THE WAY WE TEACH...
Paediatrics S. R. MEADOW
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S. R . Meadow, M A , BM, FRCP, DCH, D . O B S T . R C O G , is Senior Lecturer in Paediatrics and Consultant Paediatrician, Department of Paediatrics and Child Health, University of Leeds, 27 Blundell Street, Leeds LSl3ET, U K . Outpatient teaching is allocated more time i n the formal eight-week paediatrics programme than any other activity. Students in residence are required to witness as many procedures as possible and to be as active as they can in helping house officers to look after children. Ward teaching is conducted on the understanding that students have done the background work. Other components of the course are seminars, which utilize MCQs; projects, to be completed b y each student and presented to the rest of the firm; case conferences, which are difficult to organize and not very popular; sessions to improve communication, with videotaped recordings of interviews with simulated patients to encourage discussion. Students are asked to complete two questionnaires i n order to provide feedback. They are graded on their performance during the attachment. There is also a formal clinical examination with both internal and external examinations at theend of their appointment. Clinical teaching is a compromise between providing a service for patients and meeting the needs of students. Individual clinical teachers have to compromise further -with the university examination requirements, with other teaching departments, and with colleagues in their own branch of medicine. Few of us teach the way we would choose to teach ideally. T h e Stage of the Curriculum for Paediatric Teaching In common with most British medical students, those at Leeds have a paediatric course in their fourth year of training, the penultimate clinical year. They have already had 12 to 18 months of clinical medicine with adults. Paediatrics should be taught in either the penultimate or final year. Children are difficult to examine, and it is easier to learn to use a stethoscope, a sphygmomanometer or an ophthalmoscope on a cooperative adult than a fractious toddler. Similarly the paediatric interview and history taking can be an awkward three-way communication between parent, child Medical Teacher Vol 1 No 5 1979
and doctor -certainly more difficult than the doctorpatient dialogue of adult medicine. The disadvantage of having students comparatively late in their course is that the students may already have rather rigid attitudes and be less malleable. I would rather teach good habits than correct bad ones. Our students have eight weeks of full-time paediatrics. That period is either preceded or followed by eight weeks of obstetrics and gynaecology (with neonatology). The association with obstetrics is a logical and happy one. However, integration of the two eight-week periods into a combined 16-weekcourse would be a benefit for teachers, who would then repeat formal teaching three times a year instead of the present six times a year. Because of the large number of students, two separate paediatric courses are run in parallel at the two main hospitals. Each paediatric teacher is involved either entirely or mainly with just one of the courses. I teach those students who have their paediatric course at St James’s University Hospital; the other half of the medical intake have their paediatric course at Leeds General Infirmary. Aims and Objectives The main aim in training a doctor is to produce a thoughtful, capable and compassionate doctor who will be able to respond to changing future needs. Within one’s own area of work more specific objectives emerge which are a paediatrician’s responsibility simply because no other teacher in other parts of the medical course will be covering those areas in detail. We want students to know about: 1. The variable pattern of normal growth and development in its physical, emotional and social dimensions. 2. Child rearing practices and the influence of culture and environment upon them. 3. Disorders: a. which are common in childhood 237
b. which are specific to children c. which have a markedly different expression in childhood compared to adulthood. Specific treatment and management of the disorders has a small place; prevention and early detection are emphasized. 4. The health, education and social services available for children.
too, which provides a good opportunity for getting to know the students from the start. We do ask the students to wear name badges throughout the course to help us remember their names. I think that the badges also should specify ‘Clinical Student’ to avoid the misunderstanding that sometimes arises between patients and students.
The main skills which we wish students to acquire during their paediatric course are taking a history from a parent and a child, and examining infants and children competently and kindly. These skills are more important than any amount of theoretical knowledge.
Outpatient Teaching
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Introductory Week We arrange an introductory week aimed at welcoming the students, making them feel at home in the hospital, the paediatric wards and department, and teaching them and giving them practice in taking histories and examining children. During the first session the students are welcomed and given a 17-page booklet containing timetables, rotas for residence and clinics, information about the course, a two-page book list, and a piece by Professor Smithells, Head of the Department of Paediatrics and Child Health, about paediatrics, the aims of the course and the final examination. The main part of each day of the introductory week consists of a talk and demonstration in the morning, following which each student is allocated a child patient on the ward to examine. Later that day the students, in groups of three or four, present their findings to a tutor. Subjects covered on separate days in the first week are: 1. Taking a history from a parent and child. 2. Examination of a child under the age of one year.
