It’s quick, it’s easy and we’ve all done it. Don’t blush, whether it’s at our leisure or behind the consultant’s back we can confess to having used the world’s sixth most popular website. You might have seen it, sitting pride of place on the podium of practically any Google result page. Of course, it’s the tell tale sign of one of Web 2.0’s speediest and most successful offspring, Wikipedia.
Now for fear of patronizing a generation who have sucked on the teat of this resource since its fledgling years, the formalities will remain delightfully short. Wikipedia is the free, multilingual, online encyclopedia, which harnesses the collective intelligence of the world’s internet users to produce a collaboratively written and openly modifiable body of knowledge. The technology it runs on is a highly flexible web application called wiki. It is open-source software; hence the explosion of wiki sites all united under the banner of combined authorship. Anyone with internet access can edit the content and do so with relative anonymity. It would be unthinkable that a source, which does not prioritize the fidelity of its content, could possibly play a role in medical education. How ironic it seems that medical students can waste hours pondering which textbook to swear their allegiance for the forthcoming rotation, yet not spare a second thought typing their next medical query into Wikipedia. Evidently it has carved itself a niche and not just among medical students, but healthcare professionals as well. According to a small qualitative study published in the International Journal of Medical Informatics, 70% of their sample, which comprised of graduates from London medical schools currently at FY2 and ST1 level, used Wikipedia in a given week for ‘clinical purposes’. These ranged from general background reading to double checking a differential and looking up medications.
We are so ensnared by the allure of instantaneous enlightenment; it’s somewhat comparable to relieving an itch. "Just Google it..." is common parlance. We need that quick fix. When the consultant asks about his or her favourite eponymous syndrome or you’re a little short on ammunition before a tutorial, the breadth and ease-of-use offered by a service accessible from our phones is a clandestine escape.
The concept of Wikipedia, the idea that its articles are in a way living bodies because of the continual editing process, is its strength. Conversely textbooks are to a degree outmoded by the time they reach their publication date. While I commend the contributors of Wikipedia for at least trying to bolster their pages with references to high impact journals, it does not soften the fact that the authorship is unverifiable. Visitors, lay people, registered members under some less than flattering pseudonyms such as Epicgenius and Mean as custard, don’t impart the sense of credibility students (or for that matter patients)expect from an encyclopedia. Since the prestige of direct authorship if off the cards, it does beg the question of what is their motivation and I’m afraid ‘the pursuit of knowledge and improving humanity’s lot' is the quaint response. There is a distinct lack of transparency. It has become a playground where a contributor can impress his/her particular theory regarding a controversial subject unchallenged. Considering there is no direct ownership of the article, who then has the authority to curate the multiple theories on offer and portray a balanced view? Does an edit war ensue? It is not unheard of for drug representatives to tailor articles detailing their product and erase the less pleasant side-effects. Obviously Wikipedia is not unguarded, defences are in place and there is such a thing as quality control. Recent changes will come under the scrutiny of more established editors, pages that are particularly prone to vandalism are vetted and there are a special breed of editors called administrators, who uphold a custodial post, blocking and banishing rebellious editors. A study featured in the First Monday journal put Wikipedia to the test by deliberately slipping minor errors into the entries of past philosophers. Within 48 hours half of these errors had been addressed. Evidently, the service has the potential to improve over time; provided there is a pool of committed and qualified editors.
Wikiproject Medicine is such a group of trusted editors composed primarily of doctors, medical students, nurses, clinical scientists and patients. Since 2004, its two hundred or so participants have graded an excess of 25,000 health-related articles according to quality parameters not dissimilar to peer review. However, the vast majority of articles are in a state of intermediate quality, somewhere between a stub and featured article. Having some degree of professional input towards a service as far reaching as Wikipedia will no doubt have an impact on global health, particularly in developing countries where internet access is considered a luxury.
March this year saw the medical pages of the English Wikipedia reach a lofty 249,386,264 hits. Its ubiquity is enviable; it maintains a commanding lead over competing medical websites. The accessibility of this information has catapulted Wikipedia far beyond its scope as a humble encyclopedia and into a medical resource. Patients arrive to clinics armed with the printouts. As future doctors we will have to be just that one step ahead, to recognise the limitations of a source that does not put a premium on provenance but is nevertheless the current public health tool of choice.
Illustrator Edward Wong
This blog post is a reproduction of an article published in the Medical Student Newspaper, November 2013 issue.
copyrighted material, used by arrangement with john wiley & sons limited. for personal use only, must not be reproduced or shared with third parties. anyone wishing to reproduce this content in whole or in part, in print or in electronic format, should contact email@example.com
Worst experience ever? - this is pretty difficult as I've worked in some of the poorest countries in the world and seen some things that should never happen like children dying of dehydration and malaria. But this recent experience was definitely the worst.
It was midnight and I was trying to get my 16 month old to sleep having woken up after vomiting in his cot. Despite paracetamol, ibuprofen, stripping to nappy, damp sponging and having the window open he went rigid and started fitting. It only lasted a minute or two yet felt like an eternity as he was unable to breathe and became progressively blue as my mind raced ahead to brain damage or some other horrible sequalae.
