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School of Medicine MBBS Programme Phase 4 Student Handbook 2012-13 i THE KING’S SCHOOL OF MEDICINE STUDENT AND DOCTOR On entering the School of Medicine the King’s School of Medicine the student will: • • • • have a high level of commitment to entering a caring profession demonstrate an interest in people and their health, and in the importance of health and cultural issues in society have achieved high academic standards and have shown qualities of self-motivation show a sense of personal responsibility and a wide range of personal interests During the undergraduate course the King’s School of Medicine the student will: • • • • • • be educated in a multi-faculty college with the cultural opportunities offered by a central London location study medicine in a local community of wide ethnic, cultural and socio-economic diversity develop an inquiring and critical approach to learning understand the scientific principles of medicine learn about patients in a variety of settings – in hospitals, general practice and the community learn the essentials of good clinical practice which will be based on the core knowledge, skills and attitudes required for the safe practice of medicine The King’s School of Medicine student will learn about: • • • • • health and its promotion the scientific basis, presentation, management and prevention of common and serious diseases and the impact of illness on the patient and the patient’s life the environmental and social basis of health and illness in the context of populations the ethical and legal issues relevant to the practice of medicine the organisation, management and provision of health care The King’s School of Medicine student will develop skills by: attending and participating in learning opportunities reflecting on and addressing personal learning needs learning to communicate effectively with patients, relatives and professionals working cooperatively with patients, peers, teachers and healthcare staff becoming proficient in essential clinical examination skills becoming proficient in essential practical procedures The King’s School of Medicine student will demonstrate appropriate attitudes by: • • • • • • treating patients with politeness and consideration, learning to involve them in decisions about their care acting honestly with patients, peers and staff showing respect for patients, relatives and colleagues that encompasses, without prejudice, diversity of background, language, culture and way of life recognizing the rights of patients and acting in their best interests, particularly with regard to confidentiality, informed consent, autonomy and dignity recognizing the need for guidance and supervision and the limits of personal competence and health respecting the professional values of competence in performance, reliability and conduct ii Bullying and Harassment The College and the Medical School are committed to providing students with a learning environment that is free from all forms of harassment, bullying and discrimination. Being subjected to such behaviour can lead to stress and anxiety. It is important that students behave towards each other and staff with dignity and respect, and avoid behaviour and communication that upsets your colleagues and staff. If you have concerns about the way you are treated, who you contact depends on where the incident took place. In College, you should discuss in confidence with your personal tutor and/or Year Head who will support, help and advise you. If you are on clinical placement, you should raise your feelings with your Sub-dean or administrator, and Year Head. Further support can be obtained from your senior house tutors and clinical advisers, the Student Welfare and Advice service, and the College Harassment Adviser. Further details are available on: http://www.kcl.ac.uk/college/policyzone/assets/files/students/Policy_on_Harassment_Bullying_and_ Discrimination_for_Students.pdf The information contained within this handbook is correct at the time of going online although the details may change before or during the academic session. iii TABLE OF CONTENTS – Part I 1. Introduction to Phase 4 1 2. The Aims and Objectives of Phase 4 2 3. Code of Practice for Student Examination of Patients 4 4. Attendance and Good Philosophy of Work 10 5. Phase 4 Term Dates 2012-13 13 6. Deadlines and Dates 14 7. Course Outline 15 8. Phase 4 Key Co-ordinators, Block Leaders and Course Organisers 17 9. CHILD HEALTH, DEVELOPMENT AND AGEING BLOCK 22 10. EMERGENCY MEDICINE, TRAUMA AND LOCOMOTION BLOCK 48 11. REPRODUCTIVE AND SEXUAL HEALTH BLOCK 71 12. Vertical Strand Disciplines 90 13. Student Selected Components 98 14. Assessments and Examinations 99 15. Example Questions 101 iv 1. INTRODUCTION TO PHASE 4 Welcome to Phase 4! Congratulations on your success in the Part 3 MBBS examination. Phase 4 promises to be an enjoyable course offering a wide range of clinical experiences. By the end of phase 4 you will have completed your training in the core subjects of the medical course. With successful completion of the phase 4 assessments, you will be ready to embark on your Elective and return for the shadow house year in Phase 5. What does Phase 4 include? Phase 4 consists of three 12-week blocks of grouped specialities: Child Health, Development and Ageing (CHDA); Emergency Medicine, Trauma and Locomotion (EMTL); and Reproductive and Sexual Health (RSH). Vertical strand subjects are integrated into mainstream specialties and symposia and include Clinical Sciences, Ethics and Law, Pathology and Laboratory Sciences, Psychiatry, Public Health, Clinical Pharmacology and Therapeutics, Genetics, Palliative Care and General Practice. The learning aims and objectives for phase 4 are outlined in this handbook and are referenced with the MB BS core curriculum presentations. This is the syllabus for the phase 4 assessments. The course is delivered consistently across five campuses: Kings College Hospital, Denmark Hill (KCH); University Hospital Lewisham (UHL); Guy’s and St Thomas’ Hospital (GST); Princess Royal University Hospital, Farnborough (PRUH); and Queen Elizabeth Hospital, Woolwich (QEH). There are minor variations due to differences in service provision. Students rotate across the sites during the year. The Community Study and health promotion, the only longitudinal case study, takes place on Fridays (see timetable for dates). The Community Study in General Practice enables you to follow the progress of a pregnant patient and her family. Special study components (SSCs) in phase 4 take place on the Fridays when you are not having your community study days. You will take two SSCs. One in rotation 1 which will be a taught SSC, the second in rotation 2 will consist of writing your elective portfolio. There is no SSC in rotation 3. Fridays during rotation 3 are designated for teaching and consolidation. You can expect to have some timetabled sessions on these Fridays. Alternatively, you may be able to arrange more self directed learning which can focus on examination technique in preparation for the OSCEs. If you are on peripheral attachments, you should stay at the DGH on these Fridays. They are not specifically revision days. What is different about Phase 4? The first two rotations begin with an introductory day, continue with 12 weeks clinical teaching, and conclude with a reading week (week 13). In the rotation 1, some students might have SSC presentations during this week. The last rotation also includes an introductory day, continues with 12 weeks clinical teaching, and concludes in week 13 with written papers for all three blocks. There is an end of year OSCE and revision sessions will be offered prior to this. In phase 4, you meet many vulnerable people- patients with disabilities, serious injuries or terminal illness, frail elderly people with carers, infants with anxious parents, and pregnant women and their partners. You will undertake very intimate examinations. In preparation, you should read the Code of Practice for Student Examination of Patients on p7. Common ethical dilemmas in phase 4 are the stuff of everyday newspaper headlines! It is important to recognise and analyse these in preparation for your career. There are attachments to district general hospitals during the RSH Block & the CHDA Block for students at Guy’s / St Thomas’ and Denmark Hill. These are for you to experience medicine away from the teaching hospital environment where you can really feel part of the clinical team and learn about important common medical problems. How to succeed in Phase 4. With its diverse specialties and large numbers of skills, phase 4 is both stimulating and demanding. In previous years you may have taken a relaxed approach to studying and concentrated revision prior to examinations. Last minute revision and cramming is not appropriate for phase 4. You need to study consistently throughout the year in order to avoid being overwhelmed by the concentration of assessments at the end of each block. Because you will move swiftly from subject to subject, it is important to consolidate your knowledge, skills and attitudes by taking maximum opportunity to clerk as many patients as possible as you progress through each block. Bookwork is no substitute for clinical experience, topic based seminars and integrated teaching in symposia, although further reading will enhance your learning. Attendance at all teaching is expected. How can the course be improved? We constantly seek to improve the course and welcome constructive feedback through SMEC, staff, questionnaires, and online block feedback. If you wish to discuss matters, please do so. I wish you all an enjoyable year. Dr Simon Hannam Head of Phase 4 1 2. AIMS AND OBJECTIVES OF PHASE 4 In Phase 4 you will build on the basic knowledge and skills developed in Phase 3 and extend these to the special groups of patients found within the Phase 4 specialties. You will acquire the core knowledge, skills and attitudes in the following disciplines, which will be grouped into three Blocks. Child Health, Development and Ageing This teaches about medicine at the extremes of age. Paediatrics, Child Health (including care of the newborn) and Child Psychiatry form an integrated course with separate clinical attachment for Medicine and Psychiatry of Old Age which includes Health Care of the Elderly, Palliative Medicine and Old Age Psychiatry. The subjects will be linked in the symposia by common themes applied to the extremes of age. Dermatology, as an all age specialty, will be taught throughout the course. Emergency Medicine, Trauma and Locomotion This includes experience in Accident and Emergency Medicine, Trauma, Anaesthesia, care of the injured patient, and specialties relating to locomotion including Orthopaedics, Rheumatology and Rehabilitation including the management of gait disorders. Reproductive and Sexual Health This is a comprehensive course in Women’s Health and Sexual Health. The integrated programme includes Obstetrics, Midwifery, Gynaecology, Family Planning, Breast Medicine including related Oncology, and Genitourinary Medicine and HIV. By the end of Phase 4, students will have achieved the following: Attitudes • Developed appropriate attitudes that relate to the vulnerable groups of patients in Phase 4. Knowledge • Completed the teaching of core knowledge in the presentation, symptoms, diagnosis, investigation and management of the Phase 4 disciplines. • Integrated the anatomical, physiological and pathological aspects of these disciplines with clinical teaching. This will be achieved through a range of innovative learning methods which will include seminars on Problem Based Learning for topics within the core curriculum, symposia for a multidisciplinary approach, and small group teaching. • Gained sufficient complementary clinical experience to support the core curriculum in these disciplines which will be taught in hospital, community and general practice. • Be familiar with the range of normal presentation and to be able to distinguish the normal from the abnormal. • Gained an appreciation of the psychological and socio-economic circumstances of patients, particularly of those who are more vulnerable and disadvantaged from age, dependency, and disadvantage. • Been introduced to and gained an understanding of the role of the multidisciplinary team in the care of dependent patients. • Been introduced to aspects of public health, epidemiology, pharmacology and therapeutics and the laboratory sciences relevant to the Phase 4 specialties. • Acquired knowledge through independent learning using a range of methods which will include Student Selected Components, case-based and problem-based learning, multimedia, and computer aided learning, and that these combined should comprise up to about 30% of the learning. 