A Momentous Occasion

Today was a momentous occasion in terms of my career as a medical student. I have been counting down to today for the past 8 weeks at least! In fact, it was a cause for celebration for at least 8 of us, although only 4 bothered to turn up. Have you guessed yet? Today was my last ever PBL session, the last 2 hours of problem based learning I'll hopefully ever have to endure (at least as a student).

I was going to bring cake, and even champagne to celebrate the occasion but I'm not sure hospital is the best place for alcohol and I couldn't find any suitable cakes. As it turned out, only 4 of us turned up anyway, quite sad really that final session was more of a damp squib than anything else, not that PBL is much more than that in the first place.

The session itself was more a small tutorial than a classical PBL, saying that, we've not done 'textbook' PBL for years. I'm just happy I never have to waste 2 more hours of my life sat in a room trying to teach each other medicine from the titbits of knowledge we've all cobbled together from various sources. It is quite ironic that such emphasis is placed on group learning and PBL, where we're encouraged to help each other to learn, only to be examined and assessed against each other when it comes to exams and ultimately ranked against each other when it comes to job applications. I can't quite understand that logic.

I must have done a couple of hundred hours of PBL in the last 5 years and I can probably count on one hand the number of useful sessions. I can't even remember how PBL is supposed to be done, it is that long since we followed the proper steps. I'm still very much of the opinion that PBL doesn't work as an exclusive method of teaching medical students. I think there are huge gaps in some of our knowledge, some of us more than others of course. Sadly too much time, effort and money has been put into developing such a course that even if those that be wanted to revert to a more traditional style, it would be far from easy.

Who knows, perhaps in a few years I'll be proved wrong and it'll be the PBL trained doctors leading the way, unfortunately I just can't see it happening that way. I expect that once more evidence becomes available, PBL will be shown to be the pointless, farcical waste of money that it is.

In the mean time, I'll rest safe in the knowledge that the words "time for PBHell" will never again cross my lips!

HELL YEAH!!!!!!!!!!!!!!!!!

Have the BBC Missed The Point?

This story appeared quietly and with little fuss over the weekend. Afterall, unless its about £100,000 salaries or patients dying, nobody seems to care what happens to doctors.


The BBC story highlights an important point, although I can't credit the BBC as the remark originally came from a professor at the Royal College of Physicians. With the complete introduction of the European Working Time Directive (EWTD) from 2009, all professions, including doctors will be limited to working 48hours a week down from the current 56 hour limit. Now I don't know about other professions but this has some pretty serious consequences for doctors and perhaps more so for patients.


The BBC article states that patient care will suffer because there will be less staff available, this clearly makes sense as if all doctors are working 48 hours rather than 56 each doctor is working 8 hours less. Who is going to cover those lost hours? Patients are still going to get ill 24 hours a day, 7 days a week. Who is going to be there when Mr Jones arrests but Drs Smith, Brown and Wood have all worked their 48 hours this week? Of course, everyone knows that the vast majority of doctors are still going to work more than 48 hours a week, they just won't get paid for it as it is effectively 'illegal'. When it comes to auditing hours, these doctors will be 'encouraged' to lie about their hours to make the trust EWTD compliant. So patient care probably will suffer in the short term, but Dr Smith and his colleagues won't leave Mr Jones to die, they will ignore the EWTD, safe in the knowledge that what they are doing is illegal and they're not getting paid for it. Another solution to this problem is the use of night nurse practitioners and such like. I'm sure Dr Crippen wouldn't approve and to be honest, I know who I'd rather be looked after in the middle of the night during an emergency.


Anyway, I think the BBC have missed the point, it isn't the short term, immediate care of patients which is at risk. I'm far more worried about the implications for the future in terms of training. Talk to a doctor who qualified 5, 10, 20, 30 years ago and they'll tell you about the 'good times', the 100-120 hour weeks, the 48 hour shifts without sleep. Strangely, most of them will tell you they enjoyed it in a sadistic kind of way. Not because they get a kick out of working more hours than there are in a week, but because of the experience they gained. Most doctors will tell you that on call, during the night is where they learnt the most.


