By Melvyn Jones

I have just co authored a BMJ piece on chest radiographs with Covid pneumonia – The role of chest radiography in confirming covid-19 pneumonia  So why is a GP publishing about Covid radiology? 

My wife is a radiologist with a special interest in chest radiology and a love of a good chest x-ray; back in March she was starting to see the x-rays of the first patients with covid pneumonia and she was shocked.  She hadn’t ever seen x-rays like this.  This was something really different.

There were real fears that hospitals would be overwhelmed and we knew clinicians who never normally look at a chest x-ray anymore were being marshalled in to support the covid response. Would they know what to look for on the chest x-ray? Could we do something to help?  So I wrote to the BMJ pitching an idea on the 22^nd March. They liked the idea and commissioned us to do a “Practice pointer”, not a traditional systematic review but an article based on evidence and clinical  experience.  I interviewed my wife to capture the key points and while she was on call went searching for good images.  My literature search revealed 20 articles and only 1 related to Chest x-rays, there really wasn’t much out there. We had our submission ready and posted it on the 30^th March and by that stage 1200 UK patients had died of Covid.

I needed to understand a bit of radiology to work though the literature. What is ground glass opacification  (“the lung markings are still visible through the Covid changes”) and how it is different to consolidation- key concepts with Covid pneumonia. Covid lockdown meant the possibility of eating breakfast outside and thinking things through in a slightly less pressured environment. Should I admit to looking at the cloud formations during those few weeks of glorious weather? I did, I do.  Cirrus clouds were my ground glass, I could still see the sky through these light feathery clouds, cumulonimbus was my consolidation; thick, opaque and ominous.

There then followed 6 revisions and further major changes requested by the team that ready it for publication.  It went out to 7 different peer reviewers; many of whom made valuable but conflicting requests for changes but the overwhelming message was – this needs to be out there, now.  We also needed input from a physician who was in the thick of it- how were they actually using imaging as part of their assessments of breathless Covid patient? I was working with James Piper – an Acute Medicine doctor at the Royal Free as part of the MB BS teaching programme and he was happy to help.

We turned round each iteration within 48-72 hours but still the requests for changes came. The numbers of UK deaths went relentlessly up. Eventually it was accepted, type set and finally published on the 16^th July.  UK deaths had now exceeded 45,000, Google scholar had hundreds of Covid articles and we were coming out of lockdown. It was a pleasure to see it finally published but there was a real sense that it was just too late.  That’s the thing with the BMJ though; the day it was published it was downloaded over a 1000 times, two weeks later it has been viewed over 7000 times.  The really helpful thing though for someone who is not a big user of social media, was seeing who Tweeted about it and where. The BMJ link had been re-tweeted 147 times and to places like South Africa, South America and India- all parts of the world which were now facing their 1^st waves of this terrible disease and today the newspaper headline is “Europe faces its 2^nd peak”.  It may be of use to a clinician somewhere having to manage yet another patient with this awful disease, so may be we could and did do something?

In this post Melvyn Jones talks about how the iBSc in Primary Health Care students visit a local GP health centre and learn about who it was developed to meet the needs of it’s patients on the eve of World War II. 

The words of a 1940s poster “fight for it now” and its gleaming image of Finsbury Health Centre directly linked fighting during that recent conflict with needs of soldiers and a beleaguered population for a better life after World war 2. The pre NHS Finsbury Health Centre which opened in 1938 on the eve of war, offered a model of community based health care away from the hospitals, to meet the needs of its very deprived population; burdened with poverty, malnutrition, lice, TB and rickets.

Roll forward nearly 80 years and the current batch of iBSc in Primary Health Care students were shown how this building was designed to meet the health needs of that time; with lead lined walls for the TB x-ray screening service, the solarium was there to prevent rickets and the layout was designed to help clinicians provide the best care they could (the corridors are bright and diamond shaped to encourage interaction between staff).  Dr Marie de Souza, one of the GPs working in the practice discussed how in some ways they are still using this building to deal with similar issues (communicable disease like HIV, vitamin D deficiency due to poor diet and lifestyle) and some issues we still can’t seem to address- we were shown the reception rooms in the basement where homeless families were temporarily housed. Yet there are newer challenges like the increasing burden for people with poor mental health. Rooms that once were used to de-louse bedding are now used to provide CBT. There are considerable constraints involved in providing 21^st century health care from this grade 1 listed building (Lubetkin’s architectural master piece).  A repair must look like an unsightly repair (so the building can be “read” by the streams of architectural students), a picture can’t be hung without permission from English Heritage, the door locks can’t be updated because the lead walls are indestructible. And yet, today on a sunny November morning, the light flooded in through the expanses of glass; glimpses of that gleaming 1940s image of hope.

The students were encouraged to think how they might shape the health service for the next 80 years and how the buildings we might get to design could reshape the care we could provide.

In this Post Melvyn Jones talks about new methods and ways of teaching/learning – something in here for us all to take away to our next class!

