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Foo20151013 2023 7owyf5?1444773963
3
158

Benchmarking Outpatient Referral Rates

Introduction GPs for a little while have been asked to compare each other’s outpatient referrals rates. The idea is that this peer to peer open review will help us understand each others referral patterns. For some reason and due to a natural competitive nature of human behaviour, I think we have these peer to peer figures put to us to try to get us to refer less into hospital outpatients. It’s always hard to benchmark GP surgeries but outpatient referral benchmarking is particularly poor for several reasons It's Very Difficult to Normalise Surgeries Surgeries have different mortalities morbidities ages and other confounding factors that it becomes very hard to create an algorithm to create a weighting factor to properly compare one surgery against another. There Are Several Reasons For The Referral I’ll go into more detail on this point later but there are several reasons why doctors refer patients into hospital which can range from: doctors knowing a lot about the condition and picking up subtle symptoms and signs lesser experienced doctors would have ignored; all the way to not knowing about the condition and needing some advice from an expert in the condition. We Need To Look At The Bigger Picture The biggest killer to our budget is non-elective admissions and it’s the one area where patient, commissioner and doctor converge. Patients want to keep out of hospital, it’s cheaper for the NHS and Doctors don’t like the lack of continuity when patients go in. For me I see every admission to hospital as a fail. Of course it’s more complex than this and it might be totally appropriate but if we work on this concept backwards, it will help us more. Likewise if we try to reduce outpatient referrals because we are pressurised to, they may end up in hospitalisation and cost the NHS £10,000s rather than £100s as an outpatient. We need to look at the bigger picture and refer especially if we believe that referrals will lead to less hospitalisation of patients further down the line. To put things into perspective 2 symptoms patients present which I take very seriously are palpitations in the elderly and breathlessness. Both symptoms are very real and normally lead to undiagnosed conditions which if we don’t tackle and diagnose early enough will cause patients to deteriorate and end up in hospital. Education, Education, Education When I first went into commissioning as a lead in 2006 I had this idea of getting to the bottom of why GPs refer patients to outpatients. The idea being if we knew why, we would know how to best tackle specialities. I asked my GPs to record which speciality to refer to and why they referred over a 7 month period. The reason for admission was complex but we divided them up into these categories: 2nd care input required for management of the condition. We know about the condition but have drawn the line with what we can do in primary care. An example of this is when we’ve done a 24 hour tape and found a patient has 2sec pauses and needs a pace maker. 2nd care input required for diagnosis. We think this patient has these symptoms which are related to this condition but don’t really know about the diagnosis and need help with this. An example of this is when a patient presents with diarrhoea to a gastroenterologist There could be several reasons for this and we need help from the gastroenterologist to confirm the diagnosis via a colonscopy and ogd etc. Management Advice. We know what the patient has but need help with managing the condition. For example uncontrolled heart failure or recurrent sinusitis. Consultant to Consultant Referral. As advised between consultants. Patient Choice. Sometimes the patient just wants to see the hospital doctor. The results are enclosed here in Excel and displayed below. Please click on the graph thumbnail below. Reasons For Referrals Firstly a few disclaimers and thoughts. These figures were before any GPSI ENT, Dermatology or Musculosketal services which probably would have made an impact on the figures. There are a few anomalies which may need further thought eg I’m surprised Rheumatology for 2nd input for diagnosis is so low, as frequently I have patients with high ESRs and CRPs which I need advise on diagnoses. Also audiology medicine doesn’t quite look right. The cardiology referral is probably high for management advise due to help on ECG interpretation although this is an assumption. This is just a 7 month period from a subset of 8-9 GPs. Although we were careful to explain each category and it’s meaning, more work might need to be done to clarify the findings further. In my opinion the one area where GPs need to get grips with is management advice as it’s an admission that I know what the patient has and need help on how to treat them. This graph is listed in order of management advice for this reason. So what do you do to respond to this? The most logical step is to education GPs on the left hand side of this graph and invest in your work force but more and more I see intermediary GPSI services which are the provider arm of a commissioning group led to help intercept referrals to hospital. In favour of the data most of the left hand side of the graph have been converted into a GPSI service at one point. In my area what has happened is that referrals rates have actually gone up into these services with no decline in the outgoing speciality as GPs become dis-empowered and just off load any symptoms which patients have which they would have probably had a higher threshold to refer on if these GPSI services were not available. Having said that GPSI services can have a role in the pathway and I’m not averse to their implementation, we just have to find a better way to use their services. 3 Step Plan As I’m not one to just give problems here are my 3 suggestions to help referrals. To have a more responsive Layered Outpatient Service. Setting up an 18 week target for all outpatients is strange, as symptoms and specialities need to be prioritised. For example I don’t mind waiting 20 weeks for a ENT referral on a condition which is bothering me but not life threatening but need to only have a 3 week turn over if I’m breathless with a sudden reduction in my exercise tolerance. This adds an extra layer of complexity but always in the back of my mind it’s about getting them seen sooner to prevent hospitalisation. Education, education, education It’s ironic that the first budget to be slashed in my area was education. We need to education our GPs to empower them to bring the management advice category down as this is the category which will make the biggest impact to improving health care. In essence we need to focus on working on the left hand side of this graph first. Diagnose Earlier and Refer Appropriately The worst case scenario is when GPs refer patients to the wrong speciality and it can happen frequently as symptoms blur between conditions. This leads to delayed diagnosis, delayed management and you guessed it, increased hospitalisation. The obvious example is whether patients with breathlessness is caused by heart or lung or is psychogenic. As GPs we need to work up patients appropriately and make a best choice based on the evidence in front of us. Peer to peer GP delayed referral letter analysis groups have a place in this process. Conclusion At the end of the day it's about appropriate referrals always, not just a reduction. Indeed for us to get a grip on the NHS Budgets as future Clinical Commissioners, I would expect outpatient referrals to go up at the expense of non-elective, as then you are looking at patients being seen and diagnosed earlier and kept out of hospital.  
Raza Toosy
almost 9 years ago
Foo20151013 2023 riytde?1444773947
3
99

