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					UNIVERSITY OF BRISTOL MEDICAL SCHOOL
Academic Unit of Primary Health Care

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GP Teachers Workshop for and 3rd Year Clinical Skills Courses

Bristol Conference Centre Shirehampton 17th May 2005
Report by David Memel Chris Salisbury and Liz Anderson

Introduction
Welcome to the report of the May 2005 workshop for GP Teachers teaching on the 2nd and 3rd Year Clinical Skills courses. We hope it will be a helpful reminder to those who attended (and can be kept for GP Appraisal purposes), and have useful information and teaching hints for those who did not. We were particularly pleased to welcome GPs who were be teaching on these courses for the first time as teaching expands in the Clinical Academies outside Bristol. This year the programme consisted of:      Overview and feedback on both courses Teaching in the Clinical Academies Teaching of Mental Health in Primary Care Demonstration of teaching sessions and discussion with current students on the Clinical Skills courses Useful hints on teaching on these courses

Overview of 2nd Year Course (Basic Clinical Skills)
David Memel
This course is the only clinical part of the 2nd year course Aims of the course are:      Develop medical history taking, physical examination, and communication skills Integration of basic science with clinical medicine Understand concept of ‘whole patient’ Feel comfortable with patients in hospital and general practice environment Be prepared for different clinical specialities within the third year

The course is mainly taught at the University and local hospitals in Bristol Weston and Bath with a half day sessions in general practices on Thursday mornings or afternoons. The benefits of the GP teaching are:     GPs have generalist clinical skills Plenty of available patients GPs have protected time for teaching Access to clinical problems that are seen commonly in general practice but not in hospital

The teaching is systems based. Each weeks teaching is repeated in successive weeks to cope with the large numbers of students. Timing of sessions are:     October: December: February: May: Cardiovascular Respiratory Abdominal (Gastrointestinal and Renal) Neurology and the Whole Patient

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In a typical teaching session two or three patients are invited up with good histories or examination findings relating to the the body system(s) of the week. GP Teachers also had

an important role in formative assessment and feedback to students which is formalised in the final week, as they have regular contact with the same small group of students over the year. This is particularly important both for early identification of
the few students who are having problems with clinical medicine, so they can be given extra support, and to reassure the majority of students who are doing well. Student feedback from this years course was presented. As in previous years they had rated the GP component of the course the highest, particularly valuing the opportunities for supervised small group learning with patients in a supportive environment. However the hospitals were rapidly catching up.
Hospital GP Commun Skills

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Organisation of Teaching Delivery of Teaching Opportunity to Practice Skills Usefulness of Feedback/Appraisal

Particularly pleasing were the high scores from Bath Academy which had only started teaching students on this course this year, and South Bristol Academy which had put a lot of effort into improving the quality of teaching at the BRI. This year we will be sending individualised feedback to GPs who have taught on the course. Changes for 2005-2006:     In the coming academic year there would be 310 students on the course instead of 260, for a single year only. The expansion would be accommodated at North Bristol and Bath. This would mean that most practices need to continue to teach each block twice. Practices might want to encourage extra doctors in the practice (such as salaried doctors and new partners) to get involved in teaching on this course.

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Overview of 3rd Year Course
Chris Salisbury
This course develops from the Basic Clinical Skills Course but with a greater emphasis on problem formulation and diagnosis. Aims of the course:     To develop clinical skills (history taking, examination and diagnosis) to enable diagnosis of common clinical problems. To appreciate differences between approach to history taking and diagnosis/problem formulation in primary and secondary care To experience conditions mainly managed in primary rather than secondary care To increase understanding of whole person medicine, ethics and communication skills

Students come to general practice for two half day sessions within each of four units in the course. The units are:     Abdo/endocrine/renal/neurology (AERON) CVS/Respiratory system/ENT/Disability (TUBES) Accident & Emergency/Musculoskeletal/Opthalmology Psychiatry and Ethics

Typical teaching session:      Discuss likely causes of back pain, and how to distinguish between them Invite 2-3 patients with relevant problem, at 30 min intervals Students take it in turns to take histories, with feedback and group participation Emphasis on relevant, focused history and examination Students identify learning needs

Support available:         GP lead in each academy Annual training workshops for teachers on years 2 and 3 Annual ‘away-day’ for all GP teachers TLHP Certificate, Diploma, Masters Teaching administrator at Primary Care Unit Academy Unit co-ordinator Dean for each academy Chris Salisbury as overall primary care year 3 co-ordinator

