Education team finalistsBMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2057 (Published 15 April 2016) Cite this as: BMJ 2016;353:i2057
Prescribing Safety Assessment
Doctors in their first foundation year often struggle with prescribing. A study in 2014 showed that they made more errors than other doctors, while doing most of the prescribing. Many admit to finding the role challenging and one for which they are poorly prepared.
“There’s no other area where the doctors’ error rate is so clear and where graduates have indicated there’s a challenge,” says Simon Maxwell, consultant physician and professor of student learning at Edinburgh University. “It’s a patient safety issue. Day to day, the opportunity is there to do good or ill every time the pen comes out.”
Backed by the British Pharmacological Society and the Medical Schools Council, Maxwell has led development of Prescribing Safety Assessment (PSA), an online tool for assessing prescribing competency now used by all 31 UK medical schools. In 2015, 7576 final year students sat the PSA, 91% passing first time. Each year 80 000 prescriptions are assessed and marked, a task that would be impossible if done manually, and the PSA has become one of the largest online medical assessments in the world. Medical schools in other countries are adopting it.
“In the early stages participation was voluntary, then some medical schools made it a requirement; now all are involved and it’s effectively mandatory,” Maxwell says. “It would have been a difficult leap to have imposed it in one go, but gradually we’ve got to that point. It shouldn’t be seen as a big stick, nor a hurdle to trip graduates up. But we’re talking about the final common pathway in all the thinking that goes into diagnostics, and however good you are as a doctor, if you don’t get the final bit right then it all falls apart.”
Team for emergency medicine
“Everybody who reads a newspaper knows that emergency medicine is a stressed specialty, in terms of the time we have to look after a patient,” says Laura McGregor, a consultant at Forth Valley Royal Hospital in Larbert. “What tends to happen is that all the time is spent on service provision, as opposed to training the doctors to do a better job. People say there isn’t time, but that’s a self defeating prophesy because you just end up with not the best patient care, not the safest patient care, and usually quite an unenthused staff, to be honest.”
In 2013, McGregor was appointed educational coordinator for emergency medicine at the Scottish Centre for Simulation and Clinical Human Factors, which is based at the hospital. She established that young doctors would value more simulation based training in emergency medicine and, with colleagues, designed and delivered a new course.
It uses a range of manikins to simulate the wide variety of situations faced in emergency departments, from a 4 year old having a fit to a woman giving birth. “Women can pitch up at the front door and the hospital may not have a maternity department,” she says. “It’s a rare event so unlikely to have been met before.” Her course on the obstetric patient in emergency care is, she believes, the only one of its type in the UK.
The day courses are designed for doctors and cost £150-£200 (€190-€250; $210-$285) but nurses have for the moment been offered places free of charge to encourage them to participate. “We’ve had really good feedback,” she says. “Doctors are discouraged from going into emergency medicine because they know they will face dangerous and critical situations and worry they’re not being taught well enough how to do it. We can overcome that fear.”
Doctors in their foundation years learn as they move through their rotations. But they can do so more effectively, Rakesh Patel argues, if they are assessed at the beginning rather than the end of the rotation. “That gives them something to work on over the next four months” he says.
Patel, academic clinical lecturer in medical education at the University of Leicester, developed a method for doing this by filming young doctors in simulated ward rounds at the start of their placements and then taking them through the results in a feedback session. He compares the process to that of a football analyst offering criticism and guidance to players based on videos of their performances in matches.
The driver for this programme, which was backed by Health Education East Midlands, was evidence of the frequency of prescribing errors. An audit of 13 993 prescriptions showed many errors and that foundation year 2 doctors made proportionately more of them. While the educational programme EPIFFany (Effective Performance Insight for the Future) is designed to do a lot more than improve prescribing, such errors are important and in this case serve as an auditable marker of doctors’ progress.
Errors fell by half after the intervention was delivered to the junior doctors, with the severity of errors also reduced. Doctors were also trained how to talk to patients about medication, and feedback from patients was positive. The results suggested that EPIFFany was equivalent to an extra year of clinical experience. The challenge now, says Patel, is to make the initiative scalable so that it can be used elsewhere in the NHS.
