GEP Medicine in Society Handbook 2019/20

1. GEP Medicine in Society

1.1. Introduction

Introduction

The curriculum at Barts and the London has been developed in accordance with the GMC’s Outcomes for Graduates (2018) These included recommendations that in all medical school curricula there should be:

• a greater emphasis on teaching outside the lecture theatre, hospital and laboratory, in community settings;
• a broader understanding of public health, and
• a greater degree of “vertical” integration of clinical and non-clinical subjects throughout the medical curriculum.
• and that the principles of professional practice must form the basis of medical education

Aims

 The aim of GEP Medicine in Society is to introduce students to patients and the patients’ experience health and ill health over the course of their lives.

Learning Outcomes

 By the end of this unit students should be able to:

• explain how patients are affected by their condition
• recognise how cultural diversity affects the experience of health and healthcare services
• list the public health influences that affect the development of ill-health and the restoration of health
• describe the roles of different members of the primary health care team
• develop good communication skills with patients, health professionals and between peers
• describe some of the skills used by healthcare professionals during consultations
• perform basic clinical examinations
• reflect on their own learning in terms of personal and professional development

1.2. Contact details

Academic and administrative contacts:

Contact details for Unit Convenor

Primary Care:

Maria Hayfron-Benjamin   

020 7882 2505

m.j.hayfron-benjamin@qmul.ac.uk 

Dr Meera Sood

m.sood@qmul.ac.uk

Secondary Care:

Dr Francis Pickersgill

Francispickersgill@nhs.net

Contact details for Unit Administrator

Mr Steven Duggan

steven.duggan@qmul.ac.uk

Tel: +44(0)20 7882 7105

2. Primary Care Timetable 2019/20

GEP General Practice Timetable 2019/20

3. Themed Days - Primary Care

Professionalism

Social issues in Primary Care

Back Pain and other Chronic Pain

Stroke

Mental Health

Addiction

CHD prevalence, inpact and prevention

Respiratory disease

Diabetes

Nutrition and GI disorders

Cancer

The older patient

Pregnancy and Childbirth

The young child

3.1. Professionalism

Medical Professionalism

Aim: to introduce students to the concept of professionalism and what it means in practice in a primary care setting.

Learning outcomes

Students will be able to

• Define professionalism
• Describe the professional attributes and behaviours expected of medical students
• Introduce themselves appropriately to patients they will interview, explaining the purpose of the interview, their role as medical students how the information will be handled, patient options - free to terminate interview, refuse etc.
• Outline their responsibilities as medical students, including reporting pathways within the healthcare environment and at Medical School
• Describe the principles of medical ethics
• Discuss the public perception of medical professionalism
• Discuss the roles of a doctor working in primary care including clinician, business partner, employer, line manager, trainer, clinical commissioner etc.

Preparatory work

Before the placement students will read the GMC guidance for Medical students and familiarise themselves with the Medical School Governance site and its guidance on issues that must be reported to the Medical School.  Please ensure you also review your communication skills teaching on patient-centred interviewing.

Read the GMC guidance on medical ethics and work through some of the scenarios.

Please watch some of the videos on GP careers on the health careers website.

Suggested activities:

Meet GP tutor and community tutor, orientation to placement

Tutorial on medical professionalism, students to present their findings from their readings

Prepare to interview their first patient as medical students, draw up interview schedule, and practice introducing themselves in pairs.

Meet a patient at home or in GP practice and find out how the patient views doctors, explore the factors that influence the patient's level of trust in the medical profession.

Discuss the roles of a GP with GP tutor or other doctors at the practice.

Meet/sit in with other members of the healthcare team and find out what being professional means to them.

Explore the practice area with guidance for the practice team and using the community profile guidance.

Debriefing tutorial.

3.2. Social issues in primary care

Aims

To introduce students to 'social issues' that impact on patient's health and their response to ill-health, including social support, ethnicity, educational attainment, sexuality, poverty and deprivation, teenage or lone parenting, drug and alcohol abuse, poor housing, domestic violence etc. and the role of the health service and other agencies in supporting these patients.

A parliamentary report from 2010 gives a political perspective on social issues in UK Society 

Dr Jonathon Tomlinson describes the impact poverty and deprivation have on his practice as a GP in his article 'A perfect Storm' from his blog 'A Better NHS'

Preparatory work

Before arriving at the placement students will have read the recommended reading and researched national and local statistics on social deprivation local to the practice area.

Whether or not your first placement is in Tower Hamlets you might like to read this Profile of Tower Hamlets so you get a feel for the area local to the Medical School, this may be similar or very different to the area where your GP practice is located.  The Tower Hamlets Fairness Commission website has lots of thought provoking information about social issues in Tower Hamlets. 

Objectives

By the end of the day students should be able to:

• List some of the social issues that impact on patient's health and their experience of heath care.
• Demonstrate an awareness of the importance of considering social factors when treating patients.
• Describe the impact social issues can have on the work of the GP and the PHCT (Primary healthcare team).
• Discuss the role of the PHCT in support and treatment of patients whose social circumstances impact on their health.

Suggested Activities

• Tutorial based on readings and student's knowledge and awareness of social issues that might impact on patient's health.
• Interview with GP or other HCP on their experience of a particular social issue. This should be negotiated in the tutorial and should be of particular significance in the GP practice area.
• Sit in with GP or nurse on routine surgery and observe when social issues are discussed and how this is done.
• Meet with patients known to have significant social issues e.g. poor/temporary housing, unemployment.
• Visit an organisation providing support for local people with social issues e.g. homeless shelter, cultural centre, refugee support organisation etc.
• Debriefing tutorial.

3.3. Back pain and other chronic pain

Aims

To introduce students to the definition, causes, risk factors for and management of chronic pain, and its effects on individuals, their families and society. 

