Crap sandwiches

Thinking through the last post, I realised I'd put up some received wisdom on the good old hamburger approach to providing feedback without backing it up with facts. In the spirit of evidence based medicine, to discover whether the crap sandwich is as crap as I thought, or not, I did a quick scout around to see what the world's great thinkers in feedback provision are saying. Caveat: very quick scout about.

A group called Success Strategies, who look like they are a group of management consultants of some kind, post an interesting discussion on the method. Their key issues are that:

(i) most people know about this method, brace themselves for the crap in the middle and discount / ignore the rest, and
(ii) it only takes a couple of rides on the crap sandwich rollercoaster to learn exactly how it works and react as for (i).

This page also provides an alternate method which avoids direct criticism and instead kicks the discussion off with suggestions of how to deal with the situation which went awry. Interesting.

Although this approach is grounded in NLP, which some consider pseudoscience (it says here - although it seems to work for Derren Brown), this group have worked with some creditable organisations which provides a degree of weight to their work.

A literature search brings up little on the subject... perhaps a fruitful research topic for someone, who knows. The search did, however, bring up an excellent article from a US Obs&Gynae educational committee of some sort describing in detail how the US is approaching the provision of feedback to medical undergrads. They outline a quite structured, complex process which necessitates a dialogue and a lot of preparation with no input from peers... quite the opposite to what Australian med schools seem be recommending. Given the lack of outcome evidence (from what I can see), who knows which approach is best.

The reference for this, should anyone be interested, is: American Journal of Obstetrics and Gynecology (2007). 196 (6). 508 -513. I think it may be available if you register, but it's an Elsevier journal so perhaps not.

On balance, I would still say the crap sandwich is on the nose. Avoid.

Med Student peer review

As part of a new phalanx of insight-laden medical students, full of reflective goodness, we receive a lot of feedback from our betters / tutors / call them what you will on a broad range of elements of performance.

Further, given all the reflective bits and bobs, we are at the pointy end of plenty of feedback from ourselves too.

All of this is assessed, and, presumably, if it looks like we're lacking in insight or something, steps will be taken remedy matters before graduation.

On top of this, joy of joys, we are subject to feedback from our peers. We are monitored to make sure that we're not too soft on one another, presumably to avoid an eBay-feedbackesque situation where everyone is nice to avoid tit-for-tat retributions and so to ensure that the feedback is honest and, therefore, valuable.

This all sounds fair enough: most jobs in the real world require an annual or semi-annual appraisal which may or may not be 360 degrees in nature. However, normally the blow of receiving this feedback is softened by (i) the medium of delivery and (ii) who is providing the feedback. And perhaps you'll get a pay rise or a promo if the review goes well.

To address the second issue first, it's going to be interesting to see how the feedback from fellow students evolves over the rest of the course given that to date for most people I've spoken to it's been somewhat lacking in positive, actionable steps.

This isn't a huge surprise given that my peers don't have a lot of experience here and have only been taught the largely discredited "crap sandwich" approach to feedback (start with something good about you, then get the meat of the feedback with something crap about you, then finish off with what to do to improve). Still, some of the stuff is useful so I suck it in and take what I can from what I'm given.

The main issue is the first: the medium of delivery. In my colourful pre-med career I received diverse feedback from diverse people in diverse situations. I've had good reviews from balls-out US investment bankers in the backs of a taxis (mental image unintended), terrible pay news from nervous European bankers over telephone lines and woolly, "what was that conversation all about" feedback from fuddled academics in labs who weren't at all keen on this type of thing. I've also had to use a number of electronic systems having nominated a number of colleagues all of whom, and this is important, have been trained in using these systems the output of which is numerical.

However, what I haven't had is an online posting system where you log in and read feedback. I'm not sure about this route to provide feedback to happy recipients: there's not a lot of room for discussion / clarification with the feedbacker, there isn't space for emotional or intonational nuances to be provided: it's rather like getting a very personal SMS from someone you barely know.

Let's see how things progress.

Dress code

Clinical attachments have begun and the dress code has been revealed. In this case, somewhat tersely by a busy surgeon in a short introductory speech.

It looks like it's back to a suit and tie, which is fine with me because I can dig out the old bags of fruit from the wardrobe (assuming that the moths haven't got to them) and my most vomit-resistant tie.

I'm a bit surprised that ties are required what with infection control and all; perhaps this chap is just a bit old school. To be honest, it's good to get a bit of straightforward guidance on this given that woolly advice has caused problems before, specifically with leather loafers three years ago (good to see that medical students remain ahead of the fashion police on this one).

The wonders of technology

This site has a lot to answer for. As does the introduction of campus-wise wireless internet and the acceptance of laptops in lecture theatres. There's nothing like trying to concentrate on a dull lecture whilst the eight guys in front of you take turns on a laptop trying to guide a bouncing ball around a maze filled with other bouncing balls.

