional boundaries are crossed to the detriment of the patient or other patients under our care? Is it possible for a doctor to be very caring 90% of the time but ‘lose it’ from time to time? If this behavior is not a fixed characteristic it may be useful to consider it as a continuum that can vary, perhaps in predictable ways. Research has shown that, in general, doctors and healthcare workers tend to be biased against patients with alcoholism, dementia or the ‘heart-sink’ patient with the thickest file but the lowest rate of serious pathology. I have seen a number of medical errors over the years that have arisen because an alcoholic has not been accorded the same level of care and attention as others. Difficult behaviour by patients often provokes a negative reaction in us and if we don’t learn to recognize and compensate for this we will make mistakes. Some of our individual biases are so deeply ingrained that we will transgress again and again. I try and teach medical trainees to actively watch out for these biases – as I try to do – and change their behavior to compensate.

So, can a doctor actually learn to recognize situations or patients that ‘make their blood run cold’ and change their behavior accordingly? Doctors would benefit from building up a self-reflective narrative portfolio to include their reflections on difficult or challenging interactions with patients. We could hope that this would encourage more insight into where we are going wrong, where our ‘CQ’ was inappropriate for the particular situation we were faced with at the time. I have put together a mind map to begin to tease out some of the positive and negative factors that could affect a doctor’s ‘CQ’. This is a work in progress!

Computer gaming as a new paradigm for medical education

In a recent Tweet Eric Topol, guru of digital medicine and author of the acclaimed ‘Creative Destruction of Medicine’, called for the ‘Gamification‘ of medical devices. Could this person centered approach also be applied to medical education?

What would you like to do today?

Instead of expecting that everyone wants to learn, it might be better to assume that everyone enjoys having a bit of fun. The benefits of play based learning has been well established in young children – can we make it work for adults as well? Computer or console based gaming is now a hugely successful industry which involves the gamer in ever more ‘immersive’ scenarios. As games have become more sophisticated they have become more interactive and many of the popular games have an online component. If medical learning is to get heard above the hub-bub of sounds and images in the new digital world perhaps we need to learn and adapt – fast!

Where would you like to start today?

Education can be fun and interactive, but it should start at just the right level for the learner and then progress at the right speed so that the user doesn’t get bored by material that is too simple or overwhelmed by material well above their level. Just as a computer game has multiple levels, a medical education tool could have levels that are unlocked by entering a code or by completing some problems. If this flexibility was to be built into the interactive learning modules it would mean that potentially the same educational resource could be made available to everyone and material could be shared by students at different levels. Students, doctors, non-medical health professionals and the general public would be able to tailor the material to their needs and contribute. The main aim of this would be to encourage participation rather than to restrict involvement e.g. to members of a professional club. The student should be able to dip in and return where they left off – the computer will record everything they have done. The huge success of the online maths ‘Khan academy’ has shown how this can be used to show the student and/or their tutor how much time they have spent on the system watching videos or working out problems and identifying areas of learning need more work/help.

How do you want to learn today?

Some people prefer text, others may prefer images or video. Some will have ‘gaps’ in their education which they would like to address to help them understand the more complex material more effectively. So why shouldn’t the learner be able to pick out their choices from a ‘menu’ of options? They could use the developer’s description of the material and view the ratings of other users. They could even choose to follow the menu choices of another user from a similar educational background. This way of exploring the educational ‘menu’ would be unique to them and their tastes, although at intervals a ‘waiter’ type advisor could prompt them with suggestions as to how they could progress.

What level of certification do you want to achieve?

The same open-source resource could be used to just give people information for answers to a specific question or problem – or form a module or even a major part of a university level degree. Employers are still likely to require some evidence of an adequate standard of learning before they will employ someone in the health service/industry. Open source models can seem unrealistic because of the financial risk, but if they prove popular there may well be a viable financial model. This could be based on online revenue, but in the early stages the revenue stream could be through tried and tested University e-Learning models. The ‘paid’ part of the resource – provided through a University – would provide personal support (tutors, face to face sessions etc.), practical sessions with the aim of leading to a validated stand alone certification. This could be a module toward a postgraduate MSc in Rheumatology for GPs or Allied health professionals or be used to provide approved CPD in Rheumatology for specialists.

Who do you want to learn with?

The majority of children and adults in Europe and the US now spend a lot of their time using the internet, and the explosion in usage of social media and youtube shows that people not only like to view images and  video but they also love to share their personal experience and discoveries with others. In one sense, they are ‘educating’ their network of friends – perhaps about what sort of person they are or what they like or find interesting. This reminds me of how students in Harvard University can ‘pick and choose’ their lecturers by asking other students to find out who the most popular ones are. If learners using the module are encouraged to do the course with others they know (who may be in geographically distant location) they may have more incentive to participate and contribute. Participants can help each other – some sites give members points or stars for posting comments and additional stars for giving good advice to others. In the case of ‘World of Warcraft’ over 11 million users invest on average 22 hours per week hours gaming, resulted in a massive Wikipedia resource. I would guess that usage of ‘Modern Warfare 3’ and similar games is similar: type in ‘modern warfare’ and YouTube into Google and you get over 380 million videos. That’s a lot of educational material!

These points and more are well illustrated in this infographic by Knewton:

Gamification of Education

Created by Knewton and Column Five Media