In preparation students should have:

• Looked at the following links: 

1. for definitions and descriptions of Chronic pain click here, 
2. to hear some descriptions of the effects of chronic pain on individuals see the Health talk Online website 
3. and for information on clinical management of this condition please see Arthritis Research UK website

• Considered questions to ask a GP or a patient about dealing with chronic pain. 

Learning objectives

By the end of the day, the student should be able to:

• Describe the factors that are important in the development of chronic, disabling pain;
• Summarise the socio-economic impact on individuals, the community and the health services of this condition;
• Discuss the effect of chronic pain that the doctor cannot 'cure' on the relationship between the doctor and the patient;
• Identify and describe a range of orthodox and complementary therapies used to deal with chronic pain.

Suggested Activities 

• Tutorial on chronic pain;
• In pairs, plan interview schedule to carry out with a GP, other Health Care professional and/or patient on dealing with chronic pain;
• Interview patient and/or health care professional about the challenges of dealing/living with chronic pain;
• Meet with practitioner providing pain management advice/treatment to people with chronic pain;
• Debrief with student group and tutor.

3.4. Stroke

Aims

To introduce students to the effects of stroke, particularly in relation to mobility and to the part played by environmental factors, healthcare and other agencies in supporting the impaired person.

Preparatory work

Students should revise what they already know about the pathophysiology of stroke.  The current guidance on management of acute stroke can be found at Stroke-NICE Guidance. For an account of a linguists recovery from stroke and the impact on his life please read 'Me talk funny': A stroke patient's personal account.

The HealthTalk Online resource has a number of interviews with patients including some young stroke survivors including a young mother.

Learning objectives

By the end of the day, students should be able to:

• Discuss the impact of stroke on an individual and their family/carers and the role of voluntary agencies in providing support;
• Demonstrate an understanding of the effect of poor mobility on the individual; and the changes needed within the community e.g. access to public buildings and public transport, improvements to pavements etc.;
• Identify the member of the MDT that are important in assessment and care of patients with impaired mobility;
• Describe a health promotion intervention that can reduce the risk of stroke in an individual at risk e.g. blood pressure management, warfarin / aspirin in patients with atrial fibrillation.

Suggested Activities

• Tutorial on stroke including risk factors, health promotion interventions to reduce risk and consequences of stroke;
• Sit in with health care professional to observe health promotion interventions e.g. blood pressure monitoring with practice nurse or district nurse, home visit with health visitor for elderly people;
• Visit to voluntary agency proving support for people with impaired mobility e.g. stroke charity, wheelchair users group;
• Home visit to patient with mobility problems.  Interview patient about specific impact of loss of mobility;
• Debriefing Tutorial

3.5. Mental health

Aims

To introduce students to health promotion strategies to improve mental health; to the impact of chronic and acute mental illness on the health of the population and the multi-agency support needed in promotion of mental health and management of mental illness.

Preparatory work

Before arriving at the placement students will have read the recommended reading and researched the national statistics on the incidence and prevalence of mental health.  The Mental Health Foundation is one source of statistics on mental health.   

The Mind website is a good starting point for learning about mental illness and how it impacts on people's lives.  It has an A-Z of mental health conditions and blogs/video diaries telling people's stories. Eleanor Longden is a psychologist who was diagnosed with schizophrenia whilst a student, she describes her recovery in a TED talk.

For recommendations on mental health services from service users please see the Comment is Free article from the Guardian.

Objectives

By the end of the day students should be able to:

• Identify local and national strategies to improve mental health;
• Discuss the national and practice prevalence of mental illness;
• Describe the local support services for people with mental illness;
• Discuss the different needs of patients with acute and chronic mental health problems.

Suggested Activities

• Tutorial on mental health promotion and acute and chronic mental illness;
• Prepare for a meeting with a patient with chronic mental illness;
• Home visit to a patient with chronic mental illness;
• Visit to voluntary agency providing support for people with mental illness;
• Debriefing tutorial.

3.6. Addiction

Aims

To introduce students to a range of addictions and addicts and how problems of addiction are dealt with by the primary healthcare team and by voluntary and community agencies.

Preparatory work

Before arriving at the placement please look at the NHS Choices website pages on Addiction it has information on different addictions, treatment options, patient stories etc.

The Action on Addiction website has information for patients and health professionals and also logs any news items on addiction so you can get a feel for how addiction stories are covered in the media.

Learning objectives

By the end of the day students should be able to

• Identify the addictions commonly encountered within the practice
• Describe the range of services, people and agencies involved in the care of people with addictions in the local area
• Discuss smoking cessation strategies in place locally
• Identify and describe some of the health promotion models used in treating people with addiction
• Discuss the impact of addictions on the health of the practice population and on public health

Suggested Activities

• Tutorial on impact of smoking, drug and alcohol misuse on GP workload, including. importance of health beliefs and behaviour change models in treatment of addiction.
• Visit to a local agency providing support for people with addiction problems locally.
• Review of services and health promotion material available within the practice for people with addictions.
• Debriefing Tutorial

3.7. Coronary heart disease - prevalence, impact and prevention

Aims

To introduce students to the pathophysiology of CHD, its impact on population morbidity and mortality, and the health promotion interventions used to try and reduce CHD.

Preparatory work

Before arriving at the placement students will have read the recommended reading - please start with the NHS choices website to get a quick overview of what CHD is, how it is diagnosed and treated and the impact it can have on patients' lives.  The primary care team play a vital role in prevention of CHD a summary of the guidance can be found here.  The British Heart Foundation website also has lots of information about CHD, its prevention and treatment.  Dr Dean Orrish, is an American physician working in the field of preventative medicine - click here to see his TED talk on diet and CHD.

