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  • 1. Clinical reviewABC of health informaticsKeeping up: learning in the workplaceJeremy C Wyatt, Frank SullivanThe amount of biomedical knowledge doubles every 20 years, This is the ninth in a series of 12 articlesand new classes of drug (such as phosphodiesterase 4 A glossary of terms is available at become available when lectures at medical school content/full/331/7516/566/DC1are over. Therefore, a practice risks fossilising after doctorsfinish professional training. Many continuing medical educationor continuing professional development activities help doctorscarry on learning and improving their skills. These activitiesinclude courses, conferences, mailed educational materials, Patrick Murphy is a 8 year old boy who has recently returned home from a hospital admission. The dischargeweekly grand rounds, journal clubs, and using internet sites. In letter asks you to prescribe inhaled steroids and amany countries, evidence of this process is needed for doctors phosphodiesterase 4 inhibitorto continue to practice. Although these activities may increaseknowledge, their impact on clinical practice is variable The aim of traditional medical education is to commitknowledge to memory and then use this knowledge in theworkplace. The way knowledge is learnt influences its recall and Workplace learning means finding solutions to clinicalapplication to work. One tactic to improve the process is to problems when they arise, or soon after, with minimum effort. When unsure about what has happened, why, orensure that learning happens in the clinical workplace. Lessons what to do, answers should be looked upare learnt faster and recalled more reliably when they originatein everyday experience. Learning in the workplace means spending a minute hereor three minutes there to find answers prompted by the clinicalquestions and learning opportunities that come up in everyworking day, rather than doing continuing medical educationfor an intensive two hours a week, or a few days a year.Workplace learning is hard to achieve. It emphasises problemsolving and learning skills—such as how to find relevant answersfast—not learning facts.Barriers and solutionsNobody can find a satisfactory answer to every clinical questionor information need, especially as there are about two needs forevery three clinical encounters. Many important clinicalquestions have no satisfactory answer—for example, what is thecause of motor neurone disease? Other questions are simplyinteresting rather than information needs. A range of practicaldifficulties face doctors who follow the approach of learning inthe workplace. Some suggestions about how to overcome thedifficulties follow. In the United Kingdom, the National electronic Library for Health aims toToo many questions, not enough time provide answers within 15 seconds that take only 15 seconds to readDoctors generate approximately 45 questions about patientcare every week, and they probably allow two minutes to answereach one. This adds up to an extra hour and a half per week,and even though it represents only 3% of their working time,where do doctors find this time? Time is always short. Theyoften have to adjust the threshold for seeking answers, Prioritisation of clinical questionsprioritising questions that have the highest clinical impact and 1 Answers needed noware quickest to answer. 2 Answers needed before patient is seen next Prioritising clinical questions by the likely impact of the 3 Answers needed to guide care of other patients or to reorganise clinical practiceanswer means distinguishing between the questions in the box 4 Answers that have interest to doctor andopposite. When doctors have time, they can pursue all answers. patient, but carry no obvious clinical impactWhen under pressure, they pursue answers that are needednow (category 1). If they never pursue other answers, they willmiss many clinical advances. It is often hard to recognise whenknowledge is lacking, and so it is important to sometimespursue answers even when only slightly uncertain of the answer.BMJ VOLUME 331 12 NOVEMBER 2005 1129
  • 2. Clinical review To ease time pressure, clinicians can spend less timeanswering a question by using knowledge resources that arecomprehensive, and can be instantly accessed and easily Oxford Centre for EBM question log booksearched. They could also increase the time available forworkplace learning. Individually, doctors can work for longer Patient ID: Date:hours, reserving time for “reflective practice” with a preceptor Issue:or mentor, exploiting “teachable moments,” perhaps byanswering an educational prescription. Overall, the medicalprofession needs to recognise the sanctity of workplace learning Question (PICO):throughout doctors’ careers: life long, self directed learning. Search:Lack of clear questions Main Reference:Asking clear questions is not easy. Sometimes doctors feeluncertain and fail to formalise a question, which makes it Adapted from a page from theharder to find the answer. Immediate identification of clinical Oxford Centre forquestions is important, and is easiest to do on ward rounds or R Y/N/? A % M Evidence Basedwhen teaching students. When working alone, some clinicians Clinical bottom line: Medicine’s logbooklog their questions (for example, on BMJLearning), then look (R=randomised and representative,up the learning resources on the website (the “just in time A=ascertainment orlearning” package on childhood asthma) or other sources, or Notes: follow-up ratethey discuss the answer with peers later. Structuring clinical percentage,questions using the problem, intervention, comparison and M=measures unbiased, relevantoutcome (PICO) model makes them easier to focus, recall, andanswer.Turning clinical problems into easily investigated formats Intervention (or cause, prognostic factor, Patient or problem treatment) Comparison (if necessary) OutcomesTips for building Starting with your patient Ask “Which main Ask “What is the main Ask “What can I hope to ask “How would I describe intervention am I alternative to compare with accomplish?” or “What a group of patients similar considering?” Be specific the intervention?” Be specific could this exposure really to