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Horses for courses, or Courses for horses?

I just got back from beautiful Fremantle (Perth) – completed the REST (Remote Emergency Skills Training) course and then spent a day running an introduction to ED Bedside US for rural GPs.  So I got to be on both sides of the educational table this week.

Whilst there I had the chance to catch up with Dr Tim Leeuwenberg (@KangarooBeach  ki-docs.wordpress.com ) and we chewed the fat over the value of these rather pricey and time-consuming courses in the context of FOAMed.  So I thought I would write my opinion: where are we at with “ongoing professional development”?  Including a review of the REST course and my own “ED USS for GPs” course.  I know – how could I be biased – well read on….

The REST course was designed to be a 2 day intensive training course for rural & remote doctors.  It is really intended for the PGY2 – 4, the newly arrived OTD or even the city doc who is contemplating a semi-retirement in locum land – servicing the remote communities of Australia.  As a rural ED / Proceduralist type of Doc it was not really what I had expected after reading the comprehensive, if slightly dated manual pre-course.  The basis of the REST course is sound – DRSABC….primary, secondary surveys –  a structured and safe platform for dealing with sick and traumatized patients.  And there was even an inkling of “newer practices”.

The REST course is taught well by the ACRRM crew – a big ask for such a diverse group of students and a lot to cram into 2 days.  The atmosphere was nice, friendly and open for discussion – though the pressure of time was evident.  The use of simulation was OK, however I thought it could have been made more complex / realistic, forcing the students to think and think again.

Now for the downside – I have concerns – the REST course is designed to get new country docs “up to speed”, however the syllabus is really not in touch with modern practice.  I think if you were a new grad or OTD going bush for the first time and RESTed on your ‘REST laurels’ – you would end up being competent, but the experienced nurses you would go out into the bush and work alongside will be practicing (and expecting you to practice) a more evidence-based, up to date version of emergent care.

REST is like most “resus guideline” based courses – it follows simple algorithms that are really designed for the layperson or volunteer to apply in the community – once we walk into a modern ED we practice very differently.  Resuscitation is about prioritization and resource management – it relies on a practical skill set also which are not really covered in the REST course.

In fairness the REST course is up for a review this year.  However, I think it might be impossible to cater to all levels of training in the current format. 

REST is an entry-level course and certainly has its place as the minimum requirement for remote practice.  For more experienced rural doctors though there really is not a course that offers contemporary training in Emergent care in the GP sphere.  More on this to come….

When I was asked to run a full-day workshop for novice US users I had to think long and hard about the format, the audience and the material.  I decided to offer a superficial taste of all the modalities that I find useful or “life-saving” in my practice.    In the era of FOAMed I think that the role of the face-face workshop is to correct and perfect the hands-on minutia of US – the learning can all be done online in advance.  The individual needs to commit to a long, uncomfortable period of trial in practice to learn technique once the basics have been taught.  The workshop really just acts as a focus – a date , a place, a commitment to learn.

My goal was to try to inspire my colleagues by showing the enormous advantage of US in common clinical scenarios – to try and spread the US bug and encourage them to engage in their own online learning.  I am not convinced many would have walked away with much in the way of usable skills – but hopefully some got the bug – a desire to try to improve care with bedside US.

OK, so it seems a bit bleak!  So how do I see the future of GP education?

Well this gets right at the heart of why I started this blog in the first place.  I don’t believe there should be any distinction between patient care based on geography, who is at the bedside or what “specialty” covers their disease process.  If there is a g0od answer to a problem, evidence-based therapy then it should be delivered no matter when, where or who.  So how does this apply to GP education?

There are 2 basic options available to us:

(1)  develop great, competitive, evidence-based and cutting edge training opportunities for GPs –

(2) Join in on the specialist education – take our place at the table and eat up the knowledge these docs have.  Who knows – we might even have a bit to offer ourselves!

Up until recently I was a fan of option (1) – but now I am leaning to option (2).  The power of FOAM has shown me how applicable specialist knowledge and practice can be to us as remote generalists. 

Next March in Sydney there will be a conference not quite like any other – there will still be beer, but this time we (the GPs) will be there – learning and sharing our collective wisdom.  In case you have been living under a rock – check out SMACC 2013 at smacc.net.au . For me this is the answer to our educational woes – a chance to get involved and learn how to deliver great care anywhere.  SMACC is the physical manifestation of all the great free, online education that has exploded over the past few years. 