3. Examination of a child over the age of one year. 4. Developmental assessment of a child under the age of
six years. The week is supplemented by introductory seminars on the use of growth and development charts, urine testing, immunization schedules, the organization of paediatric care and the facilities for children and families in hospital and the community. We sometimes have a full day in which the students assume the role of a nurse. They clock on for a full nursing shift, and are under the supervision of the senior nurse on each ward. Their duties are entirely nursingfeeding, changing and bathing children, helping with the medicine round, etc. The aim is to make students feel at ease on the wards and with children, as well as to understand the problems for nurses on a children’s ward. The success of that day depends largely on how busy the ward is and on the skill of the sisters or staff nurses in using the medical students as nurses. Professor Bevis and his obstetric colleagues at St James’s give a party on the first evening for each batch of new students. The paediatric department staff are invited 238
During the main course, outpatient teaching is allocated more time in the formal programme than any other activity (Table 1). It is sad that this area where teaching is of the greatest importance is the one where the needs of the patient and the needs of the student conflict most. Patients like to see doctors privately, and, as a doctor, I much prefer to talk to patients on their own, rather than surrounded by students and helpers. It was all very well for James Spence to pontificate about the ‘intimacy of the consulting room’ (Spence 1960). I wonder if he envisaged consultations taking place before an audience of trainee nurses, therapists and medical students? By the time you have added a social worker, a secretary and a helpful nurse, the consulting room looks like an interviewing panel. I limit the number of sitters-in to two, whether it be two nurses, two medical students or two helpers. I would prefer it to be one. I use outpatient teaching to discuss with the student: doctor-patient relationships, the art of history taking and the selectivity of examination. At the start of the session I ask the students where they think they ought to sit, where I and the patient ought to sit and who should sit on which chair, and why. Before seeing old patients I give them the briefest clinical detail, and subsequently refuse to discuss disease details with them. I tell them to look up facts of that nature in the textbooks and advise them which books to use. I do ask them, before the patient comes in, to note the things that are worrying the parents or child and to note the things that I misunderstand, the things that I do well and the things that I do badly. When the patient has gone I ask them for their comments and also ask them why I have asked a particular question or examined one part of the child and not another. I ask them to tell me how I could have better helped the patient. A select few new patients are interviewed and
Table 1. Paediatric undergraduate teaching at St James’s
University Hospital, Leeds. Hours per week ~
~
Outpatient clinics Ward teaching Clinical/study periods Seminars Project preparation Lectures and combined topic teaching Case conference -social paediatrics
7 6 4
3 3 2+ 1+
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examined first by a student before I see them. The students like this very much indeed; I hate it. I find it difficult to acquire subsequently a satisfactory feeling of intimacy and competence with the patients’ problems. I would like to sit in as a student at the outpatient teaching of some of my colleagues and see how they manage; but I never will, for teaching is done in private and we each assume that everyone else has a higher degree of competence than oneself. I do not have the same two students in my clinic each week. The theory is that all students should gain experience of as many different types of patients and as many different types of doctors as possible. This makes the students a little unsure of themselves each time they go to a new clinic, and it also makes effective communication between the doctor at the clinic and the students more difficult. I would prefer to have the same two students with me for a prolonged period. It does not matter that they would see ‘too many’ children with renal and urinary tract disorders, for disease details are not the central part of my outpatient teaching. Paediatric Residencies The students spend two separate weeks in residence at the hospital, two students being in residence at any one time. Their remit is to see everything that is going on. They should be bleeped when a child is admitted or whenever there is any activity on the children’s wards. They are asked to witness as many procedures as possible and to be as active as they can in helping the house officers to look after the children. They are asked to help the nurses and mothers to bathe, feed and play with the children. They are encouraged to talk with the living-in parents and the staff about the children. The value of the period of residence depends upon how much the house officers are willing to ‘bleep’(page) the students and use them. Our house officers have been particularly conscientious about this and have provided rich paediatric experience for the students. The fortnight of residence is the most popular part of the paediatric appointment. Ward Teaching There are four ward teaching sessions, but because some of the students are attending outpatient clinics the number of students at any session varies between five and eight. Each session is confined to the patients under the care of a single consultant; in that way the students know, for instance, that on Tuesday afternoons the patients who will be discussed are those who are under my care. Therefore there is no excuse for them not to be well informed about the patients, not to have talked to the parents and examined the child, and not to know about the treatment. I refuse to teach unless the students have done the background work. My ward teaching has two main aims. First, the teaching is about the child and the family, and the reasons why that child came into hospital. We discuss in depth how the child came, why he came, what his Medical Teacher Vol 1 No 5 1979
problem might be and how we can help the family. If there are physical signs, radiographs or other investigations to discuss, we do that too. We sit down in an area adjacent to the child and, in general, bring the mother and child into our discussion circle. Ward teaching is also about what goes on on a children’s ward and how we should behave as doctors. Therefore, anyone in trouble takes priority over our discussions. If a child is crying, someone goes off to comfort the child. If a baby needs changing, somebody changes the baby and then cuddles it until the baby is happy. If a parent is standing up looking lost, he or she is offered a seat and asked if we can help. In fact, I make a point of behaving on those ward rounds like the doctor I wish I was (and not like the one I fear I aml). I always hope for responsive, active groups of students. I like angry, excited students, and am bored with and resentful of placid ones who accept present-day medicine and hospitals as satisfactory.
The ‘It’Box We don’t have a swear box; instead any person who refers to a baby or child as ‘It’ has to put lop into the ‘It’fund. Anyone caught addressing a parent as ‘mother’or ‘father’ rather than Mr Smith or Mrs Smith, is fined 5p. A similar fine is made for not knowing which Christian name or abbreviation the child likes to be called by. Lectures and Seminars One afternoon a week is devoted to a two and a half hour session of theoretical teaching for a large group of students (40); they have two formal lectures or presentations complete with slides and other teaching aids. Several sessions are devised as combined teaching sessions with representatives from the basic sciences. Such ‘integrated teaching’ has many proponents. I always enjoy it for the first time, because I enjoy hearing the views and jokes of Professor X from -010gy. Repeating the teaching with the next lot of students four months later, I am less amused. Repeating it for the third time later in the year, I am not only less amused but embarrassed at Professor X having to hear my views for the third time too. It is bad enough hearing one’s own jokes for the third time, but it is positively cruel to be asked to inflict them on a respected colleague. The lectures might be more popular with the students if they were not given consecutively on the same afternoon. But, as with many other medical schools, we have problems in trying to get together a large group of students for a formal lecture.
Seminars Each group of 10 students has three seminars a week (conducted by three different tutors). We advertise the title of the seminar beforehand, e.g. ‘Physical growth’ or ‘Asthma’, and ask the students to read up the subject beforehand so that we can have a discussion rather than formal teaching. The amount of preparation by the students is variable and sometimes disappointing. Some
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seem to want to sit back with a notebook and write down everything that is said, as if they were at a formal lecture, which is a waste of small-group teaching. I have tried to get more audience participation by asking students to prepare material for the sessions. More recently I have been using multiple choice questions on the advertised subject, and at the start of the session give them a paper with 10 multiple choice questions on it and ask them to prepare their answers. Fifteen minutes later we meet and go through the answers. We do not discuss those questions which everyone answered correctly, but we spend considerable time on those questions where there is a difference of opinion or a lot of error. We have found that students learn best by dividing them into pairs and sending them into different rooms to complete the answers, so that they can argue with each other and arrive at a consensus. Answering the questions as a pair seems to provoke more interest than answering them in a larger group where I suppose the quieter person is able to remain silent if he wishes. The students enjoy this type of teaching, not only because it gives them practice at multiple choice questions but because they learn the limits of their knowledge. It forces them to think and they enter the subsequent discussion energetically.