2 Skills • Developed the special communication skills required for the groups of patients represented in Phase 4 which will include the taking of a history from a third party as with infants, elderly and disabled people, and the injured patient, and have developed elementary counselling skills required in their management. • Developed appropriate attitudes and professional skills as they relate to the groups of patients in Phase 4. • Gained an understanding of ethical issues and their application in the context of the many controversial and sensitive areas presenting in the management of these patients. Assessment • Demonstrated the core knowledge, skills and attitudes through in-course and end of year assessment that will satisfy the standards required for certification as a medical practitioner before progression to Phase 5. Student Support • Been supported during the course through personal contact with tutors and clinical supervisors in tutorials and small group teaching and offered appropriate help for educational and personal needs. 3 3. CODE OF PRACTICE FOR STUDENT EXAMINATION OF PATIENTS Medical consultations, examinations and investigations are potentially distressing for patients particularly when involving intimate areas of the body, and may easily be misinterpreted or misunderstood. The General Medical Council receives frequent complaints that doctors have behaved improperly, inappropriately or roughly when undertaking intimate examinations. Many of these allegations prove to be unfounded and have arisen from patients’ misinterpretations, often of a sexual nature, of the actions or approach of well-intentioned practitioners. Students are also at risk of allegations from patients. Students should develop appropriate expertise and sensitivity when undertaking intimate examinations. For your own and your patients’ protection, you should observe this code of practice: 1. Ensure you maintain your membership of a defence organization. At King’s College London School of Medicine it is compulsory to be a member of a defence organization throughout the course. 2. Wear an identity badge prominently displayed at all times on the wards, in outpatients, general practice, and when visiting patients at home. Wear your white coat in specialties where this is customary. 3. Always ask permission from a qualified doctor or nurse to examine a patient or undertake a procedure. This is not essential when taking a history from a patient without examination, although it would be courteous to do so. Discuss the need for a chaperone and, if advised, arrange to have one. 4. Introduce yourself to the patient by name. Explain that you are a medical student and where you are studying. Do not pose as a doctor. 5. Explain to the patient what the examination involves and the reason for it. Check that the patient understands and obtain his or her verbal permission to proceed. 6. For intimate examinations or general examinations in which intimate body areas are exposed, ALWAYS USE A CHAPERONE. Examples include: gynaecological examination rectal examination examination of female breasts examination of male genitalia procedures involving any of these areas e.g. urinary catheterisation. 7. You should be supervised by a qualified doctor or specialist nurse when undertaking invasive examinations and procedures of the rectum, vagina and bladder. Until you have been formally assessed as competent, you should not undertake these without clinical supervision. 8. Allow the patient privacy to undress and dress, explaining which garments should be removed. Minimise the patient’s exposure, and provide a covering for exposed parts of the body when not being examined. 9. Avoid examining patients in poorly lit areas, closed cubicles, or through their garments. 10. Keep any discussion relevant. Do not make personal comments or use names of endearment such as “pet”, “dear”, “love”. 11. If a patient becomes uncomfortable, difficult, or is aroused, or you feel ill at ease about the situation, discontinue the consultation or examination courteously. 12. Record and sign any examination in the patient’s notes. Report any adverse comments to a member of staff and record them in the notes. Who should be your chaperone? Discuss with the patient his or her preference for a chaperone or companion. Surveys have shown that adults of both sexes would prefer a nurse as chaperone and teenagers would prefer a parent. In most wards and GP surgeries, there are insufficient staff to provide chaperones for patient examinations. Another student may be acceptable as chaperone, preferably one of the same sex as the patient. If no one is available, postpone the examination rather than put yourself at risk. Professional behaviour There is a professional code for doctors and students concerning behaviour and presentation towards patients. Observing this helps protect against allegations of familiarity. You should be clean and tidy, avoiding excessive casualness or fashions that might arouse patients or make them feel uncomfortable e.g. low cut necklines or open shirts, bare midriffs, or short skirts. A white coat, as a statement of professionalism, will discourage accusations of impropriety, although in some specialties it is customary for white coats not to be worn, as in Paediatrics, General Practice, and Psychiatry. 