Hope to see you there.  Casey

Comments

  1. minh le cong says:

    great article Casey! Yes everyone should come to SMACC 2013. not only because you will learn cutting edge, practical information on resuscitation and emergency medicine by experts and colleagues..but more importantly you will learn a better way of learning.

    entrylevel courses are an acceptable method of delivering core content in emergency medicine and resuscitation. but they are like fast food outlets.

    How would you ever know fresh fruit existed if you were only ever given Macdonalds as a child?
    Macdonalds is quick, cheap and instantly available. you know what you are getting. there is no need to be creative or make an effort.
    unlike fresh fruit where you need to know whats the best time to buy it, where to get it the best produce, then to select ripe fruit etc. that takes much more effort….
    or should it?
    Casey and I have a secret we want to share about our own learning. Its called FOAMEd.
    we work in remote locations and cant often get away to big cities to attend these courses. When we do, we often find its all the same, there is no evidence based updating of knowledge, the manuals are irrelevant and more saliently, the teaching just does not translate to where we work in rural and remote Australia. we want to know what is best practice, we dont want our patients to be second class citizens. so we want the best knowledge from the best minds and help us apply this to our remote communities. this allows us to mold that best practice into something practical .
    Its like saying that rather than going to the city to eat out at Macdonalds, it might be better to go to an organic food restaurant and be more selective about what you are filling your mind and body with.

    but aFOAMEd allows us to be selective about our educational consumption and get expert input in real time and in off time from a global perspective…all remotely!..and for the most part its totally free.

    ok let me get on a soap box here. I have an interest bordering on obsession on emergency airway management. here in Australia, the main accepted method of learning airway skills is to go to elective anaesthesia lists in hospitals and practice supervised airway management by anaesthetists. I think this is a good way to impart core skills and knowledge. now many fall into a trap that this is considered the best way to maintain and attain further proficiency in airway skills.
    this is wrong..in fact in one way it is risky.
    in fact if you really want to improve your airway skills , you must look to other disciplines and indeed other professions. Surgical airway, active oxygenation techniques, non technical skills..these are all things that other discipines and professions can help us with. I learnt this via a variety of sources but in last two years, it is via FOAMed that I have learnt the most to improve my airway skills management. Most of my FOAMEd airway teachers I have never met in person. I certainly have not spent time in an OT with them . but they have taught me simple resilient, physiologically based airway techniques that you would never learn in anaesthesia currently as its practiced and taught. several of these techniques are done simply with plain gear you wuld find in any remote hospital.
    Ultrasound is another area where you can learn an incredible amount via FOAMEd and make a major improvement in your bedside care of patients.
    Courses for horses
    or
    Big Mac vs mango

  2. Agree Casey

    I still think a ‘rural doc’ masterclass has got legs – more so if bolstered by FOAMed and delivered by ACRRM as the peak body for rural docs (smacc.net.au looks awesom, but may be too far weighted to crit care for some rural generalists)

    Ideal world? Rural GP masterclass delivered by enthusiastic bods who are embedded with FOAMed cutting edge concepts applicable to the ruralist….a smorgasbord of EM, trauma, obs, paeds, anaes etc, smallgroup hands on sessions and perhaps sim. Crisis management, human factors, logistics over startegy and ‘making things happen’

    Content evolves over time and run in bite-sized chunks…

    I’m game. Lets hope the College listens…

  3. minh le cong says:

    guys, I think You are both right.
    I propose we actually deliver this rural masterclass in FOAMEd style. At least a lot of it can be delivered online, live and recorded. by us, the rural GP FOAMEd club and friends

    what I have discovered via my FOAMEd online airway training program is that there is a hunger for this stuff and this is the way to deliver it.

    Ultrasound for the rural GP proceduralist via FOAMEd online sessions..why not?
    Critical care airway and anaesthesia for the rural resuscitationist via FOAMEd online sessions…why not?
    Ventilation masterclass for the occasional intensivist via FOAMEd online sessions…why the heck not?
    Close quarter airway skills for the nightmare larynx via FOAMEd online…absolutely!
    The Hitchhikers guide to procedural sedation in strange and austere places via FOAMEd…bring it on.
    Taming the tiger , the occasional psychiatrists guide to acute agitation management in remote settings via FOAMEd…
    is that enough for a basic online rural masterclass curriculum.?
    how to proceed?
    how bout the three of us commit to at least a monthly broadcast, starting with the above topics?
    if it gets lots of hits and feedback, we can ramp it up as we see fit.
    happy to setup the show.
    just need my co hosts

    • I’m in.