Projects Each student is asked to complete a project during the eight-week course. The group is given a list of projects so that there is a choice for each student, though no two students are allowed to do the same project. We try to devise projects that force the student to talk to many parents of ill children or to talk to or examine many children (Table 2). We try to avoid projects which would cause students to spend more time in the library, or which could be completed by sifting through hospital notes or books. We also tell them not to spend too much time on the project, because it is not the most important part of the course. However, most students become quite interested in the project and make a good job of it. They are asked to write up their project on a maximum of four sides of paper (some of them get round this by writing so small that the whole result looks like one of Charlotte Bronte’s diaries). During the last week of the appointment each student presents his or her project to the rest of the firm during one of the seminar sessions. The time limit for the presentation is eight minutes, which is strictly adhered to. Students are encouraged to use audiovisual aids, and there is a prize for the best presentation. Each project is discussed in two parts: first the group discuss the quality of the spoken presentation and its audiovisual aids, then we move on to discuss the scientific and clinical aspects of the project itself. Case Conference The lecturer in community paediatrics together with the specialist health visitor attached to the university department conduct a weekly case conference with 20 240
Table 2. Projects. 1. Compare blood pressure measurement in young children by auscultation, flush and Doppler methods. 2. Correlate the plantar response with a . child’s age and walking ability. 3. What do parents know of their child’s illness? (Diagnosis, treatment, proposed length of stay, etc.) 4. From what age is clinical evaluation of the visual fields reliable? 5. Incidence and characteristics of functional heart murmurs in children. 6. The immunization status of children attending hospital (and reasons for omission of immunization). 7. The dismibution, number and size of bruises in children under five years. 8. Degree of bow-leggednessand knock-knee in toddlers. 9. Palpability of abdominal organs in childhood. 10. Cost to a family of having a child in hospital (travel, and gifts to the child). 11. Survey of teeth decayed, missing and filled in children attending hospital, related to age, illness and carbohydrate intake. 12. Incidence and nature of squints in hospital population. 13. The protein intake of children aged between one and five years, taking into account preparation of food, source of protein and social class. 14. Age at which children know their full name and address. 15. Variation in fontanelle size and skull circumference with age. 16. The Goodenough “Draw-a-man’’ test in children of varying ages. 17. Variation in respiratory rate with age in infants. 18. Age of establishment of laterality. 19. The things that children of school age most dislike about doctors and hospitals.
paediatric students. Twp students are briefed to investigate a paediatric patient and family, and it is suggested that they talk to those in the hospital and community who know that child and family. They visit the home, and sometimes talk to the health visitor and the general practitioner. A week later they present their findings, and the case is discussed with the group, calling in any other additional health visitors, social workers or therapists involved. These case conferences are difficult to organize. They are even more difficult to make popular with the students. A few students find them very interesting, and some students are particularly grateful for the opportunity to visit patients’ homes and to get to know the family in some depth. But the other 18 non-participating students are not so enthusiastic. One thing which students find difficult is the hopelessness of many of the situations. They want problems which have easy solutions and become resentful with the cycle of deprivation, unemployment and insoluble housing problems. (They are also Medical Teacher Vol 1 No 5 1979
resentful if any problems or solutions which they identify do not receive prompt attention by those in authority.) It would be better if the consultant officially responsible for the case were always able to be present at the case conference.
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Tape-Slide Machines We have a limited number of tape-slide programmes, mainly those produced very economically by TALC (The Foundation for Teaching Aids at Low Cost, Institute of Child Health, Guilford Street, London WClN IEH) (TALC 1979). We also use their inexpensive tape-slide machine. There is a different tape-slide programme for each week, together with a notice giving details of the programme. Most of the students use it but it is not popular. The students tend to find the programmes rather too long (the average length is about 30 minutes). I suspect that the ideal tape-slide programmes are ones which are very easy to use and do not last more than 10 minutes. Course in Communication
A weekly course in communication has been held during one of the seminar periods. I ran this in order to provoke discussion about doctor/patient relationships. After experimenting with several different methods, I ended up using videotaped recordings of simulated interviews to encourage discussion (Meadow and Hewitt 1972). Each student was told that he or she was playing the role of a locum House Officer. A number of actors and actresses had been trained in the role of worried parents, bereaved parents or angry parents of an ill child. ‘The House Officer’ was asked to deal with the parents. The interviews were recorded. The following week we would play back the videotaped interviews and discuss them. Although the individual students did learn things by which they might improve their powers of communication, the main purpose of these sessions was to get active discussion about communication problems in medicine. The recorded interviews provoked splendid discussion; some of the students became really excited by it and others quite aggressive. It was a stimulating teaching experience for students and teacher alike. Sadly, reorganization of the student timetable and the bringing forward of student exams has prevented the course from continuing. Communication problems need to be discussed throughout medical training, and I do not think it matters who does it, so long as it is someone who is concerned about the problems and interested in them. Clinical and Study Periods There are periods in the timetable which are not scheduled for formal teaching. The students are encouraged to spend most of this time on the wards, talking to parents and examining children, and less time in the library studying. Unfortunately, students seem to find libraries more exciting than wards.