4 Examination of special groups of patients 1. Patients with mental illness On psychiatric wards and clinics, it is the policy of the school that medical students do not see patients unaccompanied. This is a safety precaution and protects against possible intimidation or violence particularly from sexually provocative patients. You should always have a chaperone when you clerk a patient. For all other visits to patients, you should always inform ward staff of your intentions and take their advice. When you are working with another student, you are advised to choose mixed sex pairs where possible. 2. Nervous patients and those with personality disorders Nervous or embarrassed patients may be apprehensive about being examined. A chaperone provides reassurance. Students should be alert to signals of distress from patients; you should apologise and discontinue under these circumstances. 3. Adults with learning difficulties Adult patients with learning difficulties should be treated as fully consenting adults with the capacity to decide whether to consent or refuse. As with all patients, it is essential to show respect and privacy. If the patient suffers severe mental disability, discuss your intended examination with an accompanying family member. This is both as a courtesy and to help put the patient and carers at ease. You should note that legally no-one can give consent on behalf of another adult without a Court’s permission. 4. Children and adolescents Infants and children under 16 years of age should always be clerked and examined with a parent, guardian or member of staff present. Children are easily upset, and need the reassurance that comes from the presence of their family; they are taught not to talk to strangers and are generally suspicious of unfamiliar faces. Be aware that child abuse or mishandling is a real fear for parents; students should avoid situations where their intentions can be misinterpreted. 5. Ethnic, cultural and religious groups Expectations vary according to individual circumstances, but remember that Muslim and Hindu women are brought up with a strong taboo against being touched by a man other than their husbands and have a clear preference for women practitioners when intimate examinations are necessary. Male students examining women from these cultural groups should have a chaperone at all times. The Islam, Hindu and Orthodox Judaism religions have taboos about menstruation, so a gynaecological examination during menstruation is unacceptable except in an emergency. 6. The anaesthetised patient If you are asked to make an intimate examination on a patient under anaesthesia (EUA), check with the surgeon or gynaecologist that the patient has given written consent pre-operatively to this examination and that student examination is automatically covered. If the EUA is additional to the surgical procedure for the benefit of the student, you need the patient’s signed consent either on the official consent form or one specifically designed for the situation with an addendum which states that “the EUA will be undertaken by a medical student under supervision of the consultant”. Once signed this must be filed in the patient’s notes. Examination of patients away from King’s College London School of Medicine hospitals Visiting patients at home We ask tutors to consider your safety and security whenever you are asked to visit patients at home. You should always discuss this with your tutor if you have any concerns at all. In earlier years of the course you are often able to visit patients paired with another student but this will often not be possible in phase 5. If after discussion with your tutor you remain very uncomfortable or feel pressurised, you are entitled to decline to visit. If you do visit alone, be sure not to put yourself in a compromising position, in particular avoid carrying out any examination which could be misconstrued. Your tutor takes responsibility if you are acting under his or her guidance. 5 Overseas visits on short-term attachments The same considerations apply when undertaking clinical attachments abroad. Customs and professional etiquette vary in different countries and you will need to be aware of local practice. In countries where health care provision is scarce, students may feel under pressure to exceed their role. You must check that you have professional supervision. Always recognise your clinical limitations. Protocol for Intimate Examinations of Patients by Students in the Healthcare Professions (Recommendations in this protocol are under consideration by NHS Trusts and are at different stages of implementation. You will find that clinical practice varies across hospitals.) Introduction Consultations with healthcare professionals, examinations and investigations are potentially distressing for patients when involving intimate areas of the body. Acceptable professional behaviour, good communication, and respect for patients’ rights to be fully involved in decisions about their care will reassure patients and avoid misunderstanding. Complaints are not infrequently made that health professionals have behaved improperly or roughly when undertaking intimate examinations or invasive procedures. Students in healthcare professions are at similar risk. For your patients’ and your own protection, you should follow this protocol when performing intimate examinations. These include: vaginal examination and inspection of the perineum rectal examination of both sexes examination of female breasts examination of external male genitalia Requirements for intimate examinations You should first practise the examination on a model, mannequin, or a gynaecology teaching assistant. Before examining a patient, you must have approval from your supervising practitioner at the time of the examination. For all vaginal and rectal examinations and first examinations of female breasts or male external genitalia, you must examine the patient in the presence of your supervisor. The patient must have a chaperone. You should obtain the patient’s permission and explain that this will be recorded in the patient notes, as follows; Verbal permission