Reflection

Just as a bit of an intro, my name is Conrad Hayes, I'm a 4th year medical student studying in Staffordshire. My medical school are quite big on getting us into the habit of writing down reflections. It's something I feel I do subconsciously whilst I'm with patients or in teaching sessions, but frankly I suck at the written bit and I feel on the whole it's probably because there's nobody discussing this with us or telling me I'm an idiot for some of the things I may think/say! So I think if I'm going to attempt to complete a blog then I am going to do it in a reflective style and I do look forward to peoples feedback and discussions. I'll try to do it daily and see if that works out well, or weekly. But hopefully even if it doesn't get much response it can just be a store for me to look back on things! (Providing I keep up with it). So I'll start now, with a short reflection on my career aspirations which have been pretty much firmed up, but today I gave a presentation that I felt really galvanised me into this. So I want to do Emergency Medicine and Expedition Medicine (on the side more than as my main job). Emergency Medicine appeals to me as I love primary care and being the first to see patients, but I want to see them when they're ill and have a role in the puzzle solving, as it were, that is their issues. Possibly more to the point I want to do this in a high pressure environment where acutely ill individuals come in, and I feel (having done placements in A&E and GP and AMU) A&E is the place for me to be. Expedition Medicine on the other hand is something I accidentally stumbled upon really. In 2nd year I was part of a podcast group MedHeads that we tried to set up at my medical school. I interviewed Dr Amy Hughes of Expedition & Wilderness Medicine, a UK company, and I got really excited about the concepts she was talking about. Practicing medicine in the middle of nowhere, limited resources and sometimes only personal accumen and ingenuity to help you through. It sounded perfect! And since then I've wanted to do it, particularly being interested in Mountain Medicine and getting involved with some research groups. Today in front of my group I gave a presentation on the effects of altitude on the brain (I'm on Neurology at the moment and we had to pick a topic that interested us). I spoke for 15 minutes, a concept that usually terrifies me truth be told, and I thoroughly enjoyed myself. Now I've given a fair number of presentations but this was the first time I was actively excited and really happy about talking! It seems to me that if that isn't the definition of why you should go for a job, then I need to talk to a careers advisor. This experience has definitely ensured I pursue this course with every resource I have available to me! I would be interested in hearing how other people feel about their careers panning out and what got them into it so feel free to leave a comment!!  
Conrad Hayes
almost 9 years ago
Foo20151013 2023 aoqg73?1444773932
2
89

A Humble NHS?