Name change

Time goes by and being a good reflective practitioner in training I've been thinking about the title of this blog. It's time to commit so I've lost one of my faces and gone with a new name that reflects how I feel amongst my peers.

Hot 100: John Peel and lugging too much stuff around clincial placements

Being an old northern England indie boy at heart, but with techno lungs and an ambient spleen, I grew up listening to John Peel on Radio 1 (FM or otherwise). From being a small lad confused by what I was hearing, through the wilderness years where I stopped listening due to the intrusion of work and other interests, to returning to the fold just prior to his death, John Peel was something of a constant in my life and the lives of most average bedroom-bound music obsessives.

Each Christmas, he compiled a list of listeners' favourite songs released that year. It had to have been released in current year to prevent "Anarchy in the UK" winning again. Compiling the "Festive 50" seems to have been a pain in the backside, but each year out it came and out it still comes.

Inspired by this, a friend of mine from school, now sadly demolished (the school that is), who by some miracle has made it to medical school, saw a solution to a problem he faced. Being back in the days of CDs, pre-MP3, he faced the prospect of starting a series of short-term clinical placements music-free unless he chose to cart his record collection around from placement to placement. And it was largely a record collection, because he was largely a fan of 60s rarities and US imports which came in vinyl only. Taping wasn't an option or him due to loss of self-esteem, sad obsessive that he was (as discussed). Having said that, I would have been just as bad.

Thus began his "Hot 100" where he selected only those 100 records he couldn't live without ("hot" in this case being a highly subjective term unless you were a big fan of Wingtip Sloat). Even then, 80 odd vinyl records is a lot to lug from one place to another every six weeks or so.

Reading back through this, it sounds like a story from the dark ages, sitting here with an iPod I will never get close to filling to capacity. Then again, pre-1999 or thereabouts, student digs hadn't changed all that much since the 50s: different posters, dansettes / ghetto blasters / portable CDs players notwithstanding. There may have been an occasionally laptop in the 1999 vintage study rooom, but that was still unusual for undergrads. My friend would have traded a kidney to get his hands on a small device that could have contained all his music.

So spare a thought for the poor old clinical phase medical student of the pre-iPod 80s / 90s. They may have been guaranteed a training place and have been spared MTAS and the rest, but they had to make the difficult decision of whether to pack Speedy J or Loop.

Professionalism

A common thread running through both medical courses is a focus on reflective practice. Indeed, there is a strong similarity between Australia and the UK regarding the emphasis being placed on this aspect of the training. I can appreciate the importance of ensuring that doctors in training have an understanding of the importance of self-awareness, but I suspect I am in the minority among my student peers on that.

One difference, however, is the almost absolute lack of formal "professionalism" lectures and assignments here in Australia. "Professional behaviour" was almost fetishistically followed in the UK. Whether Australia considers professionalism to be a no-brainer, or whether the previously discussed lack of a Shipman means that the importance of teaching this formally is not appreciated, is hard to say. Perhaps later in the course we will get lectures on this but I can't see anything in he course outline so far.

Unlike reflective practice, the case of drumming professionalism into young medics is, I think, rather less clear cut. By formalising the process of ensuring professional behaviours, by providing all and sundry with the "unprofessional" stick with which to beat 18 yr olds, the importance of such behaviours is eroded. Further, certain parties, including peers, have a tendency to conflate "professional behaviour" with "doing as I say and shutting up". Here are a few examples of "unprofessional behaviour" as defined in UK:

• Not putting hand up prior to speaking in a public forum having been requested to ask a question.
• Not wearing a tie for a social work client encounter having been told previously that wearing a tie would intimidate their clients.
• Ditto another student being reported for wearing trainers which turned out to be smart casual leather shoes.
• Not using Vancouver referencing system correctly (that is, missing out on a comma or two).
• Forgetting to hand in a marking guide cover sheet on an assignment.
  

And on it went in all its nit-picking glory.

Cheerfully, currently the Australian course seems rather more relaxed as to whether the cover sheet on your assignment is 12 or 14 point font. Perhaps this is not setting the right standard up front and perhaps this course will turn out terribly slapdash students who will be unable to recite the 12 or so Duties of a Doctor (the number is hard to pin down because the list isn't MECE and is very hard to fit into a mnemonic). Or perhaps it means that sanctions can be saved for less trivial errors and oversights.

Who is the leading figure in British medical education today?

Prior to heading to med school, if asked which person would feature most often in the early stages of British medical education I would probably have guessed at Galen, or possibly the PM or health minister, or perhaps a local medical hero. Here in Australia, I would have plumped for Victor Chang or Fred Hollows. Most other laypeople would probably give a similar response and name someone who made a significant contribution to the progress of medicine, someone who will control your future progress, or someone inspiring.