East London Foundation Trust quality improvement programme
Attempts to improve quality of care in hospitals can lack focus. Staff who would not tackle any new medical problem without first reading the literature tend to ignore the fact that there is also an extensive literature on quality improvement. “Most people have no skills in this area,” says Amar Shah, associate medical director of East London NHS Foundation Trust, a mental health trust employing 5000 people.
“That means training is a big part of the work, but it’s only one part. The second is about engaging people in the work and celebrating their work; the third is trying to redesign all of our organisation to be improvement focused and making sure we’re driven by our improvement goals and not by other things; and the fourth is supporting projects across the organisation. We have 160 of them at the moment—each with a team tackling a problem. That probably involves about 1000 people using the method every week to tackle something we haven’t been able to tackle before.”
Two years after the project started, the trust is beginning to see benefits, he says, such as a 23% reduction in inpatient violence—“I don’t know anywhere else in the world able to have done that”—and a 15% reduction in the waits for community appointments. Staff survey results show the highest scores in England for staff engagement and feeling empowered to contribute to improvement at work.
The costs are in training and having a dedicated central team, and amount to about £300 000 a year. “You can cover that by realigning resources—it doesn’t all have to be new money—but in the grand scheme of things the costs are relatively small compared to the return on that investment.”
Anybody who has ever dozed through a Power Point presentation should welcome PechaKucha, an innovation from Japan that aims to put the pep back into talks. The method (named from the Japanese for chit chat) allows lecturers 20 slides, each shown for 20 seconds and advancing automatically, over which they talk.
A team at NHS Lothian, which runs emergency departments in Edinburgh and Livingston, has used this method to teach emergency medicine to undergraduates. “We wanted something edgy and exciting to inspire them—that spark to help them learn more,” says Jonathan Carter, emergency medicine consultant. “How do you deliver that in a busy department? We found PechaKucha.” Students see the six minute talks online, then turn up for interactive case based tutorials, based on real patients.
“They can watch them anywhere,” says Janet Skinner, also an emergency medicine consultant. “At home, on a bus on their smartphone, wherever. They’re freely available.” The talks are on topics—undifferentiated chest pain, major trauma, head injuries, for example—not diagnoses. The tutorials focus on cases and allow to-and-fro discussions. “Students like it, and staff find teaching this way more satisfying.”
Katy Letham, another emergency medicine consultant, says that the videos are widely watched. “In the first year of the project they’ve each been seen more than 3000 times, which is really interesting because they were designed for 250 final year medical students. People from Botswana, the Philippines, all over the place, have seen them. We’ve moved on to make short clinical videos, and the rest of the department and the medical students have got on board, bringing their own stuff to the project. So it’s grown arms and legs and become self propagating.”
Water, says Sumantra Ray, senior clinician scientist at the University of Cambridge, is an easily forgotten nutrient. “We rely on thirst to tell us how much water we should drink, but unfortunately it’s a blunt indicator,” he says. “By the time it kicks in, it’s possibly already a little bit late. For healthy individuals this may not matter, but for children, older adults, and those with comorbidities, infirmities, or at risk from other health factors, dehydration can make all the difference.
“Very often when an elderly patient is admitted to hospital, maybe after a fall, one of the underlying causes we often detect, and then correct, is dehydration. A lot of this can be prevented, and we think that something as simple as hydration advice in primary care can be quite effective in its outcomes.”
As part of a broader initiative to improve both hydration and nutrition training in GPs, an education package was developed for delivery in a half day workshop. It was well received—“we were blown away by the feedback,” he says—and before and after questionnaires showed that GPs’ knowledge of hydration guidelines, initially poor, was greatly improved by the session. “With that feedback we’ve further improved the material available. It needs to be short, sharp, and with an impact, and I think we’ve achieved that.”
The material was developed through the Need for Nutrition Education/Innovation Programme, which is based in Cambridge and of which Ray is founder, chair, and programme director. Its success has led to a mandate to run an annual summer school module in Cambridge, which will take place for the first time this June.
The Education Team of the Year Award is sponsored by Stanford Medicine X. The awards ceremony takes place on 5 May at the Park Plaza Hotel, Westminster. To find out more go to thebmjawards.com.