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Time Off There is no formal programme on Wednesday afternoon or on Saturday or Sunday. Only the two students in residence have to be in hospital on those days. The paediatric teachers have students every week throughout the year, apart from brief breaks during bank holidays. Although I do not think that clinical teachers require as long vacations as other university teachers in which to re-charge their batteries, I have no doubt that I and most other medical teachers would teach better and more enthusiastically if we had periodic spells away from teaching. It is an ideal for which we should aim. Feedback The students have two questionnaires to fill in and a period of discussion with their tutor. The first questionnaire is a check list which we distribute at the beginning of the appointment, listing items which we think they ought to experience during the eight-week course and another list of items which they should try to cover if they can. These vary from technical procedures to specific illnesses (Table 3). More than half the students keep this list fairly conscientiously and hand it in at the end of the appointment. It is a help to see what they are actually experiencing or, for that matter, missing. The second questionnaire is about the appointment. Students are asked to score in terms of ‘usefulness to your medical education’ the 16 different items of the course. The four-page questionnaire asks in particular for frank comments about each of the following aspects of paediatric teaching: Ward teaching Residence Outpatient clinics Seminars Punctuality and reliability of teachers. There is plenty of space on the form for lengthy comments and in addition more space for ‘other comments, praise, suggestion or criticism’. Students need not identify themselves on the form if they do not want to. These forms are circulated to all their teachers and are most useful; first, in clearing up minor administrative problems of timetabling, and second, in correcting bad habits. If successive groups of students all complain about doctor Y being 20 minutes late for his teaching sessions, it is highly likely that when doctor Y has read that enough times he will alter his habits. It is a fairly painless way of correcting bad habits. My research into student assessment of teachers suggests that by far the most important factor for successful teaching is the personality of the teacher rather than the method of teaching or the subject that is being taught (Meadow 1970; 1978). Moreover, in a prospective long-term survey, I found that at the end of their paediatric appointment the students’ opinions about the merits and value of items of the course did not change significantly over a seven-year period when they were asked to give their opinion in retrospect about the teaching. The teaching they most valued as students was that which they most valued seven years later 24 1
Table 3. Paediatric check list.
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~
This leaflet contains a check list of procedures and conditions which you should do or see during your paediatric appointment. Please carry it with you at the time. It will help us if you record the date and place at which you saw a particular procedure, and hand back the completed-or part completed-leaflet at the end of the appointment. The maximum possible score is 120, but pass is 90. Please add any additional procedures which you found helpful to perform and observe and which you think should be added to the list. Procedures (Scoring 5 ) YOUshould DO the following: Date Place ...... ...... 1. Make up a baby's feed ...... ...... 2. Feed a baby ...... ...... 3. Change an infant's nappy ...... ...... 4. Bathe a baby 5 . Take a baby's blood pressure in ...... ...... arms and l e p by flush method 6. Perform a developmental assesment on a child between the ages of 6 months and 1 year, and record the details of the examination in the ...... ...... hospital notes 7. Examine an infected urine by ...... ...... microscopy 8. Administer medicinehablets to ...... ...... a young child in hospital Score . . . . . . . . . Pmcedurar (Scoring 2) You should OBSERVE as many of the following as possible: Date Venepuncture by external jugular ...... puncture Heel prick collection of capillary blood ...... ...... Setting up scalp vein infusion ...... Application of urine collection bag Suprapubic aspiration of urine ...... Lumbar puncture ...... Subdural tap ...... Ventricular tap ...... Physiotherapy, breathing exercises and postural drainage ......
Place
......
...... ...... ...... ...... ......
...... ...... ......
when well advanced in their clinical careers (Meadow 1978).
Examination and Assessment Every two months, at the end of the student's attachment, Professor Smithells holds a meeting for the paediatric teachers to discuss and assess the students. The aims are to identify those in need of extra help and to grade the students on their performance during the attachment. That grade contributes to their final mark in the MB examination. Leeds students have an obstetric and paediatric examination at the end of their appointment. It is their first formal clinical examination with both external and 242
Bone marrow aspiration Jejunal biopsy Renal biopsy Peritoneal dialysis Micturating cystogram Skin sensitivity testing Nasogastric tube feeding of an infant Cardiac catheterization Ipecacuanha induced vomiting of childhood poisoning Gastric lavage \ Administration of an enema
......
...... ...... ...... ......
......
......
......
......
......
......
...... ......
......
......
...... ......
...... ......
...... ......
......
Score.
.
, .
Conditions (Scoring 2) You should see and, if possible, examine a child with: Date ...... A fit (at the time of the fit) Otitis media ...... Acute tonsillitis ...... Croup ...... Pneumonia ...... Bronchiolitis ...... Asthma ...... Gastroenteritis ...... Infective hepatitis ...... Measles ...... Chickenpox ...... Whooping cough ...... Pyloric stenosis ...... Hydrocephalus ...... Spina bifida ...... Cerebral palsy ...... Leukaemia ...... Non-accidental injury ...... Coeliac disease ...... Cystic fibrosis ...... Score. .
Place
...... ......
...... ......
...... ...... ......
...... ...... ...... ......
...... ...... ...... ...... ......
...... ...... ...... ...... ..
Other pmcedurar
Totalscore..
........
internal examiners and is part of their final MB. It consists of two parts: 1. Written papers. One essay question, chosen from three options, has to be written. This is followed by a 45-minute multiple choice question paper, made up of 25 standard MCQs, each stem having 5 responses, each of which may be correct or false. 2. The clinical exam. Each student has a long clinical case to test his skill at taking a history from a parent and child and examining a child. That is followed by two or three short cases. Although examinations are of value to both students and teachers in assessingthe standard and knowledge, I regret that formal examinations occur in the penultimate Medical Teacher Vol 1 No 5 1979
clinical year and, in particular, that they occur at the end of the paediatric course. Towards the end of their paediatric appointment the students are more and more concerned with what is necessary for the exam; they do not want to be educated - they wish to be told how to pass the exam. I would prefer to have a simple assessment at the end of the paediatric course. For though I am a dedicated teacher of paediatrics, I am first a medical teacher and second a teacher of paediatrics. Acknowledgement Teaching courses develop from the ideas and energy of many different teachers, and blossom in an environment where criticism is happily received, innovation is welcome and initiative is given a long rein. I thank Professor Dick Smithells for creating that environment in his department.
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References Meadow, S. R . . Student assessment of clinical teaching, Guy’s Hospital Reports, 1970, 119,263-274. Meadow, S. R . , Student’s assessment of paediatric teaching and their opinions seven years later, Archives of Disease in Childhood, 1978, 53,
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Meadow, S. R. and Hewitt. C., Teaching communication skills with the help of actresses and videotape simulation, British journal of Medical Education, 1972,6,317-322. Spence, J . , The Purpose and Practice of Medicine, pp. 273-274, Oxford University Press, London, 1960. Teaching Aids at Low Cost, Medical Teacher, 1979, 1, 106-107.