Following the Dean's ten minute introduction on Day 1 at my UK med school, the next academic to speak spent most of his allotted time standing in front of a full-screen picture of a bearded and bespectacled GP from northern England. This motif continued throughout my time there: the presence of Harold Shipman was never away from an ethics or "professional behaviours" lecture either implicitly, or indeed explicitly via a full screen picture and another re-telling of his terrible story. A high-level read around the subject of Modernising Medical Careers now reveals how often his example is invoked by those who set the educational agenda.

So far here in Australia the medical role (or anti-role) models encountered have conformed to my expectations. Whether it is because the medical school is saving the pleasures of "new" professionalism for a later date, whether they do not think that Shipman was such a problem, or whether they did not experience Shipman first hand and so do not acknowledge potential poisons in the Australian mud is hard to say.

There's a lot in the MMC approach to education which is long overdue and will, I think, improve the quality of med school product. However, I must say that it is refreshing to see the medical students being allowed to be inspired by medical practice before being clobbered repeatedly by the examples of practice gone awry.

Dissection plus prosection vs prosection alone

There seems to some debate at the moment regarding whether the next generation of surgeons will lack a certain amount of expertise due to the phasing out of dissection in med schools. The UK is wrestling with this along with the imposition of the European Working Time Directive which will reduce the number of hours a surgeon will have under their belt by the time they are free to operate. The reason I mention this is that it may be a confounding factor when the time comes to analyse whether removing dissection has had a deleterious impact on the quality of surgeons produced.

Not that dissection is much of an option at the present time: I recall there being only 600 cadavers available in the UK in 2005 or thereabouts. Given the huge number of med students in the pipeline, even at twelve to a body the aren't enough to go around.

Twelve seems to be the max you can accommodate. There will be two or three students who are generally not that into it, two or three who are not in the correct state of mind and / or body during that particular class and two or three who are a bit too timid to get too involved thereby leaving four or so horribly assertive aspirational surgeons to get on with it. Any more than that would lead to ugly scenes, I would imagine, particularly as the cadaver gets smaller during the year.

Being the partial, unfinished and highly imperfect work-in-progress product of two med schools, one with dissection and one without, I've had chance to reflect (see first post) on the pros and cons of including dissection in the syllabus.

Pros

• Dissection eases you into the physically challenging aspects of the course. You go from prosection, plastinated organs which are visually quite removed from the in situ organ, to body sections, to eventually the whole body, a process which help to get students comfortable with handling and examining body parts and, indeed, bodies. The process of respectfully gaining an understanding of anatomy via dissection provides the opportunity to apply challenging procedures to another human body.
• Working around a cadaver was, I found, a good collegiate learning environment where discoveries could be shared and learnings consolidated through the process of dissection. It was also a strong bonding experience to be working in such a privileged environment.
  
• Each and every student, as you would expect, maintained a high degree of professionalism at all times during the process: excellent preparation for future experiences.
  
• Dissection provides the opportunity to understand how tissues relate to one another and how to remove certain tissues and organs to reach another. If you are a visual learner like what I am (grammar) , you can visualise what was where and how you got to it a long time after the event.

Cons

• From the med school's point of view, it's a logistical and cost headache which is fair enough.
• Dissection can prove too challenging for some to encounter so early in the course.
• We're still waiting for proof, as far as I can tell, that experience with dissections makes for a better doctor, which would appear to be the clincher...
• ...that and the fact that there aren't many donors anymore.
  

However, I found it one of the most valuable aspects of the course I started in the UK and will miss it here in Australia: if you have the choice, choose a school with dissection on the syllabus

First posting: setting out my stall

There are many reasons for keeping this blog, one of which is that I have been recommended by the medical school that I keep a diary to assist on reflective practice. A public forum may not be the best place for this, but there are a few elements of what I am experiencing that will probably benefit from broader input and are appropriate for here. Up to a point.

Another reason is to discuss some other things I find of interest. Pretentiously solipsistic? Moi?

You would have to hesitate to call this a creative outlet but perhaps it could be. I've been following several medical blogs over the years, some written by medical students, others by experienced practitioners, and I have always enjoyed the non-medical aspects of their writings.

Finally, depending on whether I actually get any constructive comments whatsoever, it would be educational to discuss the more content-driven aspects of the course. Given the amount of PBL and peer-driven medical courses out there, this approach can't be much worse than sitting in a room with an F1 doc who is making a guess at whether asthma is an obstructive disorder or what.

Finally, FWIW I have an iterative writing process which will lead to inevitable typos and missing words despite best proofreading efforts.

Let the tumbleweed roll!