The view from here
Do we teach medical students acute care skills? Alexander Carpenter, Severn Deanery, Bristol, UK Reshad Khodabocus, Emergency Medicine, Mid Yorkshire NHS Trust, UK The concepts and skills fundamental in this setting were new to me
W
hat, I wonder, are most newly qualified junior doctors most afraid of on our first day at work or our first night shift? Is it the performance of a thorough history and examination, detecting signs and symptoms of chronic disease? Or is what we fear most having to manage an acutely unwell and distressed patient in whom the diagnosis may be unclear, who may be unable to give a history and may be visibly deteriorating? There is an abundance of competing information: blood pressure, abdominal examination and the computerised tomography (CT) scan from yesterday. As well as an endless range of possible actions: give oxygen, insert a
cannula, perform an electrocardiogram (ECG) or take bloods. All of which seem somehow necessary. How do we organise our thoughts and actions? My first Foundation Year 1 (FY1) post was in the Emergency Department. I was able, with supervision, to assess and manage acutely unwell patients in the resuscitation room. The concepts and skills fundamental in this setting were new to me – I had to learn them on the job. Representative of my peers, I had graduated after 5 years of medical school as a clinician ill-equipped in the recognition and management of the acutely unwell patient.
We are taught how to manage system-specific conditions: cardiovascular emergencies and the acute exacerbation of chronic obstructive pulmonary disease (COPD). In reality, however, such patients can often best be described as ‘the breathless patient’ or ‘the unrousable patient’, and it becomes inconveniently difficult to decide which ‘systems’ box they fall into. Do we expect junior doctors to perform multiple, full-system examinations, or accept that there is a separate, different way of assessing acutely unwell patients in a focused and timely manner? If the answer to this second question is yes, then what is this
148 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 148–149
tct_12096.indd 148
3/5/2014 5:27:35 PM
examinations provides a grounding in the basics of recognising disease. Medical undergraduates need to go beyond this, integrating systems-based thinking with patient presentations. We need to ingrain the fundamental principles of dealing with acutely unwell patients into the undergraduate curriculum, rather than treat it as an afterthought. Finally, we need to appreciate that the approach to such patients should be taught as a generic framework, one that helps us to do our job in the real world, and that features in all modern resuscitation training: ABCDE.3 system, and more importantly, when should we learn it? One of the first and foremost duties of a doctor is to manage acutely unwell patients. Yet we relegate the education of this vital skill to the shadowing period and 1- or 2–day postgraduate courses. Evidence exists that junior doctors handle acute care situations sub-optimally. The 2005 National Confidential Enquiry into Patient Outcome and Death found serious failings in the recognition and management
of acutely unwell patients by junior doctors.1 A 2007 systematic review published in the Journal of Intensive Care Medicine concluded that both medical students and junior doctors ‘lack knowledge, confidence and competence in all aspects of acute care, including the basic task of recognition and management of the acutely ill patient’.2 Learning how to perform systems-based history taking and
Medical undergraduates need to integrate systems-based thinking with patient presentations
REFERENCES 1.
Cullinane M, Findlay G, Hargraves C, Lucas S. NCEPOD 2005: An Acute Problem. Available at http:// www.ncepod.org.uk/2005aap.htm. Accessed on 8 June 2013.
2.
Bion JF, Bullock I, Perkins GD, Smith CM. Undergraduate training in the care of the acutely ill patient: a literature review. Intensive Care Med 2007;33:901–907.
3.
A systematic approach the acutely ill patient. Resuscitation Council (UK), 2005 Available at http:// www.resus.org.uk/pages/alsabcde. htm. Accessed on 8 June 2013.