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Paediatrics S. R. MEADOW
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S. R . Meadow, M A , BM, FRCP, DCH, D . O B S T . R C O G , is Senior Lecturer in Paediatrics and Consultant Paediatrician, Department of Paediatrics and Child Health, University of Leeds, 27 Blundell Street, Leeds LSl3ET, U K . Outpatient teaching is allocated more time i n the formal eight-week paediatrics programme than any other activity. Students in residence are required to witness as many procedures as possible and to be as active as they can in helping house officers to look after children. Ward teaching is conducted on the understanding that students have done the background work. Other components of the course are seminars, which utilize MCQs; projects, to be completed b y each student and presented to the rest of the firm; case conferences, which are difficult to organize and not very popular; sessions to improve communication, with videotaped recordings of interviews with simulated patients to encourage discussion. Students are asked to complete two questionnaires i n order to provide feedback. They are graded on their performance during the attachment. There is also a formal clinical examination with both internal and external examinations at theend of their appointment. Clinical teaching is a compromise between providing a service for patients and meeting the needs of students. Individual clinical teachers have to compromise further -with the university examination requirements, with other teaching departments, and with colleagues in their own branch of medicine. Few of us teach the way we would choose to teach ideally. T h e Stage of the Curriculum for Paediatric Teaching In common with most British medical students, those at Leeds have a paediatric course in their fourth year of training, the penultimate clinical year. They have already had 12 to 18 months of clinical medicine with adults. Paediatrics should be taught in either the penultimate or final year. Children are difficult to examine, and it is easier to learn to use a stethoscope, a sphygmomanometer or an ophthalmoscope on a cooperative adult than a fractious toddler. Similarly the paediatric interview and history taking can be an awkward three-way communication between parent, child Medical Teacher Vol 1 No 5 1979
and doctor -certainly more difficult than the doctorpatient dialogue of adult medicine. The disadvantage of having students comparatively late in their course is that the students may already have rather rigid attitudes and be less malleable. I would rather teach good habits than correct bad ones. Our students have eight weeks of full-time paediatrics. That period is either preceded or followed by eight weeks of obstetrics and gynaecology (with neonatology). The association with obstetrics is a logical and happy one. However, integration of the two eight-week periods into a combined 16-weekcourse would be a benefit for teachers, who would then repeat formal teaching three times a year instead of the present six times a year. Because of the large number of students, two separate paediatric courses are run in parallel at the two main hospitals. Each paediatric teacher is involved either entirely or mainly with just one of the courses. I teach those students who have their paediatric course at St James’s University Hospital; the other half of the medical intake have their paediatric course at Leeds General Infirmary. Aims and Objectives The main aim in training a doctor is to produce a thoughtful, capable and compassionate doctor who will be able to respond to changing future needs. Within one’s own area of work more specific objectives emerge which are a paediatrician’s responsibility simply because no other teacher in other parts of the medical course will be covering those areas in detail. We want students to know about: 1. The variable pattern of normal growth and development in its physical, emotional and social dimensions. 2. Child rearing practices and the influence of culture and environment upon them. 3. Disorders: a. which are common in childhood 237
b. which are specific to children c. which have a markedly different expression in childhood compared to adulthood. Specific treatment and management of the disorders has a small place; prevention and early detection are emphasized. 4. The health, education and social services available for children.
too, which provides a good opportunity for getting to know the students from the start. We do ask the students to wear name badges throughout the course to help us remember their names. I think that the badges also should specify ‘Clinical Student’ to avoid the misunderstanding that sometimes arises between patients and students.
The main skills which we wish students to acquire during their paediatric course are taking a history from a parent and a child, and examining infants and children competently and kindly. These skills are more important than any amount of theoretical knowledge.
Outpatient Teaching
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Introductory Week We arrange an introductory week aimed at welcoming the students, making them feel at home in the hospital, the paediatric wards and department, and teaching them and giving them practice in taking histories and examining children. During the first session the students are welcomed and given a 17-page booklet containing timetables, rotas for residence and clinics, information about the course, a two-page book list, and a piece by Professor Smithells, Head of the Department of Paediatrics and Child Health, about paediatrics, the aims of the course and the final examination. The main part of each day of the introductory week consists of a talk and demonstration in the morning, following which each student is allocated a child patient on the ward to examine. Later that day the students, in groups of three or four, present their findings to a tutor. Subjects covered on separate days in the first week are: 1. Taking a history from a parent and child. 2. Examination of a child under the age of one year.