A Recap Last week in my personal blog I reflected on humility as defined by James Ryle: God given self-assurance that eliminates the need to prove to others the worth of who you are and the rightness of what you do. Ryle suggests, from 1 Peter 5:5-7, that central to humbling ourselves is throwing our cares on to God. Every concern, care and fear being hurled on to God who is faithful and powerful enough to handle them. When we know that we are loved by Him no matter what and that He is in control no matter what, then we remove the need to prove ourselves or protect ourselves. We become humble – secure enough to allow God to be in control and to serve others. Once our eyes are lifted from ourselves we are able to see others to love and serve them. Stafford Hospital Just before writing the last post I was reading an article about the report by Robert Francis QC on the appalling treatment of patients at Stafford Hospital. One of the recurring comments made by many different people is that the pressure of targets and incentives increasingly displaces focus on compassion and patient care. When doctors, nurses and managers alike are bombarded with ever increasing and regularly changes hoops to jump through and targets to meet, no wonder their attention and efforts are dragged from patient care. I’ve seen something of the effects of this in a family member who for many years worked as a Health Visitor. In their decades of service they saw an ever increasing and ever changing string of targets and goals alongside cost cutting moves that stripped resources and personnel. Their desire to be compassionate and offer the best care possible became more and more stressful until it finally proved too much. She recently changed jobs. Now I’m not trying to attack the NHS and I am well aware that so many people receive great care. But this is not a new concern that is being bandied around with fresh vigour in the light of Stafford Hospital. What struck me is that it demonstrates on an institutional level what also seems true at a personal level. Namely, that when we are forced to operate from a place of insecurity we begin to miss the most important things. NHS services have to meet targets to receive funding to simply keep operating – there will be no patient care if there is no hospital. Oftentimes, especially as a leader, we can live with a sense that, unless we meet expectations or make people like us or recognise our worth, then we’ll have no influence to do any of the things we know we are called to do. The secret of personal humility is to recognise that we are already loved by our Father before we even move our finger; to recognise that He is control and we can throw every care on Him. A person who can live from that place of security finds, free from the need to prove themselves or their actions, can begin to simply do what they are made and called to do. They are no longer pulled in different directions by a multiplicity of cares. What about an institution? It strikes me that a similar solution is needed for the NHS. Is there a way to give security for doctors, nurses and caring professionals so that they are able to do what they are called to do without constantly watching their back? Obviously there is a need for accountability for the safety of patients and to ensure a good standard of care, but the constant need to prove worth and achievement cannot be helpful for those who are called to compassionate care. I’m not a healthcare professional. I don’t know exactly what this would look like. But I recognise in the diagnosis of struggles in the NHS, God’s diagnosis of struggles in many people’s lives. The way He designed us to live with Him is often a good basis to begin to imagine a new way for every level of society to function. So, my question is this: what would a humble NHS look like? To whom could a National Health Service throw it’s concerns and cares?  
Rev Samuel Pollard
almost 9 years ago
1
0
29

How long can someone be infected with a Schistosoma parasite and have Schistosomiasis but remain asyptomatic?

If a patient had been swimming somewhere such as Lake Malawi and come back to the UK and did not get tested for Schistosomiasis, is it possible that they could be infected many years later and not know it, as they are asymptomatic?  
Jeremy Walker
about 9 years ago
10
0
7

Is it really true that the medical professions drink more alcohol than other professionals?

There's a well known reputation that doctors drink a lot. Is there any evidence to back this up or is it all circumstantial?  
Dr Witt
about 9 years ago
11
0
3

How is it best to cope with situations in medical training that bring back bad memories?

I have a a friend who has had painful experiences with illness and death in her family. Obviously there are times where she struggles with sad memories as she is learning various parts of medicine. How is it best to deal with this sort of situation?  
Jeremy Walker
about 9 years ago
30314
4
57

Examination of the Spine: A Pain in the Back

Tommy attempts to perform an examination of the spine.  
Ronak Ved
over 9 years ago
29985
14
872

Animation of Initiation of Atherosclerosis - Macrophage Activation 2

This animation shows a simplified version of the macrophage's role in the initiation of atherosclerosis. In an atherosclerotic-prone blood vessel, macrophages invade the subendothelial space. Oxidised Low-Density Lipoproteins (oxLDL) present within the vessel wall will bind to scavenger receptors on the macrophage's surface, such as CD36. This will activate the macrophage, and it will phagocytose the oxLDL. As this process continues, the macrophage increases in size and forms a Foam Cell, which is too large to pass between the endothelial cells back into the lumen. Therefore, the foam cells remain in the subendothelial space and are the main cells present within an atherosclerotic plaque. *** Done for Student Selected Component (SSC), University of Aberdeen. Year 2. 2011. Made in Adobe Photoshop CS2 and Adobe Imageready.  
Victoria Lee
over 10 years ago
29961
21
1129