Objectives

 By the end of the day, should be able to

• Explain the process of development of CHD
• Outline the impact of CHD on individuals and on population morbidity and mortality
• Describe key health promotion interventions to reduce morbidity and mortality due to CHD
• Discuss the impact of CHD on an individual patent
• Identify key policy documents relating to CHD

Suggested Activities

• Tutorial on the pathophysiology of CHD and the impact it has on the workload of the practice
• Review of the practice strategy for monitoring and managing patients with known CHD and at risk of CHD (NSF targets etc.)
• Observation of health promotion interventions aimed at preventing or reducing the risk of CHD
• Interview patient with CHD at home or at the practice
• Debriefing Tutorial

3.8. Respiratory disease

Aims

To introduce students to respiratory illness, its impact on patients, society and the practice workload; and to introduce students to health promotion measures designed to improve respiratory health.

Preparation

The Inhale website provides a breakdown of the impact of respiratory disease for each CCG area (in London many CCGs cover the same population as the local authority area) to find out which local authority your practice is in please see Directgov website and insert practice postcode.  A summary of the burden of respiratory disease can be found on the British Thoracic Society website.

For further information please visit Asthma UK  or British Lung Foundation. The British Lung Foundation exists to provide a complete package of support for people living with lung disease and the people who look after them, in hospital and at home.

Learning outcomes

By the end of the day students should be able to:

• List common respiratory illnesses in children and adults that are seen in primary care
• Describe the basic assessment of a child with an upper respiratory tract illness (URTI)
• Describe and reflect on the impact of chronic respiratory disease from a patient's perspective, focusing on the issues of loss of function, autonomy, and well-being and its impact on daily life.
• Outline the health promotion interventions, interventions, provided by the practice team to prevent or manage respiratory illness.
• Demonstrate a basic examination of the respiratory system.
• Demonstrate the measurement and interpretation of peak expiratory flow.

Suggested Activities

• Tutorial on respiratory diseases and its impact on patients and the practice team's workload
• Sit in on routine surgery and observe particularly respiratory presentations
• Visit patient in pairs
• Introduction to examination of the respiratory system, practice examination on each other
• Debrief with GP and/or community tutor

Work to be included in the learning log

• List of activities for Day 4
• Reflective worksheet
• Self-assessment on learning outcomes

3.9. Diabetes

In preparation students should:

• Read the recommended reading from their reading list.  The Diabetes UK website is a good starting point for information about diabetes and its treatment.  There are resources for patients and health care professionals so whatever you're level of prior knowledge you should be able to find some useful information.
• For a patient perspectives on living with diabetes please see the HealthTalk Online resource - the diabetes area is introduced by Anthony Worral Thompson.
• Revised/researched the causes and treatments of Type 1 and Type 2 diabetes.  Please cover this at a basic level the Diabetes UK website will have adequate information.

Aims

To introduce students to the pathophysiology, and the individual and public heath impact of diabetes.

Objectives

By the end of the day students should be able to:

• Describe the incidence and prevalence of Type 1 and Type 2 diabetes and the impact of diabetes on the general practice workload
• Discuss some factors that may be contributing to the rise in prevalence of Type 2 diabetes
• Describe the impact of diabetes on an individual
• Describe some health promotion interventions to reduce the prevalence of Type 2 diabetes

Suggested Activities

• Introduction to the monitoring of patients with diabetes at the practice e.g. tutorial with the practice nurse on diabetes registers, identification at patients at risk, diabetes checks, annual reviews, patient education, medication, impact of National Service framework on service delivery.
• Observe a consultation with a patient with diabetes e.g. sit in with GP, visit a patient at home with district nurse.
• Interview a patient with diabetes at home or at the practice about the impact of their disease on their life
• Interview a health care professional involved with the care of the patient they have met.
• Compare the patient's and professional's views on the management of diabetes and its impact on the patient's life.
• Debriefing tutorial

3.10. Nutrition and gastrointestinal disorders

Aims

To increase students awareness of the relationship between food, health and ill health and to introduce students to how patients present with GI disorders.

Preparation

In preparation students should have:

• Read the recommended reading including looking at the NHS Choices website pages on food, diet and weight management.  
• The Mental Health Foundation has produced some guidance on diet and mood.  
• For a patient perspective on living with an inflammatory bowel condition please click here.  Alternatively take a look at Michael Serres' TED talk on his bowel transplant and on his views about how health care practitioners should communicate with and involve their patients in the decision making processes.
• If you have a bit more time you might want to take a look at Dr David Kessler's 

•  (it is a bit of a slow start) or perhaps you might want to take a look at his book - The End of Overeating.
• Considered the sensitivities of investigating patients' attitudes to diet and exercise.

Learning objectives

By the end of the day, students should be able to:

• Describe the components of a 'healthy diet'
• List the current recommendations for daily exercise
• Describe some of the broad spectrum of symptoms that relate to the GI tract
• Describe the impact of a chronic bowel disorder on a patient's life
• Discuss how symptoms seen as embarrassing might influence people's decision to visit their doctor
• Discuss the role of the primary care team in encouraging people to lead healthier lives

Suggested Activities 

• Tutorial on GI disorders
• 'Beliefs about food and exercise' - develop a survey to explore peoples' beliefs around food and exercise e.g. what foods are 'good' and 'bad' for you?  How important is exercise in peoples' lives?
• If possible carry out a small-scale survey at local shopping centre, public place and review results.
• Visit to an organisation/activity relevant to diet and/or exercise e.g. local group providing advice on diet, nutrition and/or cooking to young mothers, meet with fitness instructor providing 'exercise on prescription', meet adviser from local 'Weight Watchers' group.
• Have individual formative feedback discussion with tutors on progress on the Medicine in Society course
• Debriefing tutorial

3.11. Cancer in primary care

Aims

To introduce the students to the topic of cancer and its impact on the patient, their family and carers, the primary healthcare team and the wider health and social care professionals.