3. Examination of a child over the age of one year. 4. Developmental assessment of a child under the age of
six years. The week is supplemented by introductory seminars on the use of growth and development charts, urine testing, immunization schedules, the organization of paediatric care and the facilities for children and families in hospital and the community. We sometimes have a full day in which the students assume the role of a nurse. They clock on for a full nursing shift, and are under the supervision of the senior nurse on each ward. Their duties are entirely nursingfeeding, changing and bathing children, helping with the medicine round, etc. The aim is to make students feel at ease on the wards and with children, as well as to understand the problems for nurses on a children’s ward. The success of that day depends largely on how busy the ward is and on the skill of the sisters or staff nurses in using the medical students as nurses. Professor Bevis and his obstetric colleagues at St James’s give a party on the first evening for each batch of new students. The paediatric department staff are invited 238
During the main course, outpatient teaching is allocated more time in the formal programme than any other activity (Table 1). It is sad that this area where teaching is of the greatest importance is the one where the needs of the patient and the needs of the student conflict most. Patients like to see doctors privately, and, as a doctor, I much prefer to talk to patients on their own, rather than surrounded by students and helpers. It was all very well for James Spence to pontificate about the ‘intimacy of the consulting room’ (Spence 1960). I wonder if he envisaged consultations taking place before an audience of trainee nurses, therapists and medical students? By the time you have added a social worker, a secretary and a helpful nurse, the consulting room looks like an interviewing panel. I limit the number of sitters-in to two, whether it be two nurses, two medical students or two helpers. I would prefer it to be one. I use outpatient teaching to discuss with the student: doctor-patient relationships, the art of history taking and the selectivity of examination. At the start of the session I ask the students where they think they ought to sit, where I and the patient ought to sit and who should sit on which chair, and why. Before seeing old patients I give them the briefest clinical detail, and subsequently refuse to discuss disease details with them. I tell them to look up facts of that nature in the textbooks and advise them which books to use. I do ask them, before the patient comes in, to note the things that are worrying the parents or child and to note the things that I misunderstand, the things that I do well and the things that I do badly. When the patient has gone I ask them for their comments and also ask them why I have asked a particular question or examined one part of the child and not another. I ask them to tell me how I could have better helped the patient. A select few new patients are interviewed and
Table 1. Paediatric undergraduate teaching at St James’s
University Hospital, Leeds. Hours per week ~
~
Outpatient clinics Ward teaching Clinical/study periods Seminars Project preparation Lectures and combined topic teaching Case conference -social paediatrics
7 6 4
3 3 2+ 1+
Medical Teacher Vol 1 No 5 1979
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examined first by a student before I see them. The students like this very much indeed; I hate it. I find it difficult to acquire subsequently a satisfactory feeling of intimacy and competence with the patients’ problems. I would like to sit in as a student at the outpatient teaching of some of my colleagues and see how they manage; but I never will, for teaching is done in private and we each assume that everyone else has a higher degree of competence than oneself. I do not have the same two students in my clinic each week. The theory is that all students should gain experience of as many different types of patients and as many different types of doctors as possible. This makes the students a little unsure of themselves each time they go to a new clinic, and it also makes effective communication between the doctor at the clinic and the students more difficult. I would prefer to have the same two students with me for a prolonged period. It does not matter that they would see ‘too many’ children with renal and urinary tract disorders, for disease details are not the central part of my outpatient teaching. Paediatric Residencies The students spend two separate weeks in residence at the hospital, two students being in residence at any one time. Their remit is to see everything that is going on. They should be bleeped when a child is admitted or whenever there is any activity on the children’s wards. They are asked to witness as many procedures as possible and to be as active as they can in helping the house officers to look after the children. They are asked to help the nurses and mothers to bathe, feed and play with the children. They are encouraged to talk with the living-in parents and the staff about the children. The value of the period of residence depends upon how much the house officers are willing to ‘bleep’(page) the students and use them. Our house officers have been particularly conscientious about this and have provided rich paediatric experience for the students. The fortnight of residence is the most popular part of the paediatric appointment. Ward Teaching There are four ward teaching sessions, but because some of the students are attending outpatient clinics the number of students at any session varies between five and eight. Each session is confined to the patients under the care of a single consultant; in that way the students know, for instance, that on Tuesday afternoons the patients who will be discussed are those who are under my care. Therefore there is no excuse for them not to be well informed about the patients, not to have talked to the parents and examined the child, and not to know about the treatment. I refuse to teach unless the students have done the background work. My ward teaching has two main aims. First, the teaching is about the child and the family, and the reasons why that child came into hospital. We discuss in depth how the child came, why he came, what his Medical Teacher Vol 1 No 5 1979
problem might be and how we can help the family. If there are physical signs, radiographs or other investigations to discuss, we do that too. We sit down in an area adjacent to the child and, in general, bring the mother and child into our discussion circle. Ward teaching is also about what goes on on a children’s ward and how we should behave as doctors. Therefore, anyone in trouble takes priority over our discussions. If a child is crying, someone goes off to comfort the child. If a baby needs changing, somebody changes the baby and then cuddles it until the baby is happy. If a parent is standing up looking lost, he or she is offered a seat and asked if we can help. In fact, I make a point of behaving on those ward rounds like the doctor I wish I was (and not like the one I fear I aml). I always hope for responsive, active groups of students. I like angry, excited students, and am bored with and resentful of placid ones who accept present-day medicine and hospitals as satisfactory.
The ‘It’Box We don’t have a swear box; instead any person who refers to a baby or child as ‘It’ has to put lop into the ‘It’fund. Anyone caught addressing a parent as ‘mother’or ‘father’ rather than Mr Smith or Mrs Smith, is fined 5p. A similar fine is made for not knowing which Christian name or abbreviation the child likes to be called by. Lectures and Seminars One afternoon a week is devoted to a two and a half hour session of theoretical teaching for a large group of students (40); they have two formal lectures or presentations complete with slides and other teaching aids. Several sessions are devised as combined teaching sessions with representatives from the basic sciences. Such ‘integrated teaching’ has many proponents. I always enjoy it for the first time, because I enjoy hearing the views and jokes of Professor X from -010gy. Repeating the teaching with the next lot of students four months later, I am less amused. Repeating it for the third time later in the year, I am not only less amused but embarrassed at Professor X having to hear my views for the third time too. It is bad enough hearing one’s own jokes for the third time, but it is positively cruel to be asked to inflict them on a respected colleague. The lectures might be more popular with the students if they were not given consecutively on the same afternoon. But, as with many other medical schools, we have problems in trying to get together a large group of students for a formal lecture.
Seminars Each group of 10 students has three seminars a week (conducted by three different tutors). We advertise the title of the seminar beforehand, e.g. ‘Physical growth’ or ‘Asthma’, and ask the students to read up the subject beforehand so that we can have a discussion rather than formal teaching. The amount of preparation by the students is variable and sometimes disappointing. Some
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seem to want to sit back with a notebook and write down everything that is said, as if they were at a formal lecture, which is a waste of small-group teaching. I have tried to get more audience participation by asking students to prepare material for the sessions. More recently I have been using multiple choice questions on the advertised subject, and at the start of the session give them a paper with 10 multiple choice questions on it and ask them to prepare their answers. Fifteen minutes later we meet and go through the answers. We do not discuss those questions which everyone answered correctly, but we spend considerable time on those questions where there is a difference of opinion or a lot of error. We have found that students learn best by dividing them into pairs and sending them into different rooms to complete the answers, so that they can argue with each other and arrive at a consensus. Answering the questions as a pair seems to provoke more interest than answering them in a larger group where I suppose the quieter person is able to remain silent if he wishes. The students enjoy this type of teaching, not only because it gives them practice at multiple choice questions but because they learn the limits of their knowledge. It forces them to think and they enter the subsequent discussion energetically.