Animation of Initiation of Atherosclerosis - Macrophage Activation 1

This animation shows a simplified version of the macrophage's role in the initiation of atherosclerosis. In an atherosclerotic-prone blood vessel, macrophages invade the subendothelial space. Oxidised Low-Density Lipoproteins (oxLDL) present within the vessel wall will bind to scavenger receptors on the macrophage's surface, such as CD36. This will activate the macrophage, and it will phagocytose the oxLDL. As this process continues, the macrophage increases in size and forms a Foam Cell, which is too large to pass between the endothelial cells back into the lumen. Therefore, the foam cells remain in the subendothelial space and are the main cells present within an atherosclerotic plaque. *** Done for Student Selected Component (SSC), University of Aberdeen. Year 2. 2011. Made in Adobe Photoshop CS2 and Adobe Imageready.  
Victoria Lee
over 10 years ago
Preview 300x225
6
229

Immunology & Schistosomiasis (Bilharzia)

An interactive learning resource that explores the life cycle of the Schistosoma mansoni parasite and how it exploits the human immune system in order to survive. All links are back up and running. Please let me know if you experience any diffuclties. Thank you!  
Daniel Sapier
over 10 years ago
29749
7
396

Cranial Nerve Examination - Abnormal

Cranial Nerve 1- Olfaction This patient has difficulty identifying the smells presented. Loss of smell is anosmia. The most common cause is a cold (as in this patient) or nasal allergies. Other causes include trauma or a meningioma affecting the olfactory tracts. Anosmia is also seen in Kallman syndrome because of agenesis of the olfactory bulbs. Cranial Nerve 2- Visual acuity This patientâs visual acuity is being tested with a Rosenbaum chart. First the left eye is tested, then the right eye. He is tested with his glasses on so this represents corrected visual acuity. He has 20/70 vision in the left eye and 20/40 in the right. His decreased visual acuity is from optic nerve damage. Cranial Nerve II- Visual field The patient's visual fields are being tested with gross confrontation. A right sided visual field deficit for both eyes is shown. This is a right hemianopia from a lesion behind the optic chiasm involving the left optic tract, radiation or striate cortex. Cranial Nerve II- Fundoscopy The first photograph is of a fundus showing papilledema. The findings of papilledema include 1. Loss of venous pulsation 2. Swelling of the optic nerve head so there is loss of the disc margin 3. Venous engorgement 4. Disc hyperemi 5. Loss of the physiologic cup an 6. Flame shaped hemorrhages. This photograph shows all the signs except the hemorrhages and loss of venous pulsations. The second photograph shows optic atrophy, which is pallor of the optic disc resulting form damage to the optic nerve from pressure, ischemia, or demyelination. Images Courtesy Dr. Kathleen Digre, University of Uta Cranial Nerves 2 & 3- Pupillary Light Refle The swinging flashlight test is used to show a relative afferent pupillary defect or a Marcus Gunn pupil of the left eye. The left eye has perceived less light stimulus (a defect in the sensory or afferent pathway) then the opposite eye so the pupil dilates with the same light stimulus that caused constriction when the normal eye was stimulated. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Inspection & Ocular Alignmen This patient with ocular myasthenia gravis has bilateral ptosis, left greater than right. There is also ocular misalignment because of weakness of the eye muscles especially of the left eye. Note the reflection of the light source doesn't fall on the same location of each eyeball. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Versions • The first patient shown has incomplete abduction of her left eye from a 6th nerve palsy. • The second patient has a left 3rd nerve palsy resulting in ptosis, dilated pupil, limited adduction, elevation, and depression of the left eye. Second Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerves 3, 4 & 6- Duction Each eye is examined with the other covered (this is called ductions). The patient is unable to adduct either the left or the right eye. If you watch closely you can see nystagmus upon abduction of each eye. When both eyes are tested together (testing versions) you can see the bilateral adduction defect with nystagmus of the abducting eye. This is bilateral internuclear ophthalmoplegia often caused by a demyelinating lesion effecting the MLF bilaterally. The adduction defect occurs because there is disruption of the MLF (internuclear) connections between the abducens nucleus and the lower motor neurons in the oculomotor nucleus that innervate the medial rectus muscle. Saccades Smooth Pursui The patient shown has progressive supranuclear palsy. As part of this disease there is disruption of fixation by square wave jerks and impairment of smooth pursuit movements. Saccadic eye movements are also impaired. Although not shown in this video, vertical saccadic eye movements are usually the initial deficit in this disorder. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Utah Optokinetic Nystagmu This patient has poor optokinetic nystagmus when the tape is moved to the right or left. The patient lacks the input from the parietal-occipital gaze centers to initiate smooth pursuit movements therefore her visual tracking of the objects on the tape is inconsistent and erratic. Patients who have a lesion of the parietal-occipital gaze center will have absent optokinetic nystagmus when the tape is moved toward the side of the lesion. Vestibulo-ocular refle The vestibulo-ocular reflex should be present in a comatose patient with intact brainstem function. This is called intact "Doll’s eyes" because in the old fashion dolls the eyes were weighted with lead so when the head was turned one way the eyes turned in the opposite direction. Absent "Doll’s eyes" or vestibulo-ocular reflex indicates brainstem dysfunction at the midbrain-pontine level. Vergenc Light-near dissociation occurs when the pupils don't react to light but constrict with convergence as part of the near reflex. This is what happens in the Argyll-Robertson pupil (usually seen with neurosyphilis) where there is a pretectal lesion affecting the retinomesencephalic afferents controlling the light reflex but sparing the occipitomesencephalic pathways for the near reflex. Video Courtesy of Dr.Daniel Jacobson, Marshfield Clini and Dr. Kathleen Digre, University of Uta Cranial Nerve 5- Sensor There is a sensory deficit for both light touch and pain on the left side of the face for all divisions of the 5th nerve. Note that the deficit is first recognized just to the left of the midline and not exactly at the midline. Patients with psychogenic sensory loss often identify the sensory change as beginning right at the midline. Cranial Nerves 5 & 7 - Corneal refle A patient with an absent corneal reflex either has a CN 5 sensory deficit or a CN 7 motor deficit. The corneal reflex is particularly helpful in assessing brainstem function in the unconscious patient. An absent corneal reflex in this setting would indicate brainstem dysfunction. Cranial Nerve 5- Motor • The first patient shown has weakness of the pterygoids and the jaw deviates towards the side of the weakness. • The second patient shown has a positive jaw jerk which indicates an upper motor lesion affecting the 5th cranial nerve. First Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 7- Motor • The first patient has weakness of all the muscles of facial expression on the right side of the face indicating a lesion of the facial nucleus or the peripheral 7th nerve. • The second patient has weakness of the lower half of his left face including the orbicularis oculi muscle but sparing the forehead. This is consistent with a central 7th or upper motor neuron lesion. Video Courtesy of Alejandro Stern, Stern Foundatio Cranial Nerve 7- Sensory, Tast The patient has difficulty correctly identifying taste on the right side of the tongue indicating a lesion of the sensory limb of the 7th nerve. Cranial Nerve 8- Auditory Acuity, Weber & Rinne Test This patient has decreased hearing acuity of the right ear. The Weber test lateralizes to the right ear and bone conduction is greater than air conduction on the right. He has a conductive hearing loss. Cranial Nerve 8- Vestibula Patients with vestibular disease typically complain of vertigo – the illusion of a spinning movement. Nystagmus is the principle finding in vestibular disease. It is horizontal and torsional with the slow phase of the nystagmus toward the abnormal side in peripheral vestibular nerve disease. Visual fixation can suppress the nystagmus. In central causes of vertigo (located in the brainstem) the nystagmus can be horizontal, upbeat, downbeat, or torsional and is not suppressed by visual fixation. Cranial Nerve 9 & 10- Moto When the patient says "ah" there is excessive nasal air escape. The palate elevates more on the left side and the uvula deviates toward the left side because the right side is weak. This patient has a deficit of the right 9th & 10th cranial nerves. Video Courtesy of Alejandro Stern, Stern Foundatio Cranial Nerve 9 & 10- Sensory and Motor: Gag Refle Using a tongue blade, the left side of the patient's palate is touched which results in a gag reflex with the left side of the palate elevating more then the right and the uvula deviating to the left consistent with a right CN 9 & 10 deficit. Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 11- Moto When the patient contracts the muscles of the neck the left sternocleidomastoid muscle is easily seen but the right is absent. Looking at the back of the patient, the left trapezius muscle is outlined and present but the right is atrophic and hard to identify. These findings indicate a lesion of the right 11th cranial nerve. Video Courtesy of Alejandro Stern, Stern Foundation Cranial Nerve 12- Moto Notice the atrophy and fasciculation of the right side of this patient's tongue. The tongue deviates to the right as well because of weakness of the right intrinsic tongue muscles. These findings are present because of a lesion of the right 12th cranial nerve.  
Neurologic Exam
almost 11 years ago
%3fr=0
8
516