for examination with the patient awake Written permission for examination under anaesthesia, using a student form Patient consent for examinations and invasive procedures It is a requirement of clinical practice that consent for any procedure is obtained from patients by the clinician who takes responsibility for their care and that the patient is adequately informed about the procedure, the possible risks and consequences, and alternative management options. This is known as informed consent. Giving consent requires the patient to have sufficient mental capacity to consent. Consent can be verbal or written and must be given voluntarily. Students in training are not legally qualified to obtain informed consent from patients but must obtain the patient’s agreement for history taking and examination. Preparing patients for an intimate examination Before you perform an intimate examination, you must obtain the patient’s permission. Start by explaining what is involved and asking whether the patient has previous experience of the examination, whether the experience was painful and if so discuss with your supervisor. Offer an opportunity for questions and discussion, and supplement with an information leaflet if available- remember that patients need time to reflect on information. Explain that patients have choices and that declining an examination will not adversely affect care. Explain that your supervisor will be present during the examination. Women from some backgrounds and cultures may have beliefs about not being touched by a man other than their husbands and some women may express a preference for women practitioners for intimate examinations. Such requests should be respected. You should avoid examining women during menstruation except in an emergency. You should also be sensitive to the potential for embarrassment or misunderstanding in other circumstances such as examining the chest of a female with exposure of the breasts, or examining the eyes by fundoscopy in a dimly lit room. 6 Keeping good clinical records You should record the examination in the patient’s notes. State that the patient gave permission, whether your supervisor was present, whether the patient was chaperoned and if so by whom. Date and sign your entry with your name and student status clearly printed. Final year students assessed as competent in the examination should record their clinical findings as a contribution to team-care. Who should chaperone the patient? Whenever students perform intimate examinations, the patient should have a chaperone. The option of a chaperone should be discussed with the patient and your supervisor. A chaperone should be a member of staff and may include your supervisor, or a friend or a relative accompanying the patient. The chaperone should be of the same sex as the patient. Studies have shown that adults of both sexes prefer a nurse as chaperone, and teenagers prefer a parent. If staff are unavailable, another student may be acceptable if the same sex as the patient. If no one is available, postpone the examination rather than examine the patient alone. If asked to be a chaperone stand or sit by the patient unobtrusively and observe the procedure. If the patient is distressed, report this to the examiner and suggest the examination is discontinued. Patient examination under anaesthesia (EUA) Permission for students to gain experience during EUA must always be obtained from the patient. The procedure should be explained prior to the “premed” before the anaesthetic and the patient asked to give written agreement. Ideally this should be done in outpatients or the ward rather than in the operating theatre, but practicalities on the day of the procedure may preclude this. In some trusts, student consent forms may be available in the operating theatres, outpatients, wards, or on the Trust intranet. These forms are different from the standard NHS forms used by staff when obtaining patient consent to a surgical procedure. As a student, it is your responsibility to check with your supervising gynaecologist or surgeon that the patient has agreed to the examination. It is your supervisor’s responsibility to explain the procedure and obtain the patient’s signature. Consent may be obtained in this way for up to two anonymous students for each examination or procedure. The consent form must be countersigned by your supervisor before surgery and filed in the patient notes. If student consent forms are not available, permission should be verbal and should be recorded in the patient notes. If permission has not been obtained from the patient, you must not proceed with EUA. If pressed to do so, you should explain to your supervisor that it is a School requirement to obtain permission. Intimate examinations during pregnancy and childbirth Student midwives and medical students are expected to participate under supervision in the care of pregnant women. This may involve vaginal examination and inspection of the perineum. The most appropriate time to discuss student involvement is during the antenatal period and should be done by the midwife or obstetrician with clinical responsibility for the patient. Written information about this may be included in the patient-held antenatal records. Giving consent is an on-going process throughout the period of maternity care. During labour and the post-natal period, it is essential that the patient is asked for verbal permission for a named student to perform vaginal or perineal examination, and that examinations are recorded in the patient notes. Intimate Examinations of special groups of patients Because some patients may not have the capacity to give consent, students should not perform intimate examinations on the following groups: 1. Patients with severe mental illness 2. Adults with severe learning difficulties 3. Children and adolescents under age 16 years 4. Non-English speaking patients 5. Patients at home, when medical students accompanied by their GP tutor Examination of patients at District General Hospitals (DGHs) The same professional and ethical principles apply at DGHs as at campus hospitals. You should follow this protocol. There will be slight differences in availability and wording of student consent forms. If you are concerned about what you are being asked to see or do, discuss with your local supervisor or subDean. If this does not satisfy your concerns, you should raise it with your Clinical Adviser. If you feel ill at ease about performing an intimate examination, do not proceed. 