Projects Each student is asked to complete a project during the eight-week course. The group is given a list of projects so that there is a choice for each student, though no two students are allowed to do the same project. We try to devise projects that force the student to talk to many parents of ill children or to talk to or examine many children (Table 2). We try to avoid projects which would cause students to spend more time in the library, or which could be completed by sifting through hospital notes or books. We also tell them not to spend too much time on the project, because it is not the most important part of the course. However, most students become quite interested in the project and make a good job of it. They are asked to write up their project on a maximum of four sides of paper (some of them get round this by writing so small that the whole result looks like one of Charlotte Bronte’s diaries). During the last week of the appointment each student presents his or her project to the rest of the firm during one of the seminar sessions. The time limit for the presentation is eight minutes, which is strictly adhered to. Students are encouraged to use audiovisual aids, and there is a prize for the best presentation. Each project is discussed in two parts: first the group discuss the quality of the spoken presentation and its audiovisual aids, then we move on to discuss the scientific and clinical aspects of the project itself. Case Conference The lecturer in community paediatrics together with the specialist health visitor attached to the university department conduct a weekly case conference with 20 240
Table 2. Projects. 1. Compare blood pressure measurement in young children by auscultation, flush and Doppler methods. 2. Correlate the plantar response with a . child’s age and walking ability. 3. What do parents know of their child’s illness? (Diagnosis, treatment, proposed length of stay, etc.) 4. From what age is clinical evaluation of the visual fields reliable? 5. Incidence and characteristics of functional heart murmurs in children. 6. The immunization status of children attending hospital (and reasons for omission of immunization). 7. The dismibution, number and size of bruises in children under five years. 8. Degree of bow-leggednessand knock-knee in toddlers. 9. Palpability of abdominal organs in childhood. 10. Cost to a family of having a child in hospital (travel, and gifts to the child). 11. Survey of teeth decayed, missing and filled in children attending hospital, related to age, illness and carbohydrate intake. 12. Incidence and nature of squints in hospital population. 13. The protein intake of children aged between one and five years, taking into account preparation of food, source of protein and social class. 14. Age at which children know their full name and address. 15. Variation in fontanelle size and skull circumference with age. 16. The Goodenough “Draw-a-man’’ test in children of varying ages. 17. Variation in respiratory rate with age in infants. 18. Age of establishment of laterality. 19. The things that children of school age most dislike about doctors and hospitals.
paediatric students. Twp students are briefed to investigate a paediatric patient and family, and it is suggested that they talk to those in the hospital and community who know that child and family. They visit the home, and sometimes talk to the health visitor and the general practitioner. A week later they present their findings, and the case is discussed with the group, calling in any other additional health visitors, social workers or therapists involved. These case conferences are difficult to organize. They are even more difficult to make popular with the students. A few students find them very interesting, and some students are particularly grateful for the opportunity to visit patients’ homes and to get to know the family in some depth. But the other 18 non-participating students are not so enthusiastic. One thing which students find difficult is the hopelessness of many of the situations. They want problems which have easy solutions and become resentful with the cycle of deprivation, unemployment and insoluble housing problems. (They are also Medical Teacher Vol 1 No 5 1979
resentful if any problems or solutions which they identify do not receive prompt attention by those in authority.) It would be better if the consultant officially responsible for the case were always able to be present at the case conference.
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Tape-Slide Machines We have a limited number of tape-slide programmes, mainly those produced very economically by TALC (The Foundation for Teaching Aids at Low Cost, Institute of Child Health, Guilford Street, London WClN IEH) (TALC 1979). We also use their inexpensive tape-slide machine. There is a different tape-slide programme for each week, together with a notice giving details of the programme. Most of the students use it but it is not popular. The students tend to find the programmes rather too long (the average length is about 30 minutes). I suspect that the ideal tape-slide programmes are ones which are very easy to use and do not last more than 10 minutes. Course in Communication
A weekly course in communication has been held during one of the seminar periods. I ran this in order to provoke discussion about doctor/patient relationships. After experimenting with several different methods, I ended up using videotaped recordings of simulated interviews to encourage discussion (Meadow and Hewitt 1972). Each student was told that he or she was playing the role of a locum House Officer. A number of actors and actresses had been trained in the role of worried parents, bereaved parents or angry parents of an ill child. ‘The House Officer’ was asked to deal with the parents. The interviews were recorded. The following week we would play back the videotaped interviews and discuss them. Although the individual students did learn things by which they might improve their powers of communication, the main purpose of these sessions was to get active discussion about communication problems in medicine. The recorded interviews provoked splendid discussion; some of the students became really excited by it and others quite aggressive. It was a stimulating teaching experience for students and teacher alike. Sadly, reorganization of the student timetable and the bringing forward of student exams has prevented the course from continuing. Communication problems need to be discussed throughout medical training, and I do not think it matters who does it, so long as it is someone who is concerned about the problems and interested in them. Clinical and Study Periods There are periods in the timetable which are not scheduled for formal teaching. The students are encouraged to spend most of this time on the wards, talking to parents and examining children, and less time in the library studying. Unfortunately, students seem to find libraries more exciting than wards.