Changes for 2005-2006:     No major changes to the course itself Main development is increasing decentralisation to Academies Discussions about how to increase primary care involvement at a time when there are an increasing number of students – more GP based small group sessions not likely to be feasible Discussions are continuing about the possibility of some seminar type teaching of common clinical problems in each academy

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Clinical Academies
The expansion of student numbers over the last three years has seen the establishment of Clinical Academies, so that students can have more of their clinical teaching outside Bristol. Students from the 3rd year onwards spend up to six months based in one academy. The last year has seen the appointment of GP Academy Leads at most centres to help organise our courses at local level and help support local GPs with their teaching. The GP Academy Leads introduced themselves at the workshop and are happy to be contacted. Academy Leads at North Bristol and North Somerset are due to be appointed shortly. Gloucestershire: Martin Nicholas: email Martin.Nicholas@bristol.ac.uk, or Martin.Nicholas@gp-L84040.nhs.uk. Tel: 01242 515363 Somerset (Taunton) Sue Neville: email sue.neville@harleyhouse.nhs.uk. Tel: 01643 703441 Somerset (Yeovil) Jill Wilson : email jewilson@dsl.pipex.com. Tel: 01460 52354 Bath: Sharon Gillings: email Sharon.gillings@gp-L81080.nhs.uk. Tel: 01225 422911 South Bristol: Kate Reading: email katereading@another.com. Tel 0117 9493988

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Teaching of Mental Health in Primary Care
Liz Anderson (Teaching Lead for Psychiatry)
The teaching of clinical skills in mental health is important in both the second and third year courses. During the Basic Clinical Skills we want students to acquire the basics of psychiatric history taking and mental state examination, particularly during the final ‘Whole Patient’ session. This is expanded during the third year Psychiatry and Ethics Unit. The Psychiatry and Ethics Unit is delivered in Year 3 of the MB ChB programme and students spend nine weeks on clinical placement. During this time, they will arrange to spend two half-day sessions with a general practitioner. The unit has seven key aims with specific learning outcomes. 1. To enable students to competently take a psychiatric history 2. To introduce students to psychiatric phenomenology and classification 3. To ensure that all qualifying doctors are able to perform a competent mental state examination 4. To ensure that all qualifying doctors are able to diagnose the major psychiatric disorders 5. Ensuring that all qualifying doctors are able to recognise the following disorders and undertake first line management and appropriate referral 6. Gaining an awareness of how to manage the common psychiatric states that present in and are often managed within the primary care setting 7. Encourage students to develop the ability to think about normal and abnormal functioning of individuals in the context of their whole life, informed by concepts of biological, psychological and social vulnerabilities, together with the role of predisposing, precipitating and perpetuating factors These form the focus for all the teaching and learning in the Unit. Each student is provided with a Workbook so that they can self-assess against the course aims and learning outcomes. This self-directed learning approach is one that is recommended for undergraduates by the GMC. As well as history taking and examination, the two key aims of most relevance to primary care (6 and 7) are produced in full below. Students’ experience within a general practice setting, provides an opportunity to make progress towards meeting the learning outcomes most directly associated with caring for psychiatric patients in the community. Students are exposed to a range of learning opportunities, and they are not expected to achieve any particular number or range during the time they learn with their GP tutor. The emphasis is on teachers encouraging the use of the workbooks to help the student reflect on what they have learned. Students have extra resources, such as a DVD that takes them through the steps of History Taking and a Mental State Examination, as well as a variety of online tutorials available via Blackboard. These cover core skills and students can use them to support learning. GP teachers are good at providing the type of learning experiences that encourage students to problem solve and reflect. Using the learning outcomes as a focus for organising the teaching sessions, will ensure that the GP attachment continues to contribute so much to the effective delivery of the Psychiatry and Ethics Unit. Liz demonstrated extracts of the DVD. Copies are available on loan (see resources at end of report).

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Key Aim 6 Gaining an awareness of how to manage the common psychiatric states that present in and are often managed within the primary care setting Learning Outcomes
Students will be able to: 1. List the most common psychiatric conditions, including medical illnesses that present with psychiatric symptoms that present in primary care 2. Know the mechanisms for action (basic pharmacology) of the most commonly used psychiatric drugs. 3. For each major psychiatric condition, state how you would assess risk to self (through suicide, deliberate self-harm or self-neglect) and to others (aggression) 4. For each major psychiatric condition, discuss the main types of investigation and treatment required in the acute and later stages. 5. Summarise the main features of sections 2, 3 and 5(2) of the Mental Health Act 6. Describe the role and function of Care Approach Programme in co-ordinating treatment for patients with a mental illness.