      Last 12 months have been a revelation for me, using #FOAMed – it has rekindled passion for medicine and indeed I’ve learned more about the necessary stuff to enhance my patient care as a rural doc through #FOAMed than I ever would have through courses and conferences.

      And I’m an EMST Director! Great for entry level or a quick snack (Maccas) but no finesse (organic soul food)

      So yes Minh, I’ll commit

      Asynchronous learning, through #FOAMed. Bringing “quality care, out there”

      Awesome.

  4. Very interesting analysis Casey, i am Completely agree with you…#FOAMed was a revolution in the last years and a great tool that all docs across the world can use, furthermore it gave the possibility to share different points of view between docs of different countries like Europe, USA, Australia, NZ etc…I hope that i can join SMACC 2013!!!

  5. Agree with your comments completely on REST Casey (ours was called RESP, no resting on laurels!). It was pitched to be an essential course prior to heading out bush. I found it to be a re-jog of the many BLS/ALS sims and tutes from medical school and junior hospital years.

    I think myself and fellow regs would have definitely preferred something with a FOAMed flavour that was on the cutting edge, but that also benefits from the wide range of experience from others. Why have a 2 day tute from 4 people when you can hear from someone from Broome, Cairns, Ireland, NZ and yes, even KI! There will always be a place for hands on, muscle memory type, in person tutes. But the core of learning (and spark/interest) as Minh said could certainly come from a FOAMed platform.

    Im definitely looking forward to attending SMACC and even spearheading a culture shift at my GP training provider to not only acknowlege the existence of FOAMed, but to integrate it into our GPtraining. I have a great opportunity (and time) to do this in 2013 in my academic term. Would any of you guys be willing to give me a hand/mentoring to do this? it could perhaps be a great model for other GP training providers to use. Watch as Gerry prepares to ‘SMACC’ AOGP upside the head….

    There is a real potential for FOAMed to extend past critical care, ED and trauma through to our garden variety rural general practice. I for one would love to see this and help it push forward!

    Cheers

    Gerry

  6. Awesome – Gerry could fly the flag for SA and indeed encourage the GP RTPs to ‘GET FOAMed’

    Gonna have to podcast with you Gerry…

  7. Ewen McPhee says:

    OK guys, I am an assistant Director Medical Education – Rural for an RTP. I have a cohort of new GP registrars and Rural Generalist Provisional Fellows starting out of the blocks next year. I want to encourage the Rural Stream Registrars a “new way of learning” but without the acronyms.

    I think prolific use of hashtags like #FOAMed is in itself an unconscious submission to being “hip” and “exclusive”, rather than “inclusive”. I do also think you need to be kinder to the Colleges, you know the field is changing quickly, and they need to be nurtured along.

    How do we do it where do we start? I have been using SoME for a while now, I have seen your blog posts and I find some inspirational for their direct learning opportunities and Just in Time approach.

    There needs to be a greater focus on asynchronous up to date education, but with respect, there needs to be a high quality evidence base and avoidance of opinion (level 5 evidence).

    • Hi Ewen
      I gave a talk on this exact topic at the RMEC12 conference in Sydney – not sure if you were there. I think it is online somewhere?
      I think you are correct in that the #FOAMed “community” looks like an exclusive group – but be assured it is actually a meritocracy. The people making contributions do so because they have passion and enjoy doing it.
      At this time it is dominated by ICU / ED / crit care teachers – and they do it well. However, we – remote / rural docs have so much more potential gain from online / asynchronous learning.
      It is tough to generate the same sort of fluid, asynchronous environment in the context of an institution such as a RTP or a hospital. I have spent 2 years trying to make my “classroom” go asynchronous, it cannot be forced. The participants must do so of their own undertaking – or else it doesn’t work.

      I apologize if I / we have given the impression that our colleagues are somehow deliberately “out of date” or backward, this is not intended. I / we want to use educational tools such as blogs, podcasts etc to level the playing field – make it possible for rural practitioners to deliver “the best care, anywhere”. For too long we have used the tyranny of “distance” as a reasonable excuse / barrier to getting access to the type of education that allows the average country doc to stay up to date with contemporary practice. This has all changed in the last few years.