Learning outcomes

By the end of the day the students will be able to: 

• Identify the key National Government strategies that impact on the primary care team 
• Describe the national campaigns for screening for cervical breast and bowel cancer and the stigma around uptake in primary care
• Describe the public health campaigns and the role of the GP, in improving earlier diagnosis of cancer
• Identify the wider health and social care team that can be involved with a patient with cancer
• Describe the common red flag symptoms that may indicate a cancer diagnosis.
• Describe the impact of a cancer diagnosis on the patient (or their carer) and their primary care team.

Preparatory work

Please read about the NHS Cancer Plan through the link http://www.england.nhs.uk/cancer

Please watch

Look at the website from the NHS campaign on raising awareness of cancer.

Look at one or two videos on patient experiences of cancer through healthtalk.org website.

Suggested activities

1. Small group tutorial (e.g. on screening for cancers and debates surrounding its efficacy; clinical signs & symptoms of different cancers; two week wait referrals)

2. Sit ins with GP or nurse looking at possible pathways for referral for cancer investigation (including two Week Wait)

3. Visit to/from an Allied Health/social care professional/cancer charity support/Bereavement group

4. Debrief after meeting with patients with a cancer diagnosis and impact on the students and healthcare team

Further reading/resources

Interesting Film/books:         

Paul Kanathi - When Breath Becomes Air

Atul Gawande -   Being Mortal

John Diamond - C: Because Cowards Get Cancer Too 

Ruth Picardie - Before I Say Goodbye

https://drkategranger.wordpress.com/page/6/

3.12. The Older Person

Aims

To introduce students to the concept of ageing both as a biomedical and social phenomenon, the demographic changes in the population and the implications for health and the use of services.

Preparatory work

• Read the recommended reading about ageing including a blog account of Elderspeak
• Considered the implications for society, and medical and social services of an increase in the elderly population

Objectives

By the end of the day, the student should be able to:

• Recognise ageing is a natural, developmental process
• Describe some of the different ways that the elderly are regarded within different groups and communities
• Describe the range of services; people and agencies are involved in the support of the older patient in the local community
• Explain some of the implications for the health and social services of an increasingly elderly population
• Identify key policy documents relating to care of older people

Suggested activities

• Tutorial on ageing and communication with an older person.
• Home visit to independent, healthy older person (See Appendix for guidance on home visits)
• Tutorial on Health promotion services for older people provided by the practice e.g. over 75 checks, meeting with health visitor for older people.
• Visit to local voluntary agency working with older people
• Debriefing Tutorial

3.13. Pregnancy and Childbirth

Aims

To understand that pregnancy and childbirth are normal processes; the implications of this for services; and the factors which influence women's choices around birth.

Preparatory work

In preparation students should have:

• Found out about the range of local maternity services available to women; and some local and national data relating to childbirth
• Prepared some questions in order to talk to a pregnant woman about her choices for antenatal care and the birth of her child
• Please look at the NHS Choices website, it has a wealth of information for patients from everything from conception to childrearing.  Please take a closer look at the antenatal care area.  
• For a short account on the current situation regarding teenage pregnancy see Polly Toynbee's account The drop in teenage pregnancies is the success story of our time
• There are thousands (at least) of blogs written by women (and a few men) detailing infertility, fertility treatment, pregnancy, childbirth and parenting.  Some are of questionable quality
• The Health Talk online site has a number of interviews with parents a number of them focus on choices around how and where to give birth Thinking about where and how to give birth.

Objectives

By the end of the day, students should be able to:

• Recognise pregnancy and childbirth as normal processes
• List the possible choices that women can make in relation to antenatal care and place of birth
• Discuss the potential impact of pregnancy and childbirth on partners or husbands
• To consider the different factors e.g. access, support from GP, independent midwives etc. which influence women's choices in pregnancy and childbirth
• To give students an opportunity to meet a pregnant woman

Activities

• Tutorial: Is childbirth a normal process? If so, what is the role of the medical profession - both doctors and midwives? - based upon preparatory readings
• Health promotion: smoking, diet, exercise, and alcohol in pregnancy. What information is available within the practice? What services does the practice offer for antenatal care and childbirth?
• Visit to pregnant woman, to discuss her choices, and how she (and her partner/family) arrived at them
• Debriefing Tutorial

3.14. The Young Child

Aims

To gain an understanding of the health monitoring and health promotion provided for babies and young children by the primary health care team.

In preparation students should have:

• Read or reviewed the recommended resources including taking a look at the NHS Birth to Five book, this book was until recently given to all new parents in the UK.  It is still available as a PDF from the Northern Ireland Public Health Agency.  In England and Wales it has been superseded by the NHS Choices website pages, particularly the Babies and Toddlers and Your Newborn tabs. Both resources provide information for parents on all aspects of caring for a new baby and both include the voices of new parents.
• The Mumsnet website is worth taking a look at it, in particular as it hosts many discussions threads and will enable you to see some of the concerns both new parents, and more experienced ones have about caring for their children.
• You may see the administration of vaccines in a baby clinic or a routine appointment.  The current UK vaccination schedule can be found here.