Learning Opportunities
    Specialist lectures week 4 [psychopharmacology, primary care, MHA,] – University of Bristol GP attachment Compulsory & optional clinical experiences [see clinical activity sheet] Tutorials during clinical attachment – as you present or discuss cases, think about how these learning outcomes are applied.

Assessment
Formative: Summative: Case presentations Viva and end of year examination

Resources
Online tutorials Forensic Psychiatry; Affective Disorders Case Study [mild] and Anxiety Disorders

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Key Aim 7 Encourage students to develop the ability to think about normal and abnormal functioning of individuals in the context of their whole life, informed by concepts of biological, psychological and social vulnerabilities, together with the role of predisposing, precipitating and perpetuating factors. Learning Outcomes
Students will be able to: 1. Describe the bio/psychosocial/model and summarise a case using a holistic framework 2. Differentiate predisposing, precipitating and perpetuating factors using examples from clinical practice 3. Summarise the differences between CBT and dynamic psychotherapy 4. Describe the social and psychological implications of common psychiatric conditions on the life of the individual, their carers and their families

Learning Opportunities
      Lecture series week 4 - [Psychotherapy in the NHS, Psychiatry in primary care] – University of Bristol Witnessing an assessment for CBT [see clinical activity sheet] Care Planning Meeting and working with multi disciplinary team members [see clinical activity sheet] GP attachment Interviewing patients [see clinical activity sheet] Formulating cases assessed during your attachment

Assessment
Formative: Summative: Observed interview, presenting range of cases using formulations in which all these concepts are introduced Viva, vignettes & end of year exam

Resources
Online tutorials – all with case studies; Liaison Psychiatry; Rehabilitation Psychiatry

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How to teach mental health in a general practice setting, scenarios based on patients with depression, anxiety, alcohol or drug addiction
In small groups, GPs were asked to prepare a 2.5 hour tutorial based on four different mental health problems commonly seen in primary care.     Anxiety Depression Alcoholism Drug Addiction

The tutorial should involve inviting in (or visiting at home) relevant patients. Groups were also asked to reflect on how their teaching session matches with the Learning Outcomes in the Psychiatry Workbook (particularly Key Aims 6 and 7). Some conclusions from the groups were as follows:   Try to have fairly clear Aims and Objectives for the teaching session, whilst being flexible to student (and patient) demand It is useful to divide the session into three parts: - Introductory discussion – eg background to topic, students previous experience, how general practice differs from hospital care, history taking and examination skills, resources - Inviting to surgery (or visiting at home) two patients - Reflection, summing up session There are particular difficulties re recruiting patients with mental health problems for teaching sessions such as: - Patients being sensitive to talking about emotional difficulties in front of students - Patients being seen by students after the acute symptoms/ signs had subsided - Patients being unreliable at turning up, eg some drug addicts Whilst these issues could be difficult, there were lots of examples of patients being used well in teaching sessions, and sometimes it is GPs rather than the patients who are sensitive/wary. Other alternatives were: - Go and visit the patient at home - Talk to carer/relative - Have a scenario to discuss in case the patient does not turn up eg ‘A new patient requesting urgent script for methadone on Friday afternoon’ It was possible to teach in parallel both the clinical skills of history taking and examination, and other aspects of psychiatry Psychiatry teaching sessions could also be useful to teach other skills, eg - Dealing with a threatening patient - How to say ‘no’ - Examining your own attitudes to certain patients The learning objectives of Key Aims 6 and 7, were useful in stimulating thoughts about how to teach psychiatry in primary care Primary care was a good setting for teaching the overlap between physical and psychological medicine (eg with patients with alcoholism and drug addiction). This was particularly useful in the Year 2 teaching Participants were generally positive about encouraging students to use the Psychiatry Workbooks.