The fitting stopped and my mind turned to whether I was going to have to start CPR. I lay him on the floor and put my ear to his chest and was glad to hear a strong heartbeat but he was floppy with a compromised airway so I quickly got him in the recovery position. The ambulance arrived in 8 minutes and after some oxygen and some observations he was strapped in and ready to go. He had been unconscious for about 15 minutes but was starting to come round, much to my relief.
The ambulance crew were great and their quick response made all the difference but then they took nearly half an hour to get to A&E in the middle of the night because they took the most awkward route imaginable. I don't know if it was a deliberate delaying tactic or just a lack of local knowledge but even without a blue light I could have done it in half the time! Why do ambulances not have GPS - ideally with local traffic info built in?
We arrived in A&E and were ushered to a miserable receptionist who took our details and told us to have a seat. I noticed above her head that the wait time was 3.5 hours, though we did see a junior nurse who took his observations again. Not long after the screen changed to a 5 hour wait and a bit later to a 6 hour wait! I am glad to say that by about 3 hours my little man was back to his usual self (as evidenced by his attempts at destroying the department) and so after getting the nurse to repeat his obs (all normal) we decided to take him home, knowing we had a few more hours to wait for the doctor, and that the doctor was now unlikely to do anything as he was now well.
I tell the story in such detail in part for catharsis, in part to share my brief insight into being on the other side of the consultation, but also because it illustrated a number of system failures. It was a horrible experience but made a lot worse by those system failures. And I couldn't help but feel even more sorry for those around me who didn't have the medical experience that I had to contextualise it all. Sickness, in ourselves or our loved ones, is bad enough without the system making it worse.
I had 3 hours of walking around the department with my son in my arms which gave me plenty of time to observe what was going on around me and consider whether it could be improved. I did of course not have access to all areas and so couldn't see what was happening behind the scenes so things may have been busier than I was aware of. Also it was only one evening so not necessarily representative.
There were about 15 children in the department and for the 3 hours we were there only a handful of new patients that arrived so no obvious reason for the increasing delay. As I walked around it was clear to me that at least half of the children didn't need to be there. Some were fast asleep on the benches, arguably suggesting they didn't need emergency treatment. One lad had a minor head injury that just needed a clean and some advice. Whilst I didn't ask anyone what was wrong with people talk and so you hear what some of the problems were. Some were definately far more appropriate for general practice.
So how could things have been improved and could technology have helped as well?
One thing that struck me is that the 'triage' nurse would have been much better as a senior doctor. Not necessarily a consultant but certainly someone with the experience to make decisions. Had this been the case I think a good number could have been sent home very quickly, maybe with some basic treatment or maybe just with advice. Even if it was more complex it may have been that an urgent outpatient in a few days time would have been a much more satisfactory way of dealing with the problem. Even in our case where immediate discharge wouldn't have been appropriate a senior doctor could have made a quick assessment and said "let's observe him for a couple of hours and then repeat is obs - if he is well, the obs are normal and you are happy then you can go home". This would have made the world of difference to us.
So where does the technology come in? I've already mentioned Sat Nav for the ambulance but there are a number of other points where technology could have played a part in improving patient experience. Starting with the ambulance if they had access to real time data on hospital A&E waiting times they may have been able to divert us to a hospital with a much shorter time. This is even more important for adult hospitals were the turnover of patients is much higher. Such information could help staff and patients make more informed decisions.
The ambulance took us to hospital which was probably appropriate for us but not for everyone. Unfortunately many of the other services like GP out of hours are not always prepared to accept such patients and again the ambulance crews need to know where is available and what access and waiting times they have. Walk-in patients are often also totally inappropriate and an easy method of redirection would be beneficial for all concerned. But this requires change and may even require such radical ideas as paying for transport to take patients to alternative locations if they are more appropraite.
The reasons patient's choose A&E when other services would be far more appropriate are many and complex. It can be about transport and convenience and past experiences and many other things. It is likely that at least some of it is that patients often struggle to get an appointment to see their own GP within a reasonable time frame or just that their impression is that it will be difficult to get an appointment so they don't even try. But imagine a system where the waiting times for appointments for all GPs and out of hours services were readily available to hospitals, ambulances, NHS direct etc. Even better imagine that authorised people could book appointments directly, even when the practice was closed. How many patients would be happy to avoid a long wait in A&E if they had the reassurance of a GP appointment the next day? And the technology already exists to do some of this and it wouldn't be that hard to adapt current technology to provide this functionality. Yet it still doesn't happen. I have my theories as to why but this is enough for one post.
In case you were wondering my son appears to have made a full recovery with no obvious ongoing problems. I think I have recovered and then he makes the same breathing noises he made just before the fit and I am transported back to that fateful night. I think it will take time for the feelings to fade.
Because of the snail's pace that education has developed at, most of us don't really know how to study because we've been told lectures and reading thousands of pages is the best way to go, and no one really wants to do that all day.