Corresponding author’s contact details: Alexander Carpenter, Severn Deanery, Severn Post Graduate Medical Education, Deanery House, Vantage Business Park, Old Gloucestershire Road, Hambrook, Bristol, BS16 1GW, UK. E-mail: [email protected]
Funding: None. Conflict of interest: None. Ethical approval: Not applicable. doi: 10.1111/tct.12096
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 148–149 149
tct_12096.indd 149
3/5/2014 5:27:42 PM
Do we teach medical students acute care skills? Alexander Carpenter, Severn Deanery, Bristol, UK Reshad Khodabocus, Emergency Medicine, Mid Yorkshire NHS Trust, UK The concepts and skills fundamental in this setting were new to me
W
hat, I wonder, are most newly qualified junior doctors most afraid of on our first day at work or our first night shift? Is it the performance of a thorough history and examination, detecting signs and symptoms of chronic disease? Or is what we fear most having to manage an acutely unwell and distressed patient in whom the diagnosis may be unclear, who may be unable to give a history and may be visibly deteriorating? There is an abundance of competing information: blood pressure, abdominal examination and the computerised tomography (CT) scan from yesterday. As well as an endless range of possible actions: give oxygen, insert a
cannula, perform an electrocardiogram (ECG) or take bloods. All of which seem somehow necessary. How do we organise our thoughts and actions? My first Foundation Year 1 (FY1) post was in the Emergency Department. I was able, with supervision, to assess and manage acutely unwell patients in the resuscitation room. The concepts and skills fundamental in this setting were new to me – I had to learn them on the job. Representative of my peers, I had graduated after 5 years of medical school as a clinician ill-equipped in the recognition and management of the acutely unwell patient.
We are taught how to manage system-specific conditions: cardiovascular emergencies and the acute exacerbation of chronic obstructive pulmonary disease (COPD). In reality, however, such patients can often best be described as ‘the breathless patient’ or ‘the unrousable patient’, and it becomes inconveniently difficult to decide which ‘systems’ box they fall into. Do we expect junior doctors to perform multiple, full-system examinations, or accept that there is a separate, different way of assessing acutely unwell patients in a focused and timely manner? If the answer to this second question is yes, then what is this
148 © 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 148–149
tct_12096.indd 148
3/5/2014 5:27:35 PM
examinations provides a grounding in the basics of recognising disease. Medical undergraduates need to go beyond this, integrating systems-based thinking with patient presentations. We need to ingrain the fundamental principles of dealing with acutely unwell patients into the undergraduate curriculum, rather than treat it as an afterthought. Finally, we need to appreciate that the approach to such patients should be taught as a generic framework, one that helps us to do our job in the real world, and that features in all modern resuscitation training: ABCDE.3 system, and more importantly, when should we learn it? One of the first and foremost duties of a doctor is to manage acutely unwell patients. Yet we relegate the education of this vital skill to the shadowing period and 1- or 2–day postgraduate courses. Evidence exists that junior doctors handle acute care situations sub-optimally. The 2005 National Confidential Enquiry into Patient Outcome and Death found serious failings in the recognition and management
of acutely unwell patients by junior doctors.1 A 2007 systematic review published in the Journal of Intensive Care Medicine concluded that both medical students and junior doctors ‘lack knowledge, confidence and competence in all aspects of acute care, including the basic task of recognition and management of the acutely ill patient’.2 Learning how to perform systems-based history taking and
Medical undergraduates need to integrate systems-based thinking with patient presentations
REFERENCES 1.
Cullinane M, Findlay G, Hargraves C, Lucas S. NCEPOD 2005: An Acute Problem. Available at http:// www.ncepod.org.uk/2005aap.htm. Accessed on 8 June 2013.
2.
Bion JF, Bullock I, Perkins GD, Smith CM. Undergraduate training in the care of the acutely ill patient: a literature review. Intensive Care Med 2007;33:901–907.
3.
A systematic approach the acutely ill patient. Resuscitation Council (UK), 2005 Available at http:// www.resus.org.uk/pages/alsabcde. htm. Accessed on 8 June 2013.
Corresponding author’s contact details: Alexander Carpenter, Severn Deanery, Severn Post Graduate Medical Education, Deanery House, Vantage Business Park, Old Gloucestershire Road, Hambrook, Bristol, BS16 1GW, UK. E-mail: [email protected]
Funding: None. Conflict of interest: None. Ethical approval: Not applicable. doi: 10.1111/tct.12096
© 2014 John Wiley & Sons Ltd. THE CLINICAL TEACHER 2014; 11: 148–149 149
tct_12096.indd 149
3/5/2014 5:27:42 PM