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How to teach students on these courses
Demonstrations with students and actors David Memel and Chris Salisbury
With the help of three 3rd year students and an actor playing a patient David and Chris ran a mock teaching session for both courses in order to demonstrate the kind of teaching which is involved to new and potential teachers. This led to some discussion about several issues including:    the pros and cons of starting sessions with some semi-didactic teaching time, to give students a framework for their questions how best to deal with over-enthusiastic and under-enthusiastic students being flexible to meet students perceived needs – the value of asking them what they want out of the sessions

Discussion with students about the Clinical Skills Courses
The three students made the following comments about the 2nd and 3rd year course         They highly valued the GP sessions, because of the chance to be observed taking histories and examining patients in small groups in a supportive environment They found the use of a ‘flipchart’ session to summarise main teaching points to be useful both before and after seeing the patients They sometimes found it more useful to see patients individually or in pairs, rather than in a group of four It was helpful if there was email communication between GP and students before a session as to the content/preparation work Important that they were allowed to make mistakes, and had a chance to repeat things, until they understood. Students welcome feedback on how they are doing Try to use patients with relatively simple histories in Year 2 teaching Student value both teaching on clinical skills and the management of common clinical problems in the Year 3 GP sessions

Small group work on practicalities of teaching on these courses
    Keep a practice register of patients who have agreed to teach with details of their disease or interesting clinical features, date they agreed, each date they were used for teaching Useful to role-play doing a consultation yourself in one of the early sessions Is worthwhile spending 5 minutes in last session with students individually, while the others have a coffee in the common room. Ask them how they think they are doing, before giving feedback. Have a standard letter to send/give patients before the teaching session, covering issues like the lack of experience of the students, not everything they say will be correct, explaining what will happen (some patients may be fearful they will be asked to get undressed etc), how long the session will take etc.

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How to find patients:
         Search on conditions (e.g seen with pleural effusion in last 6 months) Ask partners or nurses Spontaneous patients from urgent surgery that day Ask patients seen in previous surgeries Add Read code ‘of interest to students’ and text specifying problem Record who has been seen with code ‘seen by medical students’ Don’t worry about inviting one patient specifically for history and another just to demonstrate physical signs Record patients who have been asked but decline to see students Nursing homes can be a useful source of patients

Before the session:
   Ask receptionists to phone the patients first thing in the morning to come for the teaching session. Have a contingency plan in case a patient fails to attend Sometimes its good to take students to see and examine someone at their home

At the session:
        Maybe take a group photo at first session to help you remember their names If a patient doesn’t turn up, ask the students what practice they need. It is often useful to spend 30 mins teaching inhaler technique, doing dipstick tests, taking BP, doing a BM stix test, practising reflexes, doing fundoscopy. If you get short of patients, students can practice examinations on each other Give clear guidance for patients i.e. we are interested in your chest pain. Don’t tell the students the diagnosis. Introduce the patient properly to the students Provide clear guidance for students – who will take history, do examination etc. Try to encourage all students to participate Students like individual feedback in final session

After the session:
  Keep brief record of students progress after each session At the end of each session it is good to ask students to identify their learning needs and to go away to look up specific things. But this will only work if you make a note to ask them to present what they found out at the next session

Resources
DVD
Copies of the DVD ‘Psychiatric History Taking and Mental State Examination’ produced by the Academic Unit of Psychiatry, University of Bristol which Liz Anderson demonstrated at the workshop are available on loan from Sally Sterland (Sally.Sterland@bristol.ac.uk)

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Useful books:
Introduction to clinical examination. Munro & Ford Brief, simple guide on how to examine. The medical school will provide one copy per teaching practice for free when they start teaching Clinical examination. Mcleod, Munro, Campbell. Similar to above, but more comprehensive Clinical Medicine. Kumar & Clarke This is the standard undergraduate medical textbook Practical General Practice. Khot & Palmear Problem orientated text book, useful for teaching about the common clinical problems that this course is all about Also the Oxford Handbook series (Medicine, General Practice, Clinical Specialties) Useful as an aide-memoire The following Psychiatry Textbooks are recommended: Crash Course Psychiatry. D Bloye and SJC Davies. Mosby 1998 Textbook of Psychiatry. Puri et al. Churchill Livingstone 2002 Problem-based Psychiatry. Green. Churchill Livingstone 1996. Psychiatry at a Glance. Cornelius Katona and Mary Robertson. Blackwell Science 1999

Website
Bristol Uni primary care website has been extensively revised. The website is a useful source of student and GP handbooks and other resources for all courses. Click the ‘teaching’ button from the home page: http://www.bris.ac.uk/Depts/PrimaryHealthCare/

Contacts
Teaching Administrator 2nd Year GP Clinical Lead 3rd Year GP Clinical Lead Melanie Stodell Melanie.Stodell@bristol.ac.uk Tel 0117 954 6639 David Memel david.memel@bristol.ac.uk Tel 0117 954 5575 Chris Salisbury c.salisbury@bristol.ac.uk Tel 0117 954 6671

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