7 Examinations in general practice Before performing an examination, check that your patient has given verbal permission. For intimate examinations, your GP tutor or clinical supervisor must accompany you. The patient should have a chaperone of the same sex, unless by mutual agreement, the patients’ partner agrees to chaperone. After the examination, you should record in the patient’s written or computerised notes that you examined with the patient’s permission. State: your supervisor, the arrangements for and name of the chaperone, your findings, and date and sign your entry, stating your course and year of training. Electives and clinical attachments at home and abroad The same rules and etiquette apply on clinical attachments or electives abroad. Customs and professional etiquette vary in different countries. You should be aware of local practice. In countries where healthcare is scarce, you may feel under pressure to exceed your role. Check that you have professional supervision and recognize your clinical limitations. Record, date and sign your examination, stating permission was obtained, and giving the name and status of your chaperone. Procedures in Clinical Practice Basic professional requirements for students on clinical practice 1,2 Medical students are required to maintain membership of a defence organisation throughout the course. Wear an identity badge prominently displayed at all times in hospital and community. Dress should be professional and appropriate to the specialty. Dress code excludes excessively casual clothing such as jeans, shorts, baseball caps and trainers. Avoid wearing revealing clothing as this may embarrass patients. You should be clean and tidy, fingernails short, and long hair tied back. It is unprofessional to chew gum, eat, or drink in the patient’s presence. You should be polite and considerate with staff and patients. Avoid unacceptable behaviour and personal conversations in the patient’s presence or when undertaking professional activities. Introduce yourself to the patient by your full name. Explain that you are a student; state your course, and where you are studying. Never pose as a qualified professional. Always provide privacy for the patient to undress and dress. Draw the curtains around the examination couch, checking that it is covered with clean paper. Explain which garments should be removed and where they should be placed. Do not observe the patient undressing. Ask your patient to let you know when they are ready to be examined. Explain the position for the examination. Provide a cover for exposed body areas. Keep discussion relevant to the examination; avoid personal or humorous comments. You should discontinue if you feel ill at ease, or, if the patient is uncomfortable, distressed, aroused, makes inappropriate comments, or withdraws consent. Protocol for vaginal examination (patient awake) 1. Learn and practise vaginal or speculum examination on a simulator or a gynaecology teachingassistant. These are women who train students on themselves and agree to be examined. You must be signed up for this in your logbook before transferring the technique to a patient. When you perform vaginal examination, your clinical supervisor must be present throughout. Introduce yourself to the patient; explain your student status, course and year of study. 2. Explain the examination to the patient and obtain verbal permission. Discuss the need for a chaperone with your supervisor and if male, arrange for a female chaperone. Allow patient privacy for undressing. Explain the position for the examination. You should first examine the abdomen to put the patient at ease and to detect abnormal pathology. It is usual for the patient to be examined lying on her back (dorsal position) although occasionally, you may see a patient examined on her side (usually the left lateral position). 3. Before you start, check the examination tray for equipment for a vaginal speculum of correct size, lubricant jelly, examination gloves, and tissues for wiping body areas after the examination. Check the examination light is working and is in the correct position. 4. Wear surgical gloves on both hands. 5. Proceed with the vaginal examination as instructed, observing clinical etiquette. Inform your patient when you have finished, explain your findings and thank your patient. Ask your supervisor for feedback. 6. Record, date and sign the examination in the patient’s notes, stating that permission was obtained, name of your supervisor, and name and status of the chaperone. 1 General Medical Council. Good medical practice and duties of a doctor. 2002. www.gmc-uk.org 2 Royal College of Obstetricians and Gynaecologists. Gynaecological Examinations. RCOG. London. 2002 8 Protocol for ano-rectal examination 1. Learn and practise rectal or proctoscopic examination on a simulator before you transfer to a patient. Medical students should learn the technique at the Phase 3 Introductory Course. 2. When you perform ano-rectal examination, your clinical supervisor must be present throughout. 3. Introduce yourself to the patient, explain your student status, course and year of study. 4. Explain the examination to the patient and obtain verbal permission. Discuss the need for a chaperone with the patient and your supervisor. If your supervisor is of different sex from the patient, arrange for a chaperone of the same sex as the patient. 5. Allow patient privacy for undressing. Explain the position for the examination. You should start with an abdominal examination to detect pathology and put the patient at ease. It is usual to examine the rectum with the patient lying on the left side (lateral position) with knees flexed and drawn towards the chest. 