Objectives

By the end of the day, students should be able to:

• Describe some of the health promotion services provided by the practice for mothers and their babies
• Describe some of their experiences communicating and engaging with the children they have met
• Examine the most significant changes parents have to deal with after the birth of a child
• Discuss the impact of the child on the relationship and life of its parents

Activities 

• Tutorial: health promotion for mothers and babies  - vaccination, feeding advice, parenting advice
• Visit a mother/family and baby; or talk to mother and baby at the practice
• Meet with practice nurse/health visitor to discuss their role in caring for babies and young children
• Debriefing Tutorial
• Final meeting with GP and/or community tutor to assess learning log 

4. Secondary Care Timetable 2019/20

GEP Secondary Care and Clinical Examination Skills Timetable 2019/20

Please note that themes and examination systems may change

5. Secondary Care Themed Days

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5.1. Day 1 & 2 Theme: Basic Training

Before you start your Medicine in Society days at Newham you will have a 2 day basic skills training programme.  Further details will be provided on your induction day.

5.2. Day 3 Theme: Rheumatology & Orthopaedics

 Introduction – Rheumatological conditions are relatively common both in the primary care setting and within the hospital.

Rheumatologists are responsible for the diagnosis and ‘medical’ treatment of a vast spectrum of conditions ranging from the common osteoarthritis and rheumatoid arthritis to the less common systemic vasculitides. Many of these conditions are still poorly understood and their treatment remains largely palliative. However, recent advances in immunological and molecular biological sciences have helped to elucidate some of the pathophysiology underlying these complex conditions and have led to the development of new treatment strategies.

Orthopaedic surgery remains an important treatment option for those with chronic, degenerative arthritis as well as for those involved in acute trauma. Orthopaedic surgery is one of the most ‘instant’ medical subjects with patients often having immense pain and disability pre-operatively replaced by ability and freedom from pain almost immediately post-operatively. In both specialties the MDT play a very important role in both treatment and rehabilitation.

Learning Issues

• Why is the Physiotherapist so vital in both rheumatology and orthopaedics?
• What are the roles of the other members of the MDT in the management of elective and acute orthopaedic patients?
• What are the unique and common clinical skills used by the Plaster technician?
• What are the experiences of the patients you have met today regarding their inpatient and outpatient care?

Suggested Learning Tasks

• Record the mechanism of injury and / or the course of the arthritis from the patients you have met today.
• Chart the post-operative course of one orthopaedic patient, recording the MDT interventions.
• Other than analgesia, which prophylactic medications should be recorded for all older patients with a fractured neck of femur? What side effects may they have?

5.3. Day 4 Theme: Stroke

 Introduction – Cerebrovascular disease is a major cause of chronic disability and death within the western world. It is the third largest killer of adults within the UK, accounting for ~60,000 deaths annually, and it is estimated that the NHS spends 4% of its total budget on the care of stroke patients.

Stroke is a multifactorial condition crossing primary care, public health, hospital and institutional care. It affects all ages, with a total incidence of 114/100,000. The incidence doubles with every decade over the age of 55 years-old with 75% of strokes occurring in the over 65s. There is a recurrence rate of 7 -10%, with the greatest risk in the first year after the initial episode. The hospital admission of patients with stroke provides a key insight into the workings of an ‘expert’ multidisciplinary team, as well as the shortcomings of non-specialist areas in dealing with such a complicated condition. This placement should give you an overview of the management of stroke patients within a typical District General Hospital.

Learning Issues

• Compare the care of the stroke patients you have seen today in the various settings.
• What are the features of good rehabilitation common to these settings?
• What are the activities of daily living (ADL) assessed by the MDT?
• What is the role of the doctor in the care of the stroke patient in the

(a) acute setting  (b) rehabilitation setting?

• List the secondary risk factors which should be addressed on admission of stroke patients?
• List three drugs that such patients may be on.

Learning tasks

• ·      Record the ADLs of a patient and your MDT recommendations
• ·      What is meant by FAST?
• ·      What is the difference between hyper-acute, acute and rehabilitation stroke care?
• ·      Where are these services offered in East London?

References

NICE guidelines for the management of stroke:

http://www.nice.org.uk/CG68

UK Stroke Statistics:

www.stroke.org.uk/document.rm?id=877

5.4. Day 5 Theme: Psychiatry

Learning Issues

• What is the role of a liaison psychiatrist?
• Who is involved in the psychiatric multi-disciplinary team?
• Why is substance misuse (including alcohol misuse) so prevalent in East London?
• What are the problems faced my patients with mental health issues when they are on an acute hospital ward?

Learning Tasks

• ·      Read the Mental Health Act
• ·      What are the different types of ‘section’ that can be applied under the Mental Health Act?

Reference

Mental Health Act:

http://www.dh.gov.uk/en/Healthcare/Mentalhealth/InformationontheMentalHealthAct/index.htm

5.5. Day 6 Theme: Cardiovascular 1

 Introduction – Coronary Heart Disease (CHD) is the leading cause of adult death in the UK, accounting for ~90,000 deaths per year. However, the mortality rate has been falling over the past decade (45% reduction in CHD mortality in under 65s) since the Government’s implementation of the National Service Framework (NSF) for Coronary Heart Disease in 2000; this was designed to take forward its agenda of primary and secondary prevention, increased investigation, and non-operative and operative intervention for patients with CHD.

  Learning Issues

• How would you take a history from someone with chest pain?
• What is primary angioplasty and how is this service organised at the London Chest Hospital?
• What are the risk factors for coronary heart disease?
• What may be the concerns of the patient or his family after a heart attack?
• What advice would you give to your patient after a heart attack?
• What are the roles of the multidisciplinary team in the investigation and care of an inpatient with CHD?
• What are the DVLA regulations for a person who has had acute coronary syndrome?

