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