Lets consider for a second Mr Bone, a consultant orthopaedic surgeon. He became a consultant within about 11 years of graduating from medical school. When he qualified, he worked 100 hour weeks as a house officer and similarly throughout his training. That is about 50,000 hours or so of training.

Next, lets consider me (or equally one of my colleagues) who, having studied a PBL course doesn't know all that much to start with. If I were to become an orthopaedic surgeon about 11 years after qualifying having worked no more than 48 hours a week. I would have received about 25,000 hours of training. About half that of today's consultants. It certainly won't be considered acceptable to double the length of time it takes to become a consultant and so we're left with one scenario.

In 10, 15, 20 years time, the 'consultant led' NHS is going to be staffed by doctors with roughly half the amount of training their predecessors had.

Who would you want to replace your hip?

Interesting Research

I missed this in the news a few weeks ago but was reminded about it over the weekend. Slightly worrying.

Liverpool and Manchester - pioneers of PBL in the UK.

A Fitting End

Contrary to the title of this post, it isn't a story about rectal diazepam.

Tomorrow heralds the start of my final 4 week hospital placement: lower GI surgery. Rather fittingly, this is the same as my first ever clinical placement at the start of 3rd year (I wonder if the consultant will recognise me?). I wonder how much I've learnt and how far I've progressed in that time? Hopefully quite significantly! How much time I'm actually going to be able to devote to this placement I'm not entirely sure as I have an ever-growing list of other things to attend. I hope to spent most of the time with the F1 (fingers crossed that they'll be friendly and helpful, although its all change next week anyway as the F1s rotate).

The fact that this is my final placement means a couple of things: the first and most important thing is that finals are just 6 weeks away, secondly, in seven weeks it'll all be over one way or another, thirdly, that I have 4 PBL sessions left EVER and finally, that in 6 weeks I will hopefully never have to set foot in a certain city ever again!

To be perfectly honest, I wish finals were tomorrow. I just want to do them and get them out of the way. Sure 6 weeks is a long time and I've still got lots to learn, never mind revise but I'm awfully fed up of just waiting for these exams to come.

This weekend I attended the medicine version of the revision course I wrote about 2 weeks ago. It was a completely different style to the surgical one in that it concentrated on exam technique more than knowledge but it was useful nevertheless.

Kidneys - What Do They Do?

As finals are approaching fast, we're having a series of revision sessions from consultants. Yesterday's we had 2 hours on kidneys. This seems to be a notriously neglected topic by medical students, at least at my medical school. I remember back in 1st year we had a PBL case on the kidney and we were supposed to learn EVERYTHING about the kidney in a week or so with no support lectures whatsoever. I gave up before i'd even began and along with many of my collegues ended up neglecting the kidneys entirely. Fast forward 4 years to last night and this revision session was more like a first-vision.

The session itself was very useful and I feel that I learnt quite a lot. If only we'd had lectures on the kidney 4 years ago... perhaps PBL wasn't the best choice for me. I have an amazing ability to remember stupid facts that i'll probably never need to know, this is at the expense of remembering useful concepts. I haven't got the foggiest idea about renal physiology, I just about know my proximal from my distal tubule but other than that its just a load of wee.

I can tell you how many people are waiting for a kidney transplant and how long transplants last
(god knows why I remember that!) - but I can't tell you anything about ADH.

I've decided to pretend that kidneys don't exist - its much easier that way. I guess a career in renal is out then.

Bits and Bobs 2

My Portfolio meeting turned into a bit of a lame affair. I managed to waffle on for so long that the dean barely had any time to actually look through my portfolio so it didn't really matter what I had in it although he seemed quite pleased. In the past we've had some interesting debate about the course, PBL and such but yesterday was little more than a relaxed chat. I was left sort of unfulfilled because I usually enjoy moaning although I did manage to get in a few important things which the dean seemed rather concerned about.

New year's resolutions update: Well I'm not doing TOO badly really. Since the 1st of Jan, I've done some exercise and more work than usual. I've kept my car fairly clean but most impressively i've not had any chocolate, sweets, crisps or biscuits - I've almost given in a few times - so much so that I had a bag of wine gums in my hand but I forced myself to put them back. Improvements are still necessary though, more exercise and more work.