6. Before you start, check the examination tray for surgical gloves, lubricant jelly, tissues for wiping body areas after the examination, and a proctoscope if needed. 7. Wear surgical gloves on both hands. 8. Proceed with the rectal examination as instructed by your supervisor, treating your patient gently, and observing clinical etiquette throughout. Inform your patient when you have finished, explain your findings, and thank your patient. Ask your supervisor for feedback. 9. Record, date and sign the examination in the patient’s notes, stating that patient permission was obtained, name of your supervisor, and name and status of the chaperone. Protocol for examination of female breasts 1. Learn and practise breast examination first on a mannequin or a volunteer patient in a group teaching session before transferring to a patient. When you first perform breast examination, your clinical supervisor must be present throughout. 2. Introduce yourself to the patient, explain your student status, your course, and year of study. Explain the examination to the patient and obtain verbal permission. If your supervisor is male, arrange for a female chaperone. 3. Allow patient privacy for undressing. Explain the position for the examination starting with the patient in a supine position with the head end of the couch elevated to 45 degrees, and then rolling to the side. 4. Proceed with the breast examination as instructed, observing carefully and palpating gently. Inform your patient when you have finished, allow her to cover herself, explain your findings, and thank your patient. Ask your supervisor for feedback. 5. Record, date and sign the examination in the patient’s notes, stating that consent was given, the name of your supervisor and name and status of your chaperone. Protocol for examination of male external genitalia 1. For your first examination of male external genitalia, your clinical supervisor must be present. You should examine male external genitalia with great sensitivity and with no more than two students present one of who should be male if possible. 2. Introduce yourself to the patient; explain your student status, your course, and year of study. Explain the examination to the patient and obtain verbal permission. If you are examining alone, you must arrange for a chaperone who should be of the same sex as the patient. This could be a fellow student. Your hands should be warm. Do not rub them together in front of the patient! 3. Observe clinical etiquette throughout the examination. Start with the patient standing fully exposing his groins, and your eyes level with the area being examined. Observe the area and ask the patient to cough. Palpate the scrotum to determine the presence of two normal testes and any abnormal mass, and then palpate the inguinal and femoral areas for cough impulses. If you notice a swelling of the groin in the upright position, do not try to reduce it. 4. For the second part of the examination, ask the patient to lie down. The patient should gently reduce any swelling. You should examine for hernia, palpate the femoral vessels, and scrotum. Inform your patient when you have finished, explain your findings, and thank the patient. 5. Record, date and sign the examination in the patient’s notes, stating that permission was obtained, the name of your supervisor, and name and status of your chaperone. 9 4. ATTENDANCE AND GOOD PHILOSOPHY OF WORK Overnight success These days the papers are full of stories about people who shoot to fame almost overnight, seemingly without any effort on their part. They seem to forget that everyone who enjoys success in film, music, theatre, sport or any other sphere of activity has spent many years practising and training, in order to achieve their goals! It is the same with a medical career. Success in terms of doing well each year, and then qualifying with one of the world’s most highly regarded degrees, is not a free gift or a right, but something that needs to be worked at. ‘Pursuing a course of study’ The General Medical Council indicates that medical students must pursue a course of study and this means attendance at the activities organised by Medical Schools. Of course the vast majority of students turn up to most things but problems sometimes arise – including cases where it is perceived that you have not attended, when in fact you did. So we felt it would be worthwhile outlining some of the issues at the beginning of the Year rather than later when there are problems. “What is expected of me?” You are expected to attend all teaching – whether clinical, symposia, seminars or tutorials. However, it is recognised that illness and official absence may reduce this. Greater than 90% attendance is expected. If it is evident that attendance falls below 75%, your Clinical Adviser will be notified. Persistent non-attendance is a very serious issue that will be dealt with by the Senior Clinical Advisers and the Site Deans from each campus (see separate information about this process). We are particularly concerned when a student does not make an appearance at the beginning of a rotation or block, and does not collect any materials for the forthcoming period. Non-attendance is the major cause of academic problems, in our experience. However if you feel you have been hard done by in an assessment of attendance, do let the course organiser or Firm chief know. “I find it easier to learn from books than going to symposia, lectures or tutorials!” We all have different learning styles, but there is an important aspect that you cannot get from books. In group teaching we interact with teachers and student colleagues or friends. It is also important to get into the rhythm of getting up in the morning to go to a day’s teaching, it is too easy to start opting out of more and more sessions until you lose touch completely. We forget how important it is to be with other people – whether you are an extrovert or introvert – and lack of contact with others (feeling ‘out of