mine?” Balance affect?” Be specific precision with brevityExample (see In children with poorly “. . . would adding “. . . when compared with “. . . reduce the likelihoodscenario on controlled asthma . . . phosphodiesterase 4 inhibitor adding a long acting ß of readmission?”p 1129) to inhaled corticosteroid . . .” agonist . . .”Lack of answersA source of answers needs to be available in the workplace. Thissource should provide answers that are clinically relevant,scientifically sound, and in a form that can influence decisions.One solution is a library in the workplace that contains currenttext and reference books, relevant reprints, and electronicresources. The library must be close and organised for rapidaccess. The material should be filtered for clinical relevance andbe evidence based, such as Clinical Evidence in book or CD-Romformat or an indexed collection of systematic reviews. These sources will not answer all questions. In PatrickMurphy’s case (see scenario on p 1129) the treatment is notindexed, and so online access to Medline will be needed,preferably via the PubMed clinical queries search page thatprovides answers useful to practicing doctors. Ideally, doctorswill then retrieve the full text of relevant articles because relyingon the abstract alone can be misleading. When Pitkin comparedthe statements made in 264 structured abstracts in six medicaljournals with the corresponding article, a fifth containedstatements that were not substantiated in the article and 28%contained statements that disagreed with those in the article. Clinical evidence is a useful resource in workplace learningThus, tempting though it may be to rely on abstractsalone—especially because they are now so accessible throughPubMed—it can be dangerous.1130 BMJ VOLUME 331 12 NOVEMBER 2005
  • 3. Clinical review An alternative to carrying out the search yourself is to callor email a question answering service, such as ATTRACT, forclinicians working in Wales. For years, NHS poisons and druginformation services have provided similar services that giveinstant answers to specialist questions. Some libraries, primarycare trusts and academic departments have services that covermany topics. The service usually returns a telephone call orsends a summary within two to four hours. Despite theirobvious potential, these services seem underused at present.ParochialismIf doctors only look up answers to questions arising in theirown practice, their knowledge will depend on the local casemix. Most doctors broaden their knowledge by reading ageneral medical journal or looking up points raised in replies toreferrals, inpatient summaries, clinic letters, or laboratoryreports. Some participate in multidisciplinary clinics or ward A PubMed search filters for clinical queriesrounds, or join colleagues in an email discussion group. To beready for rare, serious problems that need an instant response,some clinicians use patient simulators to practice managingcardiopulmonary arrest, anaesthetic accidents, or brittlediabetes. Although time spent on simulators does not yet counttowards doctors’ continuing education, taking part in interactivecases in some journals does.Lack of incentivesTo maintain the enthusiasm to keep looking up answers toclinical questions, doctors can keep a log book of questions andanswers, or conduct clinical audits that compare practice andoutcomes with results a year ago. Such log books and auditreports will become part of doctors’ folders for accreditationand annual appraisal. Sharing insights is an incentive to learn, and giving apresentation often prompts discussion, especially if it is short,and it defines and deals with a real clinical problem (along withsources searched, the answers found, and actions taken). Thisactivity can be formalised as a single page, dated, criticallyappraised topic (CAT), and stored in a loose leaf folder or apractice intranet for others. The CATmaker tool is used to create critically appraised topicsCultural changes associated with workplace learningOld think New thinkx Passive listening to lectures x Active participation in self directed learningx Educator decides topic x You decide topicx Attend continuing medical education course you know most about x Seek out areas of ignorance and answers to your clinical questionsx Focus is on laboratory research, pathophysiology, drug mechanisms x Focus is on what works in practice, what to do, problem solvingx Read a journal or textbook x Carry out problem solving on real or simulated casesx Education to learn facts, pass exams x Learning to solve clinical problems, improve team work, clinical and information seeking skillsx Formal, timed courses x Informal, self directed, learning in the workplacex Get continuing medical education or postgraduate education x Get continuing medical education or postgraduate education allowance points for turning up allowance points for participating in workplace learning, using learning materials, improving standardsx Case presentation, journal club x Work on an educational prescription, write a critically appraised topic, use a clinical simulatorx Competition: keep knowledge to yourself x Sharing: open learning, exchange of knowledge and understanding to benefit patients and the health systemx Knowledge belongs to the individual. Continuing medical education x Communities of practice: learning is an attribute of the team and points accumulate to the individual. Recertify the individual organisation and is part of its quality and risk management strategies. Accredit the organisationx Patients are passive recipients of care x Patients are sources of questions and insights, learning collaboratorsx Errors should be forgotten and denied x Errors are a learning experience to be treasured, discussed, and understoodx Errors happen to “bad apples” x Errors happen to everyoneBMJ VOLUME 331 12 NOVEMBER 2005 1131
