AKC Lecture 9 Autumn 2008 , Physiology
How much science does your doctor need to know?
Medical education has been changing in the past 10-20 years; factual content being one of the most controversial areas. Pressures for change included:
1. Various scandals:
Bristol Royal Infirmary: paediatric cardiology scandal (1995)Concerns over high death rate ignored for nearly 10 years
Alder Hey (1998) and other hospitals had been retaining fetus and organs from children who had died without their parents consent.
Harold Shipman who was estimated to have killed about 250 patients between 1971 and 1998.
2. Popularity of alternative medicines suggesting patients felt there was something lacking in conventional medicine
3. Need to train doctors to specialist level more quickly.
How do go about deciding what should be in the medical curriculum and how and by whom it should be taught? Need to take into account:
• the rate of change of knowledge and understanding in medicine
• new understanding of old diseases
• new diagnostic techniques
• new treatments
• new diseases!
• changing patient expectations
Will what students learn at medical school be useful to their clinical practice today and will it still be relevant when they retire?
Against the backdrop of these and other pressures the General Medical Council were reviewing medical education: In 1993 it produced its recommendations in ‘Tomorrow’s Doctors’ which was revised in 2003.
Prof Peter Rubin is Chair of GMC Medical Education committee (‘Where’s the Femur? BBC Radio 4 1st January 2008): “There was a strong feeling that the curriculum was absolutely jam-packed with facts most of which doctors would never use and there was an increasing awareness that what concerned the public with doctors wasn’t that they did not know the precise course of the 12th cranial nerve but that they did not communicate well, they didn’t listen well and this theme came through again and again in concerns expressed by the public about doctors.”
The emerging view was that what was needed was to add training in some previously neglected areas e.g.:
ethics
communication skills
public health medicine
and to ‘trim’ elsewhere to produce a ‘Core Curriculum’, not just to make way for these topics but also ‘SSMs’
But exactly what should remain and how should it be taught? The GMC education committee offered little guidance on ‘core’. ‘The Education Committee does not itself have the range of expertise to enable it to define core content across all subjects even if it were thought desirable for it to do so’ Tomorrow’s doctors 1993
Medical schools have varied widely in their approaches to curriculum reform. Some have made radical changes in both the amount of information the students are required to know and also in the methods of delivering the curriculum.
Over the last 10 years many within universities, hospitals and Royal Colleges have expressed concern over some of the new teaching methods and that the scientific basis of medicine has been cut too much.More recently similar questions have been raised by members of the public.
Hazel (Where’s the Femur? BBC Radio 4 1st January 2008): “We were speaking to the senior registrar about my father’s treatment and he was going through the consultant’s notes and at one point he said‘Your father has lesions on his femur’ and then he said ‘I am not quite sure where the femur is but I think it’s the thigh’and he looked a bit confused and he looked up at the junior doctor who was also in the room with us and actually asked him did he know where the femur was. He shrugged and said‘No, I’m not sure’and to be honest it was even more concerning for us given that across the spectrum of training from the junior to senior registrar that the gap in training was so evident.”
KCL medical studentsare selected as caring, rounded, intelligent young people with good communication skills.
“I want to do Medicine because I am good at science and want to help people”
What will help these young people avoid the communication mistakes of the past?
In fact communication complaints are a bit disease dependent!
E.g.: My doctor’s were superb! My GP listened to my story and immediately recognised that I had a serious heart problem. I was admitted that day and the registrar carefully explained what the tests showed and the different options for treatment. They carried out an angioplasty which was very successful and that saved me from having a major heart attack’
Or alternatively:
I don’t think my doctor is really listening to me.I feel tired all the time and it’s really affecting my life. I get out of breath and I’ve lost my appetite.At first he just said it was ‘stress’ and I had been over doing it and I should take a week off work. Now he has given me these tablets but he has not really explained what they are for.
The second sort of encounter often occurs when the doctor is not sure what the problem is. He cannot communicate because he is unsure about what he should be communicating.
Diagnosis needs good communication skills
But also
Good communication requires a diagnosis and that you have an understanding of the patient’s condition.
If you are confused your communication will be confused.
Diagnosis is sometimes easy,E.g. When these diseases present in the usual way:Asthma,Angina,Myocardial Infarct (heart attack),Hip arthritis. Moreover we have very clear, evidence-based protocols for treating these conditions.
Here we are doing well (but lightly trained ‘barefoot doctors’ would do quite well here too!):
But in many conditions diagnosis may be much more difficult:
‘Figures from the Medical Defence Union (MDU) show that more than half of the settled claims brought against GPs in 2003 were for a delayed diagnosis.Diagnostic error accounted for 51% of all GP claims and 60% of all costs.’