Suggested Learning Tasks

• Take a history from a patient admitted with chest pain
• Interview a patient on the ward and ask how his/her illness has affected their work, life and family
• Observe how the cardiac technicians perform an ECG?
• Ask the Cardiac Rehabilitation Nurses about the advice they give out for someone who has had a myocardial infarct
• Read about the NSF for Coronary Heart Disease

References

Heart Disease Statistics (British Heart Foundation, 2010)

http://www.bhf.org.uk/heart-health/statistics/heart-statistics-publications.aspx

NSF for CHD (2000)

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4094275

5.6. Day 7 Theme: Cardiovascular 2

 Introduction – Once admitted with an acute coronary syndrome a patient’s risk for further events may be stratified using their history, examination, investigation results and on-going symptoms. The patient’s secondary risk factors should be addressed and secondary prophylaxis should be instituted to improve prognosis. Patients deemed to be in a high-risk group should undergo further investigation and possible non-operative or operative intervention.

During this placement you should observe how patients with acute coronary syndromes are investigated and treated. This includes the acute treatment of myocardial infarction and unstable angina and the subsequent work up to possible coronary artery bypass surgery. You should always bear in mind that these patients have a significant illness which may be associated with relatively acute deterioration and that post admission and operation they require a lot of rest and recuperation.

Learning Issues

• What objective parameters may be used to stratify patients’ risk of further cardiac events? Who should be considered for further investigation? What may exclude a patient from further investigation?
• What blood tests should be requested for a patient admitted with an acute coronary syndrome?
• What are the indications and contra-indications to an exercise stress test (EST)? What reasons may stop an EST prematurely?
• What are the major and minor risks of coronary angiography? What risks were your patients aware of?
• What are the indications of coronary angioplasty +/- stenting and do they have any long term benefits over operative intervention?
• What were the major problems faced by your patients post coronary artery bypass surgery? How were these dealt with by the care team and the patient?

Suggested Learning tasks

• Record the conversation you have with a patient awaiting coronary angiography or CABG surgery.
• Record the conversation you have with a patient following coronary intervention regarding the problems they may have faced post-procedure.

5.7. Day 8 Theme: Respiratory

Introduction – Carcinoma of the lung is the commonest cancer worldwide, accounting for 1.2m new cases annually. Therefore, the World Health Organization (WHO) cites tobacco smoking as the foremost preventable cause of cancer globally. In the UK, incidence is estimated at ~40,000 with annual mortality recorded at ~35,000; it is the second most common malignancy after prostate and breast cancer in men and women, respectively. The overall prognosis remains very poor with a median survival of 4 months although this varies considerably depending on histological type and staging of the cancer.

 With the Government driven two-week initiative for any patient suspected of having a cancer, the services and resources for the diagnosis and treatment of patients with lung cancer are receiving a much-needed boost. However with the present lack of specialist skills at all stages of this process, patients in the UK still have a poorer prognosis than in other developed countries around the world. During this placement you may have the opportunity to observe the management of a patient with suspected or confirmed lung cancer (however, the majority of such patients are managed as outpatients). This is often a very emotional and difficult time for patients, carers, relatives and indeed healthcare staff and you will need to use your own common sense and judgement with regard to patient privacy and space.

Learning Issues

• How may someone with lung cancer present?
• What are the possible abnormalities seen on the chest radiograph of a patient with lung cancer?
• Which members of the MDT are involved in support and counselling of the patients prior to, and after the confirmation of their diagnosis?
• What are the roles of the oncologist and the radiotherapist in the treatment of lung cancer?
• Why is the overall prognosis of patients with lung cancer so poor?
• Why is the incidence of lung cancer falling more slowly in women than in men?
• If you were the Minister of Health, what methods would you use to reduce the nation’s smoking habit, particularly that of the younger women? What evidence do you have for these methods?

Suggested Learning Tasks

• Record the conversation you had with a patient prior to diagnosis of their cancer: How are their carers and relatives coping?
• Record the conversation you had with a patient who has a confirmed diagnosis of cancer. How are their carers and relatives coping?
• Find out the role of the lung cancer specialist nurse
• What is the analgesic ladder? List the analgesics you have seen in use today and their indications.
• List five palliative measures that may be employed for patients with lung cancer.
• From your experiences today draw out a model of diagnosis and treatment for a patient with suspected lung cancer. You should include the various members of the MDT, the support services and the treatment options.

 Reference

NICE guidelines for Lung Cancer:

http://www.nice.org.uk/nicemedia/live/10962/29672/29672.pdf

5.8. Day 9 Theme: Endocrine (Patient with Diabetes)

 Introduction - Diabetes Mellitus is a common chronic condition which can be divided into Type 1 and Type 2. Type 1 is principally a disease of younger adults and children and is due to the total failure of insulin production in the pancreas. Type 2 diabetes usually affects people over age 40 but is increasingly being seen in younger age groups.

The diagnosis of diabetes mellitus has major implications for both patients and the healthcare community alike. According to the National Service Framework (NSF) for Diabetes (published 2001), patients with diabetes have:

• a life expectancy which is reduced, on average, by more than 20 years in people with Type 1 diabetes and by up to 10 years in people with Type 2 diabetes
• a significantly raised morbidity and mortality from coronary heart disease, stroke, renal failure, peripheral vascular disease and eye disease
• additional risks in pregnancy: women with diabetes have an increased chance of losing the baby during pregnancy or at birth, of the baby having a congenital malformation, or of the baby dying in infancy

The impact on healthcare resources is also significant. The NSF states that:-

• around 5% of total NHS resources and up to 10% of hospital in-patient resources are used for the care of people with diabetes
• people with diabetes are twice as likely to be admitted to hospital as the general population and, once admitted, are likely to have a length of stay that is up to twice the average
• the presence of diabetic complications increases NHS costs more than five-fold, and increases by five the chance of a person needing hospital admission
• one in 20 people with diabetes incurs social services costs and, for these people, the average annual costs were £2,450 (1999). More than three-quarters of these costs were associated with residential and nursing care, while home help services accounted for a further one-fifth. The presence of complications increased social services costs four-fold.