      At the end of the day I am interested in the utilitarian question: “what is best for the patient?”, not where or who they are. I see no reason why an old man from Billiluna community should not have access to the same standard of care as a baby-boomer from and affluent inner city suburb of Sydney. Now, distance and resources are going to make access tricky. However, my knowledge or skill should not be limiting his care. I have access to great clinical resources and teachers all over the globe and I can use this to ensure I am doing “what is best, regardless of geography or my level of traditional training (actually not a lot!).

      I do not believe that traditional education (conferences, didactic workshops, reg sessions) are able to provide the level and targeted type of education we need in our modern practices. The two are not oppositional – they complement one another. You need to spend a year doing anaesthetics to acquire skills, but then use FOAMed to hone your skills, challenge your practice and stay on the cutting edge.

      With regards to evidence: I strive to use evidence to support all of my ramblings – usually hyperlinked into the text for all to read. Many readers choose to believe me and not click on the articles – that is their prerogative. Evidence is good – but we are part of an immature science, so often we come up blank. The evidence cupboard is bare or unhelpfully null on many points. This is where our community of online teachers / learners is awesome. We can have open, free conversations with people all over the globe and arrive at a consensus – the process is Darwninian (a good thing). The best ideas propagate the errors are selected out and we get an evolved answer rather than a dogmatic “truth” from a single source.

      The future: watch this space – here is a more GP-orientated incarnation of FOAM on the horizon. Hope to have you there soon!
      Casey

  8. Ewen McPhee says:

    Cheers Casey,
    Thanks for providing a considered and balanced reply. I have reread my comment and it is a bit challenging. I too want to come along for the ride, and having seen others talk including Mihn le cong I am very impressed by the commitment and the potential is evident. I didn’t get to the RMEC conference myself. Everything seems to be long way from Home – Perth, Adelaide and Brisbane in the next three weeks for various meetings. Would be great if there was an on line community to continue those conversations in Health reform etc

  9. Minh Le Cong says:

    Hi Ewen! Great to read your comments and see you active on this blog! An educator should always lead by example!

    I totally agree any form of education for doctors should strive to promote best practice and an evidence based approach. this includes FOAMEd. We of us, using this medium to educate and inform our medical colleagues, should also be active in traditional forms of education such as peer reviewed journals, conference presentations, academic positions and research. Casey, myself, others in FOAMEd, all do this and often more. FOAMEd is just another method of delivery we have found to funnel the information. What CAsey, Tim, myself and others have realised is that this fits the rural and remote practitioner well and addresses a lot of the challenges of remote professional development.

    there is undoubtedly not only an information sharing benefit, but a social networking multiplier factor to FOAMEd. You can use otherwise empty time during travel to learn new things from around the world and your own country, but also connect and socialise with like minded professionals globally.

    In many ways this is like a virtual conference, or virtual journal club..or to be nostalgic, the virtual medical tea room/ doctors lounge.

    Evidence is good but lets face it, we value peer review and opinion more. evidence based medicine will not tell you how to read an ECG, but your colleague can and we do get such opinions from them on such matters, Same with our Online learning and education,..we value hearing what other frontline providers in similar situations are doing. But even better with FOAMEd we an also get the opinion and listen to the practice ideas of hospital specialists globally.

    its a smarter way of keeping up to date. Use the collective brains of hundreds of peers.

    And for rural practitioners it helps us brainstorm solutions to common challenges. I have been in contact with rural Canadian providers who asked about what we doin remote Oz for certain problems that. share due to remote isolation and low resource settings, often requiring aeromedical retrieval,

    registrars are already on SoMe. its up to us as educators and mentors to meet their informational needs and styles.

  10. Wow, year has gone by

    Since then

    – smacc2013 came & went – BEST conference ever

    – rural masterclass on Kangaroo Island, well-received as far as I know)

    http://kidocs.org/2013/11/annual-rural-masterclass/
    http://nomadicgp.wordpress.com/2013/11/28/rural-doctors-masterclass-roundup/

    – ETM course launched in Melbourne Nov 2013 (and I am typing this from Melb for the second ETM course, on which will blog again)

    So – here’s the question – is there interest in FOAMed course material for rural docs via th’interweb, reinforced by some F2F time?

    I;ve got resources over at ruraldoctors.net – Minh and Casey have more at their blogs

    – FOAM4gp.com is gaining momentum

    …plus online content for airway and ultrasound in the pipeline

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