‘Many patients with rare diseases, such as Kawasaki disease, myasthenia gravis and connective tissue disease, report not being diagnosed promptly or obtaining timely and meaningful support.’
Professor Mayur Lakhani, Diagnostic Error Under Scrutiny, hospitalmanagement.net 10th Sep 2007
‘Rare disease / funny presentation of a common disease syndrome’ is actually quite common!
Apart from missed diagnosis patients are likely to be less satisfied when the ‘label’ they have been given is for a condition that is generally poorly understood.Patients experience and satisfaction is likely to improve as out understanding improves. E.g.:
Ulcerative colitis: an unpleasant chronic disease with episodes of bloody diarrhoea and abdominal pain related to inflammation and ulceration of the colon lining.
In the 1930’s a series of papers reported a high prevalence (some reported 100%!) of psychological /psychiatric abnormalities in patients with Ulcerative Colitis. E.g.: ‘the disease tended to occur in a definite type of personality characterized by fearfulness and emotional immaturity, the latter trait demonstrated by lifelong dependence upon parents.’ (Brown et al 1938) “These findings appear to justify an attempt at psychotherapyfor selected early cases of ulcerative colitis.” Wittkower 1938
By 1970s the disease was thought to be largely ‘organic’ but my 1975 psychiatry textbook still thought that “Formal psychotherapy may be helpful in selective cases”
1982 Helzer et al: “we found no greater frequency of diagnosable psychiatric disorder in ulcerative colitis patients than in the control population”
Current situation:Ulcerative colitis as an autoimmune disease, incompletely understood but probably partly inherited, partly acquired. Treatment: Immune system modifying drugs, surgery.Psychological support to help cope with this distressing illness but not to ‘treat’ it.
How do you think the way ulcerative colitis patients view their doctors and their communication skills has changed?
Do you think the flawed view that ‘emotional immaturity’ and ‘lifelong dependence upon parents’ was part of the cause of this disease and its flare-ups helped or hindered effective communication with sufferers?
With increased understanding:
- Much better medicines to control the disease.
- Increased empathy and welcome loss of the burden of the disease being the fault of your flawed personality!
- Patients like doctors and doctors like patients more.
One of the diseases on that list of rare diseases often missed by GPs(Professor Lakhaniabove) was myasthenia gravis (MG).This disease of intermittent weakness was often diagnosed as ‘hysteria’ in the early part of the 20th century.
In 1934 Dr Mary Walker noticed the similarity of the symptoms of MG to those of curare poisoning where transmission from nerve to muscle is blocked. She tried physostigmine, a known antidote to curare poisoning, on her patients with remarkable benefit. She linked her clinical observations to her sound basic science background.
The better that we understand the better we communicate.
Our focus in medical education should be:
Better diagnosis of the diseases we do understand
Better understanding of the diseases we don’t yet understand.
We still have many conditions which are incompletely understood:
e.g. Chronic fatigue syndrome (ME)
Fibromyalgia
Chronic low back pain
Many other chromic pain syndromes
Gulf War syndrome
Attention deficit disorder etc.
We are not sure whether they are discreet ‘diseases’ or many different diseases
giving similar symptoms or maybe not physical diseases at all.
If we are confused, management and communication is likely to be too!
Question.How much science does your doctor need to know?
Answer. A lot and it needs to be well organised if we are to:
- maximise the chance if a correct diagnosis and good
treatment when things are less clear-cut
- maximise our progress in medicine
- answer our patients questions confidently
A house still depends on its foundations long after we have forgotten about what
wentinto them - the same is true of a house-officer! He or she depends on his or her
scientific foundations for good clinical practise and communication.
Glossary
GMC = General Medical Council. It oversees medical education in the UK
SSM = Special Study Module. A non-core module which students choose from a range on offer. They may be in a medical, basic science or unrelated subject such as a foreign language. The GMC stated in the 1993 Tomorrow’s Doctor that 1/3rd of the course should be SSMs (i.e. about 1.7 years!).
PBL = Problem Based Learning. In its purist form the students work in groups around a short clinical scenario aided by a facilitator who (even if he is able) is not allowed to ‘teach’. The students work out what they need to learn and work together to research and teach themselves the material. Unsurprisingly many less pure forms have emerged.
References
The Bristol Royal Infirmary Inquiry Final report
The Royal Liverpool Children's Inquiry (into the removal, retention and disposal of human tissues and organs)
Professor Mayur Lakhani, chair of the Royal College of General Practitioners. Diagnostic Error Under Scrutiny
Where’s the Femur? BBC Radio 4 1st January 2008 (no longer available on-line but I have a recording of this for anyone interested).
Tomorrow’s Doctors, GMC