Video Animation In Medical Education

Introduction This post describe the creation of a Stroke Summary video. The aim of this project was to assess the attitudes of medical students towards the use of video animation in medical education. An educational tutorial was produced outlining the basic principles of stroke. This aimed to provide a summary of different aspects relating to stroke, outlined in the Bristol University curriculum. This intended to be a short, concise animation covering stroke presentation, definition and recognition, with an overview of the blood supply to the brain and the classification of stroke presentation used in clinical practice. This was followed by some key facts and a summary of different management stages. After the video animation was produced an assessment of student’s attitudes using an online questionnaire was undertaken. This consisted of ten short questions and an open text feedback for additional comments. The video was then edited with reference to feedback given by students and the results analysed. This report will outline relevant research and project work that lead to this assignment being undertaken. A description of the method followed to generate the video animation and to collect feedback on students will be outlined followed by analysis of results. This will then be discussed in relation to previous work and research. Background There are a number of reasons this project has been undertaken. On a personal level, I have a long-standing interest in teaching and medical education. As part of a previous project I created a series of audio tutorials in cardiovascular medicine and assessed student attitudes to audio learning. The findings of this report showed that a large number of students found these audio tutorials useful and would like more of these available to supplement their learning. One of the questions given to students at this time assessed how useful they found different types of educational material. This project showed students reporting audio tutorials more useful than previously thought, while also reporting that they were not readily available. Although a video tutorial was not provided to them at this time, feedback questions assessed attitudes to video tutorials as a learning resource. Students reported low availability and felt they would be more useful than audio tutorials. Some results from this project are shown in figure 1. Figure 1. Results from previous research by Buick (2007), showing attitudes of students towards different learning tutorials. The majority of students report audio tutorials to be ‘quite useful’ or ‘very useful’. Video tutorials are thought by students to be more useful that audio tutorials, however there is a large proportion that do not have access to these learning resources. As a number of students reported an inability to access to video tutorials, it was thought that creating a video animation tutorial followed by assessing students attitudes would be a useful follow up project. If this is found to be a useful resource, other students may generate video tutorials in the future. Therefore student feedback also assessed attitudes towards authenticity, relating to who generates the tutorial and whether they find the ability to feedback a useful tool. Medical education is widely researched globally, although it is not often a consideration for those studying medicine. Those involved in teaching and educating future doctors have looked at different methods of passing on knowledge. A high quality medical education given to future healthcare professionals is important. It is widely accepted that a better knowledge results in better care for patients and education is at the centre of any healthcare system. This is reflected in the cost of educating medical students and training doctors in the UK. In the 1997 it was reported by the Department of Health that estimates of 200 million pounds would be spent per year for an increase in 1000 medical students being trained in the UK. This suggests that the cost of training a medical student is in the region of £200,0001. Medical education in the UK is split in two halves, with undergraduate and postgraduate training. The Department of Health has recently invested millions of pounds into the development of online tutorials for postgraduate training posts in a number of different specialities. Justification for is given by reducing the cost of training through the use of standardised online tutorials. This will be a more cost effective method than the standard in hospital teaching. This approach has not been undertaken for undergraduate medical education. Universities are seen as primarily responsible for undergraduate training. Many of these institutions have used the Internet to aid teaching and have produced video tutorials. However, as reflected in the previous project (Buick, 2007), resources are often limited and students do not feel they have ready access to these educational tutorials. The benefits of different types of learning resource have been researched. These include online audio downloads (Spickard et al, 2004), practice exam questions and interactive tutorials (Hudsen, 2004). Research showing the benefit of video was shown by Balslev et al (2005) comparing video and written text while teaching a patient case. Balsley et al (2005) found those who learnt using a video presentation rather than those given written text showed a significant increase in data exploration, theory evaluation and exploration. However, there is little research looking specifically at video animation for explaining conditions. Animation software is now available on personal computers and is also possible using Microsoft PowerPointTM, which is the most widely used presentation software. It is clear that recent trends show training can benefit from this type of learning resource. Generation of high quality video tutorials can help students learn while reducing the cost of training. It is for this reason that more material is likely to become available, either from funded production supported by external organisations or by the trainers and trainees themselves who have technology able to produce material such as this on their home computer. Ethical and Legal Issues During the development of this video some ethical and legal issues arose that had to be addressed before a final video could be made. When considering what imagery would be used in the video, I wanted to include pictures of clinical signs relevant to the audio narration. However, taking images from the Internet without prior consent was not thought to be ethical and therefore clinical signs were displayed graphically through drawings and diagrams. Plagiarism and copyright were some of the legal issues surrounding the presentation of medical information. Narrated information was generated using a number of information sources, none of which were exclusively