As with all chronic conditions, expert multidisciplinary care is essential and must form an important bridge between primary and secondary care. Diabetes Mellitus has a very high prevalence in the East End of London. As a result of the NSF, we have seen increasing amount of resources directed towards the excellent multidisciplinary teams here in Newham.

 Learning Issues

• What is the WHO definition of diabetes mellitus?
• What theories of pathogenesis are given for Type 1 and Type 2 diabetes?
• What is Impaired Glucose Tolerance (IGT) and what prognostic significance does it have?
• What common complications arise in diabetes mellitus? How are they classified or subdivided?
• What is the value of an annual diabetic review? Who should be involved in this review?
• Why is the incidence of Diabetes mellitus increasing in the UK? Why is the incidence of Type 2 diabetes increasing in the under 40s?
• How would you educate a patient with newly diagnosed diabetes? What topics would you cover?
• What are the DVLA regulations for a person with diabetes?

  Suggested Learning Tasks

• Interview and record your conversation with a person with diabetes. List the diabetic complications they have and their views on their diabetes.
• List the medications of one of the patients you interview today.
• Ask the DSN what education she provides to someone newly diagnosed with diabetes

 Reference

DVLA Guide to Medical Standards of Fitness to Drive

www.dft.gov.uk/dvla/medical/~/media/pdf/medical/at_a_glance.ashx

5.9. Day 10 Theme: Gastroenterology

Introduction – Upper and Lower Gastrointestinal disorders, weight problems and hepatobiliary disease are all common problems which often require hospital investigation and admission. The diagnosis and subsequent treatment of gastrointestinal disorders was revolutionised by endoscopy over the latter part of the twentieth century and this forms an important part of all gastroenterologists’ daily workload.

 Alimentary conditions also form a large part of the surgical workload in any hospital and abdominal pain is one of the commonest reasons for admission on an acute surgical take. During this placement you should have the opportunity to observe some patients with alimentary conditions that require admission under the medical or surgical teams for inpatient management.

 Learning Issues

• How would you take a history from someone with diarrhoea?
• What are the causes of bloody diarrhoea?
• Consider how inflammatory bowel disease may affect one’s work, life and family.
• What patient support groups are available for inflammatory bowel disease?
• What common blood tests are performed on patients with abdominal conditions?
• What medical conditions require upper and lower GI endoscopy?
• What is an ERCP and what are its indications?
• What is the role of the Endoscopy Nurse; what clinical skills do they utilise?
• Who is involved and what are the stages of patient transfer from the wards to the operating theatres and from Recovery to the ward? What are the potential hazards of this transfer?

Suggested Learning Tasks

• Make a written record of your conversation with a medical or surgical patient with an abdominal condition.

5.10. Day 11 Theme: Nutrition and Feeding in the In-patient setting

Introduction – Sick patients are often catabolic and require increased nutritional intake and support at a time when they are often unable to feed themselves or simply do not feel like eating. Neurological and gastrointestinal conditions may also affect a patient’s ability to swallow normally or safely (termed dysphagia). During the past thirty years supplemental feeding techniques and support have improved, allowing patients to be fed.

  Learning Issues

• What are the reasons why patients may not receive adequate nutrition in hospital? What simple things could you do to improve their nutritional intake?
  • How much does the NHS spend on food for each patient per day?
  • Which nutritional supplements are commonly used on the wards? Comment on their nutritional contents.
  • What are NG, PEG and PEJ and TPN feeding? What are their risks and benefits?
  • What disorders commonly stop patients eating?
  • Which members of the MDT are essential when assessing a patient’s swallow?
  • Why may pulse oximetry be used when assessing a patient’s swallow?

Learning tasks – set by SALT

• Compare and contrast your own dietary intake for your day at Newham with that of a typical inpatient.
• List three types of patient who may require ‘special’ diets and the essential elements of those diets.
• List the stages involved in assessing a patient's swallow.
• List at least 5 clinical signs of aspiration (immediate and/or delayed)
• List the risks of PEG feeding. What are the common methods used to try and avoid them and treat them once they have occurred?

5.11. Day 12 Themes: Obstetrics & Gynaecology

Obstetrics & Gynaecology

The Department of Women’s Health at Newham University Hospital is very keen to support and teach students. If you would like to expand your knowledge and experience of women’s health, we are happy to facilitate this. Please speak to Dr El-Mahdi or the GEP course organiser at Newham for more information.

Learning Issues

• ·      What is different about taking a gynaecological and obstetric history?
• ·      What do you need to consider before taking a sexual history?
• ·      What is the take up rate for cervical cancer screening in East London? How does this compare with the National average and why may it differ?

Learning Tasks

• Write down what is involved in antenatal screening?                                                                          

5.12. Day 13 Theme: Healthcare of the Elderly

Introduction – Older patients (over 75 years old) make up a significant proportion of the care load of any acute hospital trust within the UK. The first and perhaps most important standard of the National Service Framework (NSF) for Older People (published 2001) is the removal of the Endemic and Institutional Ageism that is still rife within the NHS and society as a whole.

Many people have very negative images of the older person and within Western culture their wisdom and experience is too easily dismissed and overlooked. Many of the other NSFs have recognised their specialty shortcomings and have made active inroads into offering equality of care and treatment based on need, desire and quality of life issues rather than age and life expectancy. This placement should give you an overview of the care of older patients in various settings within Newham Hospital.

 Learning Issues

• How does the care of older patients differ in the various settings you have experienced?
• What do the patients and their relatives feel about their care?
• What were the good features of care?
• How may the care of older patients differ to that of younger adults in the hospital setting?
• Why may older patients be advantaged and disadvantaged by admission to an acute care of the elderly ward?