I'm still enjoying my GP placement especially having my own surgeries. Although its slightly annoying when people book appointments with me when all they want is a repeat prescription as I can't help them and it only takes 2 minutes.

Not a lot else to say really - will blog again later.

OSCE Fun (not really sure those words go together)

Tomorrow brings with it the 3rd Year OSCEs, now they’re not real OSCEs, in the sense that they’re summative rather than formative (maybe that is the wrong way round?!). That basically means they don’t mean a thing with regards to progressing through medical school. Its more of a practice for the summer 3rd year OSCE which is important.

You won't be surprised to hear that I'm again modelling tomorrow which means I get to lie on a bed all day and be prodded and poked by the 3rd years. I wonder what my station will be this time. I've got a pretty good idea but again I'm not going to share any details just in case any 3rd years are reading.

I enjoy being a model for the OSCEs, I get £20, I get to revise something I might not have done for a while and I get free drinks and biscuits - shitters - no biscuits - stupid new years resolution! Probably for the best, last time I ate my way through 2 boxes (admittedly only stealing the best ones).

If you've not already done so, read the latest about PBL at the real little medic.
If you're new and need an invite just drop me an email to imamedicalstudentgetmeoutofhere[at]hotmail.co.uk

The Start of a New Year

Today was my first day back after the Christmas break, which I should add, seemed to go ridiculously fast. You might have remembered that I'm now doing an 8 week GP placement and I've not exactly been looking forward to it. In fact I've been dreading it, I don't know why because sometimes when I get into it I quite enjoy my GP placements. Nevertheless, I wasn't feeling very enthused when I awoke this morning.

I arrived at the GPs early and was met by friendly reception staff. The surgery is split over 2 sites, one of which was briefly my own practice. I met my supervisor who seemed really nice, I have a feeling she is going to work me hard and expect quite a lot but that is no bad thing I suppose. I spent the morning with her, although it didn't exactly go to plan to start with. 3 of the first 4 patients refused to have me in. Fair enough I suppose. The rest of the morning was surprisingly quiet, there was only a trickle of patients and about the most interesting thing was an ear with raging otitis media.

All in all it wasn't the most interesting of mornings but I'm pleasantly surprised and slightly more optimistic about the next 8 weeks. I'm also fairly pleased with my timetable, it potentially looks like Tuesdays might be all-day study days which would be fabulous, 4 day weeks are just what I need. Perhaps I will enjoy it (at least a bit) after all. It will get a lot more interesting next week when I get to have my own surgery with half hour appointments of my own! I hope the patients know what is about to hit them.

The rest of the day was taken up by my favourite thing in the whole entire world, yes that's right - PBL. The groups have changed, although 4 people out of 8 didn't make it today, apparently they are still on holiday - how bloody nice for them!!! The process itself was just as boring as ever. I even spent half an hour trying to write a poem about PBL but I was so dispirited that my creative juices were flowing like treacle up a hill.

Back to the real world, here we go with 2008 - Happy New Year!

New Years Resolution Update: Today I went to the post office and they have these amazing wine gum things that I usually eat by the crate full. I had such an urge to have 'just one packet' but I didn't I managed to resist. I almost cracked by the chocolate machine too but will-power prevailed and so far so good, i've not had any sweets, chocolate, crisps or biscuits. COME ON!

Problem Based Learning aka DIY Medicine.

I've been promising a post on Problem Based Learning (PBL) for a while now. A few people in particular have emailed me to ask about it, and medical school in general (Unfortunately I think I've terrified at least 3 people who might be coming to my medical school - oops.)

I wrote about PBL before...early in my blogging days in a post titled Learning Based Problem. Due to my developing interest in medical education, I approached the Dean to see if I could do a 3 week SSC on PBL. Fortunately he agreed and I spent most of the 3 weeks in bed reading various books and journals. It was a fairly relaxing SSC (although that's not the reason I requested to be allowed to do it!) but it was really rather interesting (I realise it probably makes me quite sad but I quite enjoyed reading about learning theory and the evidence behind PBL.) My 4500 word write up, again under the title Learning Based Problem was in the end quite good, although I didn't feel it really summarised my thoughts very well.