quoted. Therefore an end reference list was generated showing all supporting information sources. Images used in the animation were either self generated or taken from sources such as Wikipedia.org. This resource supplies images under a free software license such as GNU general public license2. This allows anyone to freely use and edit images while referencing the original source. Skills Needed To Develop This Video Animation To generate the video a number I had to develop a number of new skills. Unlike previous work that had been undertaken this media was generated using animation software. To use this effectively I had to research the different functions that were available. To do this I combined reading books aimed to teach beginners such as Macromedia Flash 8 for Dummies (Ellen Finkelstein and Gurdy Leete, 2006) and online sources such as www.learnflash.com . To generate voice narration, another program was used that allowed editing and splicing of audio tracks. This was then split up into a number of narrated sections and added to the animation. Method Script To produce the tutorial the first stage was to construct a script for narration. This involved outlining the areas to be covered. The main headings used were: Stroke definition This gave a clinical definition and a lay person recognition mnemonic called FAST which is used to help members of the general public recognise stroke. Pathophysiology This covered blood supply to the brain. This combined diagrams of the circle of Willis, with images of the brain. Arterial blood supply were then displayed over the brain images while relating this to the arterial vessels leaving the circle of Willis Classification Students at Bristol university are asked to understand the Oxford / Bamford classification. This was covered in detail with explanations of clinical signs that may be seen and graphical representation of these. Prevalence This section covered prevalence, national impact and cost of stroke in the UK. Management In this section management was split up it to immediate management, medical management, in hospital care and some of the procedures considered for different cases. Risk factors for stroke and research into this was also written up and narrated. However at a later stage this was not included due to time constraints and video length. Narration An audio narration was generated using software called ‘Garage Band’ which allows audio tracks to be recorded and edited. The narration was exported in 45 sections so that this could then be added to the animation at relevant points. Animation The animation was made using Adobe Flash. This software is used for making websites and animations used for Internet adverts. It has the facility to export as a ‘flash video format’, which can then be played using a media player online. This software generates animation by allowing objects to be drawn on a stage and moved around using command lines and tools. This was used as it has the ability to animate objects and add audio narration. It also is designed for exporting animations to the Internet allowing the material to be accessed by a large number of people. Feedback A short questionnaire was generated which consisted of ten questions and placed online using a survey collection website (www.surveymonkey.com). Students were directed to the feedback questionnaire and allowed to submit this anonymously. Adapting the tutorial Some feedback constructively suggested changes that could be made. The video was updated after some concern about the speed of narration and that some of the narrative sections seemed to overlap. Analysis and Report The results of the feedback were then collected and displayed in a table. This was then added to the report and discussed with reference to research and previous project work. Results Students were allowed to access to the video animation through the Internet. After uploading the video an email was sent to students studying COMP2 at Bristol University. These students are required to know about aspects of stroke covered in this tutorial to pass this section of the course. The email notified them of the options to view the tutorial and how to give feedback. In total 30 students completed the feedback questionnaire and out of these 4 students provided optional written feedback. The results to the questions given were generally very positive. The majority of students showed a strong preference to video animations as a useful tool in medical education. The results are displayed in Table 1 below. TABLE 1 shows the ten question asked of the students and to what extent they agreed with each statement. Results are given in the percentage of students who chose the relevant category. Written Feedback Four written comments were made: "Really useful presentation!! Would be much better if someone proof read the whole thing as there are some spelling mistakes; also if the pauses between facts were longer it would be more easier to take in some facts. Overall, really nicely done!!" "Some of speech went too quickly, but good overall" "Very clearly written with excellent use of images to match the text and commentary!" "The Video was excellent." Discussion Student attitudes to this video tutorial were very positive. This was in contrast to the attitudes previously shown in the audio tutorial project (Buick, 2007) where video tutorials were not thought to be a useful resource. These results support recent developments in the generation of online video training for doctors by the Department of Health and previous research by Balsley et al (2005). Question one showed that the majority of students strongly agreed that the stroke video would be a useful resource. Questions two, three and four aimed to establish what aspects of a disease were best outlined using a video animation. Results showed that students agree or strongly agreed that defining the condition, pathophysiology and management were all well explained in this format. Interestingly, a large majority of students (70%) felt pathophysiology was best represented kinaesthetically. This may be due to the visual aspect that can be associated with pathophysiology. Disease processes are often represented using diagrams in textbooks with text explaining the disease process. Using computer technology it is possible to turn the text into audio narration and allow the user to view dynamic diagrams. In this way, students can better conceptualise the disease process, facilitating a more complete understanding of disease and its clinical manifestations. Question five aimed to highlight the benefit of visual stimulation as well as audio narration as a positive learning method. All students agreed or strongly agreed that the combination of these two aspects was beneficial. Question six showed a very strong response from students wanting access to more video tutorials, with 70% of students strongly agreeing to this statement. It is often the