That's not the only way to study. My first year of medical school... You know when you start the year so committed, then eventually you skip lectures once or twice... then you just binge on skipping? Kinda like breaking a diet "Two weeks in: oh I'll just have a bite of your mac n' cheese... oh is that cake? and doritos? and french fries? Give me all of it all at once." Anyways, when that happened in first year I started panicking after a while; but after studying with friends who had attended lectures, I found they were almost as clueless as I was.
I'm not trying to say lectures are useless... What my fellow first years and I just didn't know was how to use the resources we had– whether we were keen beans or lazy pants, or somewhere in between. I still struggle with study habits, but I've formed some theories since and I'm going to share these with you.
While reading should not be the entire basis of your studying, it is the best place to start. Best to start with the most basic and detailed sources (ex.Tortora if it's a topic I'm new to, then Kumar and Clark, and Davidson's are where I usually start, but there are tons of good ones out there!). I do not feel the need to read every section of a chapter, it's up to the reader's discretion to decide what to read based on objectives.
If you do not have time for detailed reading, there are some wonderful simplified books that will give you enough to get through exams (ICT and crash course do some great ones!). I start with this if exams are a month or less away.
Later, it's good to go through books that provide a summarized overview of things, to make sure you've covered all bases (ex. Flesh and Bones, the 'Rapid ______" series, oxford clinical handbook, etc.). These are also good if you have one very specific question about a subject.
After all that reading, you want the most laid back studying you can find. This is where Meducation and Youtube become your best friend. (I can post a list of my favourite channels if anyone is interested).I always email these people to thank them. I know from the nice people that run this website that it takes a tremendous amount of effort and a lot of the time and it's just us struggling students who have much to gain.
Everyone should use video tutorials. It doesn't matter if you're all Hermione with your books; every single person can benefit from them, especially for osce where no book can fully portray what you're supposed to do/see/hear during examinations.
Some youtube channels I like
We're all thinking it, lectures can be boring. Especially when the speaker has text vomited all over their slides (seriously, If I can't read it from the back of the lecture hall, there's too much!. It's even worse when they're just reading everything to you, and you're frantically trying to write everything down. Here's the thing, you're not supposed to write everything down. If you can print the slides beforehand or access them on your laptop/ipad/whatever you use and follow along, do that.
You're meant to listen, nod along thinking (oh yes I remember this or oooh that's what happens? or Oh I never came across that particular fact, interesting!). It's also meant to be a chance for you to discuss interesting cases from the a doctor's experiences. If you're lucky to have really interactive lecturers, interact! Don't be shy! Even if you make a fool of yourself, you're more likely to remember what you learned better.
If you happen to be in a lecture you're completely unprepared for (basically 70% of the time?). Think of it as "throwing everything at a wall and hoping something sticks." Pull up the slides on your smart phone if you have one, only take notes on interesting or useful things you hear the speaker say. If all else fails, these lectures where tell you what topics to go home and read about.
My university has gradually increased its use of tutorials, and I couldn't be happier. Make the most out of these because they are a gift. Having the focused attention of a knowledgeable doctor or professor in a small group for a prolonged period of time is hard to lock down during hospital hours. Ask lots of questions, raise topics you're having trouble understanding, this is your protected time.
In group study activities, this is particularly hard to make the most of when everyone in your group varies in studying progression, but even so, it can be beneficial. Other people's strengths might be your weaknesses and vise versa– and it's always helpful to hear an explanation about something from someone at your level, because they will neither under or over estimate you, and they will not get offended when you tell them "ok I get it that's enough."
Myself and 3 of my medic friends would meet once a week the month or two leading up to exams at one of our houses to go through OSCE stations and concepts we didn't understand (food helps too).
Besides peer discussions, you should take advantage of discussions with doctors. If the doctor is willing to give you their time, use it well.
I am a practice question book hoarder. Practice questions book not only test and reaffirm your knowledge, which is often hard to find if your exams are cumulative and you have little to no quizes/tests. They also have concise, useful explanations at the back and, they tell you where the gaps in your studying are. For my neuro rotation, the doctor giving the first and last lecture gave us a quiz, it was perfect for monitoring our progress, and the same technique can be used in your studies.
Practical Clinical Experiences
If you freeze up during exams and blank out, and suddenly the only forms of text floating around your brain are Taylor Swift lyrics, these are bound to come to your rescue! "Learn by doing."
Take as many histories as you can, do as many clinical exams in hospital, and on your friends to practice, as you can, see and DO as many clinical procedures as you can; these are all easy and usually enjoyable forms of studying.
Have you ever had an experience where one of your peers asks you about something and you give them a fairly good explanation then you think to yourself "Oh wow, I had no idea that was actually in there. High five me."
If there is ever an opportunity to teach students in the years below you or fellow students in your year, do it! It will force you to form a simplified/accurate explanation; and once you've taught others, it is sure to stick in your head.
Even if it's something you don't really know about, committing yourself to teaching others something forces you to find all the necessary information. Sometimes if there's a bunch of topics that nobody in my study group wants to do, we each choose one, go home and research it, and explain it to each other to save time. If you're doing this for a presentation, make handouts, diagrams or anything else that can be used as an aid.