Despite having experienced 4 years of PBL, whenever anyone asks what I think of it I’m never quite sure what to say. Fundamentally I can see what the concept of PBL has to offer and I think the theory which supports PBL is sound; however most of the time, in practice, I don’t think PBL works. A successful PBL experience is dependent on too many variables which are rarely all fulfilled at the same time and as a result the process falls down, for example, a poor group dynamic or ineffective tutor can almost instantly render the whole process useless.

One important question is what are the most important qualities a doctor should posses? The GMC’s answer to that (Tomorrow's Doctors) is that more emphasis should be placed on the acquisition of general competencies rather than retention of facts. To a certain extent I agree but it is also important that doctors have the knowledge as well as general competency to be a successful doctor.

The evidence behind PBL is rather muddled, there is evidence to suggest it has benefits and weaknesses. Little has been done to compare PBL directly with more traditional courses due to the difficulties in assessing students from different courses. PBL is based on educational various educational theories. (I can't be bothered to go into this here. If you're really interested email me at imamedicalstudentgetmeoutofhere[AT]hotmail.co.uk and I'll send you a copy of my SSC.) In summary; the evidence that is available tends to suggest that PBL students have less basic science knowledge but have better clinical knowledge and basic competencies such as communication skills and team work. The latter could be explained by the fact that PBL curricula tend to have more communication skills teaching, Rather than attributing the improvement on PBL alone.

PBL is here to stay for the foreseeable future, and until someone devises an appropriate method of comparing students from both types of course the evidence base behind PBL will remain somewhat vague.

PBL does stimulate curiosity but in order to learn one must be very motivated all of the time, this is a hard concept to grasp when one is used to didactic teaching methods. PBL seems to have been taken up with some enthusiasm; however one of the main reasons for its failure in my opinion is that after the initial effort and outlay, some courses seem to be neglected, without constant update and maintenance the curriculum becomes neglected and ineffective.

In my opinion the benefits of PBL do not justify the resources required to implement such a drastic change in the curriculum. I do believe that both PBL and traditional methods of medical education have something to offer, but perhaps a combination of the two or even an entirely new approach to medical education would be best.

To be honest, I really dislike PBL. I enjoyed it in my first year (even though I had no idea what I was doing then) because it worked. Now it has just become a waste of my time, i'd be better off spending 2 hours reading a book than engaging in the pointless task that is PBL. After all, it is do it yourself medicine. Even most of my tutors are unsure about it, so what chance do we have? Saying that, I do like the freedom a PBL course gives you to learn what you want, when you want. I would have hated a completely traditional course.

Meh...that was just a muddled rant. I can never really explain PBL very well. Oh well, I hope some of you found it useful. I should just go back to moaning!

DIY Medicine

It seems like ages since I last blogged but I've not really been up to much. I'm doing a 3 week SSC at the moment, and rather than do yet another clinically based one I decided to make my own, and so I'm spending 3 weeks looking at Medical Education, I subject which I'm for some reason almost ashamed to say, fascinates me. It a fairly simple project, or so I thought, mainly a library based literature review sort of thing. Also means I don't have to drive to hospital every day which is a good thing and I get the occasional long morning in bed (when missbliss doesn't poke me for a lift to school)

So, medical education, bit of an odd topic for an SSC I hear you cry, well maybe it is. To be honest, I was hoping for the chance to write 4000 words on the shortcomings of Problem Based Learning (PBL), that is probably what I'll end up doing but already I've found so much more than that. I've even dared to venture into the depths of learning itself, what is learning? What is knowledge? Two questions which lots of old dudes with long names seem to have take a lifetime to waffle about back in the days of temples and dragons. I find myself strangely curious about it all, if somewhat embarrassed that I'm this interested.

I still don't know how to feel about PBL and I've been doing it for 4 years! As a concept its probably quite good, and it has its advantages, but in practice it just doesn't work like it should, whatever the reasons (and there are plenty.) Although saying that, I think a lecture based course would have killed me. So, this SSC is going to be a bit of a voyage into the unknown, who knows where I'll come out on the other side, and what I'll think by then, perhaps I'll have solved a few of the worlds problems along the way, one thing is for sure, if you stay tuned, I'll let you know.