case that students take part in generating teaching material, and some students may be concerned that this material is inaccurate. However, many students do not think that this is a significant problem. This is reflected by the spread of student’s opinion seen in question 7, where there was no clear consensus of opinion. It may be that as students learn from a number of different resources, that any inaccuracies will be revealed and perhaps stimulate a better understanding through the process of verifying correct answers and practicing evidence based medicine. Question nine and ten show that most students value resources that allow sharing of educational material and feel they could help others learn. They would also value the option to feedback on this material. The written feedback showed positive responses from students. However there was feedback on some aspects of the video that they felt could be changed. The narration was delivered quickly with few gaps between statements to keep the tutorial short and concise, however this was thought to be distracting and made it less easy to follow. Following this feedback the narration was changed and placed back on the Internet for others to review. Further research and investigation could include the generation of a larger resource of video animations. My research has suggested that using animation to cover pathophysiology may be most beneficial. The software used to make this video also allows for the incorporation of interactive elements. The video produced in this project or other videos could have online menus, allowing users to select which part of the tutorial they wish to view rather than having to watch the whole animation, or they include interactive questions. Reflections Strength and weaknesses Strengths of this project include its unique approach to medical education. There have been few animated videos produced for undergraduate medical students that use this advanced software. This software is used by professional web developers but can be used effectively by students and doctors for educational purposes to produce video animation and interactive tutorials. For these reasons, I passionately believe that this technology could be used to revolutionise the way students learn medicine. If done effectively this could provide a more cost effective and engaging learning experience. This will ultimately benefit patients and doctors alike. This material can be place online allowing remote access. This is increasingly important for medical students studying on placements who are often learning away from the university setting. Weaknesses of this project include that of the work intensity of generating animated video. It is estimated that it takes around 6 to 9 hours to produce a minute of animated video. This does not include the research and recording of narration. The total sum of time to generate material and the additional skills needed to use the software makes generation of larger numbers of videos not possible by a small community of learners such as a university. Although it was done in this case, it is difficult to edit the material after it has been created. This may mean that material will become inaccurate when new advances occur. The feedback sample collected was opportunistic and the response rate was low. These factors may bias the results as only a subsection of opinions may have been obtained. These opinions may not be representative of the population studied or generalisable to them. It was difficult obtaining a professional medical opinion about the video in the time that I was allocated. However this has been organised for a later time. Knowledge and skills gained During this project I was able to learn about stroke its presentation, classification, management and risk factors. I read texts, which summarised stroke and research into risk factors and management of stroke. The challenge of usefully condensing a subject into a short educational tutorial was a challenging one. I feel I improved my skills of summarising information effectively. I gained knowledge of some of the challenges of undertaking a project such as this. One of the largest challenges included how long it took to produce the animation. In the future I will be aware of these difficulties and allow for time to gather information and generate the material. I also learnt the benefit of gaining feedback and allowing for adaption to this. It took more time to respond to feedback but this resulted in a better product that other students can use. I also reflected on the impact of stroke itself. Stroke has a major impact on patients, health care and carers. Much can be done in the recognition classification and management. A better understanding benefits all areas and I have gained a better knowledge and the importance of helping others gain a good understanding of stroke. I learned how to generate a video animation for the use of teaching in medicine and combine this with audio presentation. I learned how long it can take to generate material like this and the skill of organising my time effectively to manage a project. I can use this skill in the future to produce more educational material to help teach during my medical career. I also gained skills in learning how to place material on the Internet for others to access and will also use this in the future. Conclusions Previously evidence has shown the use of videos in medical education to be beneficial. It has normally been used to demonstrate clinical examination and procedures this study suggest there is a place for explanation of pathophysiology and disease summaries. However, there has been little research in to its use for graphically representing condition summaries. Computer technology now allows people to generate animation on their personal computer. It is possible that over time more students and doctors will start producing innovative visual and audio teaching material. This project indicates that this would be well received by students. References Planning the Medical Workforce: Medical Workforce Standing Advisory Committee: Third Report December. 1997 Page 40. The GNU project launched in 1984. Balslev T, de Grave W S, Muijtjens A M and Scherpbier A J (2005) Comparison of text and video cases in a postgraduate problem-based learning format Medical Education; 39: 1086–1092 Buick (2007) Year 3 External SSC. Bristol University Medical School. Spickard A, Smithers J, Cordray D, Gigante J, Wofford J L. (2004) A randomised trial of an online lecture with and without audio; Medical Education 38 (7), 787–790. Hudson J. N., (2004) Computer-aided learning in the real world of medical education: does the quality of interaction with the computer affect student learning? Medical Education 38 (8), 887–895. Ellen Finkelstein and Gurdy Leete, (2006) Macromedia Flash 8 for Dummies. Wiley publishing Inc. ISBN 0764596918  
Dr Alastair Buick
almost 12 years ago