A room full of students staring at you – “ok teacher, teach us”.   We’ve all probably been faced by a passive group of students turning up to be taught and it can be a bit daunting. Mid way through you see the smart phones being glanced at, the odd stifled yawn. How effective is this teaching?

So faced with this should you be doing the “teaching”, or is what you are after for the students to do the learning? What is out there to help you?

I’ve tried out a few of the CALT teaching updates; a lunch hour session where you can get some fresh ideas on making student learning more effective. I went, I sat, but most importantly I took away what I had learnt and had a go.

First up “Flipped learning”- in a world where information is everywhere, is there any point in transferring facts in a lecture anymore?  Flipped learning suggests getting the student to use the face to face session with the teacher to try new things out, to understand concepts and to explore any difficulties they are having with the subject matter.  The price of this “flip” is that the student must cover the factual material before. It is no longer preparatory reading with all the “optionality” that implies; it is the “meat” of what they will learn.  The “lecture” is no longer a lecture but a discussion, an interaction using that material to advance the students’ learning.  Your job as the teacher is no longer to passively transfer that information but to help the students understand and interact with it in a way that consolidates their learning.  So what if the student hasn’t done the reading?  Well that is their problem; the logic goes that if you buckle and go into lecture mode you disadvantage the students that did do the preparation and you reduce the motivation of all the group to prepare for the next session, so hold your nerve.  Make sure your students know that this is what you expect and if you teach the same group, be consistent and try to get your other teaching colleagues to do the same.

Next up Pecha Kucha, strictly this is presenting 20 slides on a subject and moving on every 20 seconds, but I tried a “Pecha Kucha lite”,  each student talks  about a subject using just  1 slide and you set a very strict time limit; I did 5 minute slot per student  but adapt it depending on the group size and the time available.  Make it fun but also supportive; “bong” them out if they overrun, stop them if they try a second slide or bend the ground rules, but do give them constructive feedback, moderate the feedback from the rest of the group, and make sure everyone is involved.  It is a very effective way of getting students engaged, you will very quickly see if they haven’t “got it” or have misunderstood something and most importantly it is the student doing the learning and to a lesser extent you  doing the teaching. So what did my students think when I had a go? Their feedback included the following “engaged with learning especially as the result of feedback”. Job done?

Importantly these types of skills (Independent learning, presentation skills, team working), are the skills that our students need to develop, to go out and to get jobs in a very competitive world.  The UCL connected curriculum @UCLConnectedC is pushing us to develop research based education, so students learn about research but also that the research informs their learning.

I would strongly recommend these sessions.  Whether you do large group teaching, one to one supervision or bedside teaching there will be something for you. You will interact with people from a wide range of disciplines, as varied as Physics to the Built environment, think about your teaching again and probably be back at your desk by 2.30.

Dr Sophie Park, GP & Senior Lecturer in Primary Care at UCL, was highly commended for the Yvonne Carter Award 2015 for her innovative work in developing a distinct body of educational research in primary care.

Below Joanne Reeves, Amanda Howe and Sophie Park on Thursday 10th July in Oxford at the SAPC ASM.

Dr Nada Khan and Dr Sophie Park discuss the work on their systematic review of medical education in general practice in the United Kingdom.

The Primary Care Educational Research Group (PCERG) is a multi-disciplinary research group that aims to conduct high quality research looking at medical education based in the community.  For the past year a team of researchers lead by Dr Sophie Park, who chairs the PCERG, have been bringing together research looking at how medical students learn in general practice in the United Kingdom.   It’s been an exciting project, and is now coming to an end after a fruitful year of research, collaborations and plans for the future.

The research project is registered with the Best Evidence in Medical Education (BEME) Collaborative, and is titled ‘A systematic review of UK undergraduate medical education in general practice’.  For the project, the research team searched through relevant evidence and found 169 papers that looked at the topic.  By looking at this previously published research we were able to bring together the current evidence, and build upon it to develop new findings and understandings of what happens when medical students and patients are involved with teaching consultations in general practice.

What are some of the main messages coming from this project?  There are several good news findings, including that medical students seemed to learn as well in general practice as in hospital, and that medical students, GPs and patients described different ways in which taking part in teaching benefitted them.  To give a few examples, medical students got a chance to see patients as a ‘whole person’, and GP tutors felt that taking part in teaching refreshed their knowledge base.  Patients often felt a sense of gain and altruism from taking part in teaching.  There were also some challenges raised. For example, some patients felt embarrassed or anxious when a medical student sat in on their consultation. Our findings suggest that how the GP manages the relationships between the student and the patient, and the GP themselves, can make an impact on the experiences of medical students and patients in teaching consultations.   The main findings from the project will be published on the BEME website later this summer.

Following on from this project, Dr Park’s team has now received additional funding for another study. We are going to conduct focus groups and interviews with medical students and patients and discuss with them our findings relating to medical education in general practice.  This is a step towards taking a piece of theoretical research back to the people it impacts and to get their impressions and ideas on how it represents their experiences of taking part in medical education.

Another exciting outcome from this project has been a successful collaborative application by UCL and the Institute of Education to become a BEME International Collaboration Centre (BICC) for systematic reviews in clinical education.