Medical Teacher Vol 1 No 5 1979
Time Off There is no formal programme on Wednesday afternoon or on Saturday or Sunday. Only the two students in residence have to be in hospital on those days. The paediatric teachers have students every week throughout the year, apart from brief breaks during bank holidays. Although I do not think that clinical teachers require as long vacations as other university teachers in which to re-charge their batteries, I have no doubt that I and most other medical teachers would teach better and more enthusiastically if we had periodic spells away from teaching. It is an ideal for which we should aim. Feedback The students have two questionnaires to fill in and a period of discussion with their tutor. The first questionnaire is a check list which we distribute at the beginning of the appointment, listing items which we think they ought to experience during the eight-week course and another list of items which they should try to cover if they can. These vary from technical procedures to specific illnesses (Table 3). More than half the students keep this list fairly conscientiously and hand it in at the end of the appointment. It is a help to see what they are actually experiencing or, for that matter, missing. The second questionnaire is about the appointment. Students are asked to score in terms of ‘usefulness to your medical education’ the 16 different items of the course. The four-page questionnaire asks in particular for frank comments about each of the following aspects of paediatric teaching: Ward teaching Residence Outpatient clinics Seminars Punctuality and reliability of teachers. There is plenty of space on the form for lengthy comments and in addition more space for ‘other comments, praise, suggestion or criticism’. Students need not identify themselves on the form if they do not want to. These forms are circulated to all their teachers and are most useful; first, in clearing up minor administrative problems of timetabling, and second, in correcting bad habits. If successive groups of students all complain about doctor Y being 20 minutes late for his teaching sessions, it is highly likely that when doctor Y has read that enough times he will alter his habits. It is a fairly painless way of correcting bad habits. My research into student assessment of teachers suggests that by far the most important factor for successful teaching is the personality of the teacher rather than the method of teaching or the subject that is being taught (Meadow 1970; 1978). Moreover, in a prospective long-term survey, I found that at the end of their paediatric appointment the students’ opinions about the merits and value of items of the course did not change significantly over a seven-year period when they were asked to give their opinion in retrospect about the teaching. The teaching they most valued as students was that which they most valued seven years later 24 1
Table 3. Paediatric check list.
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~
This leaflet contains a check list of procedures and conditions which you should do or see during your paediatric appointment. Please carry it with you at the time. It will help us if you record the date and place at which you saw a particular procedure, and hand back the completed-or part completed-leaflet at the end of the appointment. The maximum possible score is 120, but pass is 90. Please add any additional procedures which you found helpful to perform and observe and which you think should be added to the list. Procedures (Scoring 5 ) YOUshould DO the following: Date Place ...... ...... 1. Make up a baby's feed ...... ...... 2. Feed a baby ...... ...... 3. Change an infant's nappy ...... ...... 4. Bathe a baby 5 . Take a baby's blood pressure in ...... ...... arms and l e p by flush method 6. Perform a developmental assesment on a child between the ages of 6 months and 1 year, and record the details of the examination in the ...... ...... hospital notes 7. Examine an infected urine by ...... ...... microscopy 8. Administer medicinehablets to ...... ...... a young child in hospital Score . . . . . . . . . Pmcedurar (Scoring 2) You should OBSERVE as many of the following as possible: Date Venepuncture by external jugular ...... puncture Heel prick collection of capillary blood ...... ...... Setting up scalp vein infusion ...... Application of urine collection bag Suprapubic aspiration of urine ...... Lumbar puncture ...... Subdural tap ...... Ventricular tap ...... Physiotherapy, breathing exercises and postural drainage ......
Place
......
...... ...... ...... ...... ......
...... ...... ......
when well advanced in their clinical careers (Meadow 1978).
Examination and Assessment Every two months, at the end of the student's attachment, Professor Smithells holds a meeting for the paediatric teachers to discuss and assess the students. The aims are to identify those in need of extra help and to grade the students on their performance during the attachment. That grade contributes to their final mark in the MB examination. Leeds students have an obstetric and paediatric examination at the end of their appointment. It is their first formal clinical examination with both external and 242
Bone marrow aspiration Jejunal biopsy Renal biopsy Peritoneal dialysis Micturating cystogram Skin sensitivity testing Nasogastric tube feeding of an infant Cardiac catheterization Ipecacuanha induced vomiting of childhood poisoning Gastric lavage \ Administration of an enema
......
...... ...... ...... ......
......
......
......
......
......
......
...... ......
......
......
...... ......
...... ......
...... ......
......
Score.
.
, .
Conditions (Scoring 2) You should see and, if possible, examine a child with: Date ...... A fit (at the time of the fit) Otitis media ...... Acute tonsillitis ...... Croup ...... Pneumonia ...... Bronchiolitis ...... Asthma ...... Gastroenteritis ...... Infective hepatitis ...... Measles ...... Chickenpox ...... Whooping cough ...... Pyloric stenosis ...... Hydrocephalus ...... Spina bifida ...... Cerebral palsy ...... Leukaemia ...... Non-accidental injury ...... Coeliac disease ...... Cystic fibrosis ...... Score. .
Place
...... ......
...... ......
...... ...... ......
...... ...... ...... ......
...... ...... ...... ...... ......
...... ...... ...... ...... ..
Other pmcedurar
Totalscore..
........
internal examiners and is part of their final MB. It consists of two parts: 1. Written papers. One essay question, chosen from three options, has to be written. This is followed by a 45-minute multiple choice question paper, made up of 25 standard MCQs, each stem having 5 responses, each of which may be correct or false. 2. The clinical exam. Each student has a long clinical case to test his skill at taking a history from a parent and child and examining a child. That is followed by two or three short cases. Although examinations are of value to both students and teachers in assessingthe standard and knowledge, I regret that formal examinations occur in the penultimate Medical Teacher Vol 1 No 5 1979
clinical year and, in particular, that they occur at the end of the paediatric course. Towards the end of their paediatric appointment the students are more and more concerned with what is necessary for the exam; they do not want to be educated - they wish to be told how to pass the exam. I would prefer to have a simple assessment at the end of the paediatric course. For though I am a dedicated teacher of paediatrics, I am first a medical teacher and second a teacher of paediatrics. Acknowledgement Teaching courses develop from the ideas and energy of many different teachers, and blossom in an environment where criticism is happily received, innovation is welcome and initiative is given a long rein. I thank Professor Dick Smithells for creating that environment in his department.
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References Meadow, S. R . . Student assessment of clinical teaching, Guy’s Hospital Reports, 1970, 119,263-274. Meadow, S. R . , Student’s assessment of paediatric teaching and their opinions seven years later, Archives of Disease in Childhood, 1978, 53,
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Meadow, S. R. and Hewitt. C., Teaching communication skills with the help of actresses and videotape simulation, British journal of Medical Education, 1972,6,317-322. Spence, J . , The Purpose and Practice of Medicine, pp. 273-274, Oxford University Press, London, 1960. Teaching Aids at Low Cost, Medical Teacher, 1979, 1, 106-107.
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