Suggested Learning Tasks

• Make a written record of a conversation you have had with an older patient including their housing situation, its facilities and the patient’s care provision (if any).
• Using one of the patients you have spoken to as an example, design an ‘ideal’ care pathway for an older patient’s admission to hospital.

 Reference

The National Service Framework for Older People

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4003066

5.13. Day 14 Theme: Paediatrics

Paediatrics

Newham has the youngest population in the country with 41% of the population being under 25. What explanations can you suggest for this demographic pattern? This, coupled with high levels of deprivation makes a challenging situation for health, education and social services but interventions in children can have a lifetime benefit.

Learning Issues

• What are the commonest diagnoses leading to hospital admission in children?
• What are the key expectations for children’s health services defined in the National Service Framework for children?

Learning tasks

• Of the children you see, try and classify their diagnosis into one (or more) of the following groups:
  • Genetic disease with clear Mendelian inheritance or spontaneous mutation
  • Multi-factorial disease in which genetics plays an important role
  • Congenital abnormality
  • Infectious disease
  • Problem with largely social or psychological cause
  • A nutritional disease
  • A problem arising from complications in pregnancy or delivery
  • Trauma

• If you have the opportunity, talk to the family of a child with chronic disease. What has been the impact on the child’s education, relations with peers, the parents’ work, finances and social lives? Who looks after any siblings while the child is in hospital?
• Observe children playing, how many of the skills listed on the development sheet did you see and what ages were the children?
• List the first language of every child (or parent) you see.

Reference

National Service Framework for Children, Young People and Maternity Services:

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4089100

Childhood Developmental Milestones:

http://www.med.umich.edu/yourchild/topics/devmile.htm

5.14. Day 15 Themes: Mock OSCE

 Mock OSCE

This is an opportunity for students to practise their history taking and clinical examination skills in an informal exam style situation. Students will be given their marksheet and feedback at the end of each station.

5.15. Day 16 Theme: GEP Medicine in Society Student Presentations

 Venue: Education Centre, Newham University Hospital

09.00 – 17.00                    

 The presentations will

• be on a pre-agreed topic from any area covered in the Medicine in Society course.
• be performed in pairs.
• last 12 minutes in total,10 minutes for the actual presentation and 2 minutes for Q&A.
• be performed on Power Point.
• be assessed by peer and tutor review on the day.

The presentations will be graded on the following areas, up to six marks can be awarded for each area

Grades: Merit = >22, Pass = 15 – 21, Referred = <15

The session will end with cheese and wine for students and tutors in the Education Centre at Newham University Hospital

5.16. Asessment

In Primary Care students will be assessed on their attitude and application and their completion of a learning log.  (70% of total marks)

In secondary care they will be assessed on their case presentation. (30% of total marks)

6. Assessment

In Primary Care students will be assessed on their attitude and application and their completion of a learning log.  (70% of total marks)

In secondary care they will be assessed on their case presentation. (30% of total marks)

Attendance

Student attendance is recorded at each placement. Tutors must inform us at the time of any non-attendance.

Any student unable to attend must submit an self certificate form to the University.

There may be occasions during the year when students have an in-course assessment exam on the Friday after a MedSoc day; these exams contribute only in a relatively small way to the students’ end of year marks. Students must attend their placement as usual. If tutors have any concerns about a student’s attendance, behaviour, health etc. they should contact the unit convenor as soon as possible.

6.1. Attitude and application (20%)

It is expected that students will do any recommended preparation and will contribute fully to group discussions, activities etc on each placement day.  At the end of the year students should receive a grade from A- E based on the descriptors below.

6.2. Learning Log (50%)

The learning log is intended to be a tool that is used to record and reflect learning and professional development through the year. (In addition to learning logs students may want to collect research in preparation for each MedSoc day, notes made in the course of the day, and any leaflets and information collected during the day.  This information should be collected and held in a separate folder rather than in the Learning Log.)   There are two components to the learning log: reflections on activities and self-assessment of students meeting of the learning objectives:

Guidance for grading the Learning log

For further information see ‘A generic framework for reflective writing’ Jenny Moon (2004) – link on QM+

6.3. The Case Presentation (30% of total marks)

The case presentaion is made and assessed at Newham University Hospital.  Sudents may present a patient they met in primary or secondary care.  GP tutors or community tutors are welcom to attend and assess if they would like to.

A 10 - 15 minute case presentation (students in pairs) describing a clinical condition, the effect of the condition on a patient’s life, and the social factors affecting the patient’s ability to respond to their condition i.e. personal relationships, family support, employment history, educational history etc.  Students should also consider the health promotion interventions both at an individual and societal level for that condition and the role of the multi-disciplinary team in caring for the patient. 

The presentations will be made and feedback given to the students on day 14.  General Practitioners and community tutors are welcome to attend the student presentations if they wish but they are not required to. 

The presentation should include:

• A comprehensive account of the clinical aspects of the case, demonstrating understanding rather than regurgitation of clinical and pathological details
• Discussion of the patient’s and carer’s perspectives
• Evidence of understanding of the health promotion and public health aspects of the case
• An explanation of the role of the multidisciplinary team in the case
• Appropriate use of information technology and presentation skills

The presentations will:

• Be on a pre-agreed topic from any area covered in the Medicine in Society course.
• Performed in pairs.
• Last 12 minutes in total, 10 minutes for the actual presentation and 2 minutes for Q&A.
• Be performed on Power Point.
• Be assessed by tutors.

6.4. Professionalism assessment

As part of the final assessment tutors must complete a Professionalism Assessment on each student.  Tutors are asked to give students formative feedback on their professionalism when they review progress during the year so students have opportunities to modify their behaviour before they are formally assessed at the end of the year. 

7. Reflective Writing Resources

Guidance on Reflective Writing