  • 4. Clinical review Lowering barriers is also motivating: an old BNF in a desk Further readingdrawer will be used more often than a current version in thepractice library 10 m away, or one in the health library 5 km x Wyatt J. Use and sources of medical knowledge. Lancet 1991;338:1368-73away. Electronic libraries and the internet bring the world’s x General Medical Council. A licence to practice and revalidation.literature to your desktop, but can take longer and yield fewer London: General Medical Council, 2003answers to clinical questions than paper sources. This is x Mazmanian PE, Davis DA. Continuing medical education and thechanging. A German study found that clinical use of online physician as a learner: guide to the evidence. JAMAlearning was about ten times that of print journals. 2002;288:1057-60 x Lave J, Wenger E. Situated learning. Cambridge: Cambridge University Press, 1991Summary x Ebell MH, Shaughnessy A. Information mastery: integrating continuing medical education with the information needs ofBarriers to workplace learning can be overcome, but a minor clinicians. J Contin Educ Health Prof 2003;23:53-62culture change in the medical profession is needed. This shift is x The resourceful patient website. The e-consultation: vignette. (accessed 30already taking place in undergraduate medical education and in October 2005)primary care. Clinical governance, risk management, patient x Smith R. What clinical information do doctors need? BMJ 1996;empowerment, and the National Programme for IT will further 313:1062-8advance the change. x Ely JW, Osheroff JA, Ebell MH, Chambliss ML, Vinson DC, Using clinical questions to guide workplace learning relies Stevermer JJ, et al. Obstacles to answering doctors’ questions abouton the motivation of individuals, teams, and organisations. It patient care with evidence: qualitative study. BMJ 2002;324:710 x PubMed clinical queries: hand in hand with an open attitude to clinical errors and static/clinical.html (accessed 30 October 2005)near misses. Motivation is especially necessary to fund the x Pitkin RM, Branagan MA, Burmeister LF. Accuracy of data ininstant access resources needed to provide knowledge during abstracts of published research articles. JAMA 1999; 281:1110-11clinical work. Fortunately, electronic media provide a simpler, x ATTRACT: (accessed 30cheaper method for workplace learning than paper libraries, October 2005)although there is evidence that health librarians on site are still x Harker N, Montgomery A, Fahey T. Treating nausea and vomitingneeded to support better clinical use of these resources. during pregnancy: case outcome. BMJ 2004;328:503Jeremy C Wyatt is professor of health informatics, and Frank Sullivanis NHS Tayside professor of research and development in general The series will be published as a book by Blackwell Publishing inpractice and primary care, University of Dundee. spring 2006.BMJ 2005;331:1129–32 Competing interests: None declared. Symbolism in imagery and linguistics—perception and misperception Puzzling consultations are not unusual and help make medicine Image analysis and object recognition have advanced in recent so fascinating. In this case, however, the clinical issues were years. Functional magnetic resonance imaging has recently been resolved by simple investigation and reassurance. My puzzlement used to investigate regions of the brain involved in face was from my certainty that I had met this patient previously, but recognition 2. A face-selective region of the inferior temporal lobe my inquiries elicited a confident reply that we had not. I struggled seems to be involved in facial identity, while a separate with this for, like most physicians, I have always enjoyed a facility face-selective region of the superior temporal lobe may be used for recognising my patients. For several weeks, the question to identify facial expression. My failure to “recognise” my patient recurred in my mind; how could I be so certain of recognising a may reflect an absence of any associated memories such as patient whom I had never met before? The issue was resolved altered facial expression or personality attributes usually when I did meet my patient again; this time while sitting on the associated with face identity. This suggests that both face-sensitive train I took daily to and from work—not, however, as a fellow regions identified by Andrews and Ewbank are important for the passenger but as a face in a drug advertisement in the medical wider process of person identity and recall. My experience shows journal I was reading. the power of images in advertising, but also their limitations; I Two recent reports relating to images and their interpretation remembered the face but had no recollection of its context or brought this incident to mind after an interval of 10 years. Scott circumstances. et al discuss the use of symbolism in images in drug advertising, Capturing the attention of readers is challenging for advertisers suggesting that the use of mythology may be used to mislead and writers alike. Scott et al argue that “in law and science, words doctors about therapeutic efficacy.1 They suggest that doctors are precise and accountable” and imply that writing occupies need support to resist drug advertising, and they recommend higher ethical ground; but it is evident that symbolism is regulation of journals’ advertising to clinicians and lament the use frequently used to reinforce messages, whether in linguistic or of rhetorical rather than rational argument in scientific media. image form, and not only in advertising. Let the reader beware. However, it is evident that the authors use the very techniques they warn about to persuade their readers. The article, entitled D J Sheridan professor of cardiology, Imperial College School of “Killing me softly; myth in pharmaceutical advertising,” borrows Medicine, Academic Cardiology Unit, St Mary’s Hospital, London from the title of Fox and Gimbel’s hit song recorded by Roberta ( Flack in 1973 to capture the reader’s attention. Juxtaposing the word “Killing” with “pharmaceutical advertising” conveys an 1 Scott T, Stanford N, Thompson DR. Killing me softly: myth in unhealthy and negative sense and transforms the metaphor from pharmaceutical advertising. BMJ 2004;329:1484-7. a romantic to an aggressive one. The word “myth” in this context 2 Andrews TJ, Ewbank MP. Distinct representations for facial identity and is also ambiguous, carrying a sense of deception as well as the changeable aspects of faces in the human temporal lobe. Neuro Image classical meaning. 2004;23:905-13.1132 BMJ VOLUME 331 12 NOVEMBER 2005