it’) can lead to loss of enjoyment of the course and sometimes depression. Developing professional values best happens by contributing to tutorials & practicals on communications, ethics and taking a wide interest in medico-political and ethical problems in medicine, and exposing yourself to these issues through meeting them in wards and clinics Practising & learning clinical skills, procedures, communications, team working and practical knowledge of medicine is best and most appropriately learned working with patients and staff in clinical settings Learning the clinical and scientific knowledge base is greatly assisted by drawing on the skills and experiences of senior clinicians in symposia, lectures and small group sessions, backed up with conscientious bookwork. Medicine is a bit like flying: one would not be happy being flown by a pilot who had passed his exams brilliantly but had little experience and few flight hours. To learn the practice of medicine requires both bookwork and flying hours “How much extra should I try and do?” Going to special sessions like clinical-pathological meetings, Grand Rounds and post mortem presentations can be an effort sometimes, but it helps you to feel part of the whole clinical team, as well as being good for learning. Whenever you see a patient with a particular clinical problem, read up on it and make notes- it makes it so much more memorable. 10 “What if I am ill or need to go home because of a family problem?” These kinds of problems happen to everyone. The key issue here is that you should let the relevant people know what has happened. Just as you would be bothered if someone didn’t meet you when they said they would, so teachers (especially in small-group work) ought to know why you are not there; this is part of social and professional courtesy and consideration for others, that we should aim to have. Always keep any appointments you have made with staff and be on time - and apologise if you are held up, even if it is not your fault (you may need to phone ahead as the individual may only have a limited time slot to see you). So if there is a problem: Tell the Academic Centre if you are unwell, especially if you are likely to be off sick for more than a couple of days, or have a moderate to severe illness or admission to hospital. Small group work: Tell the tutor you cannot attend (or Firm head) their session, preferably personally by e-mail or phone call, or, as a last resort, ask a fellow student to let the individual know. Large sessions (Lectures, Symposia): You do not need to inform the lecturer, but make every effort to catch up with what you missed. Timetable clashes: teachers may not know about the details of your SSC teaching that clashes with their tutorial, so do let them know if there is a conflict, and you have go off to a clinic or an SSC activity for example. “Sometimes the teachers don’t attend!” This does happen sometimes for a whole host of reasons. The hospitals and campuses are large and complex organisations and things do go wrong organisationally. Staff can get stressed and disorganised too! We try and minimise this but if it does happen, we hope you will be told what went wrong, and if a replacement session can be scheduled. Sometimes informal ward teaching does not happen because of some clinical emergency, but if you find a Firm is not delivering teaching please inform the Phase head (this will be in confidence). Money problems Students who take on employment are at serious risk of failing. The School’s view is that it is not acceptable to take days out of the week to do jobs. We understand the problems some people have, but you will always have to put your studies first. Make contact with those responsible for hardship funds and other sources of funding as soon as you can, if you are getting into difficulties. A philosophy of working… If you get behind in your studies it can have a very negative effect and inhibit concentration (‘I’ve so much to do, I can’t do any of it!’). Also, if you fall behind in background reading and other work, you can begin to lose confidence in clinics and on wards, and then with patients. Forgetting about clinical skills can also have the same effect so it is important not to leave them all for sign-ups or OSCEs but keep practising as you go along. Once signed up that does not mean you have the skill mastered – as many found out in previous years when even simple things like blood pressure measurement in the OSCEs were done badly! Sometimes we have to delay gratification i.e. defer something nice that we want to do, in order to achieve a goal. This can actually enhance our enjoyment in life because we have a greater sense of achievement - rather than a last minute panic - and our leisure time is deserved. Plan work to meet your deadlines well in advance! A philosophy of NOT working… It is also important to know how and when to relax, to have a day a week doing nothing much and just enjoying yourself! 11 Structure of Phase 4 The 3 main blocks in Phase 4 are clinically very exciting, and also demanding. You will attend a diverse range of clinical teaching, and the weekly timetables are busy and variable. You will therefore need to be organised, punctual and conscientious to ensure that you attend and get the maximum benefit from this year. This is part of showing that you are ready to assume the professional responsibilities that are required as a medical graduate. Peripheral Placements in Paediatrics, and Obstetrics & Gynaecology During the CHDA and RSH Blocks most students will undertake a three week placement at either a DGH, or at an overseas twinned institution, or at a self-arranged placement organized by the individual student. The main reason for arranging these attachments is for you to experience medicine away from the teaching hospital environment, where you can really feel part of the DGH team, and where you can learn about important common medical problems. It is, as with most things, a case of what you get out of it depending on what you put into it. We therefore strongly encourage you to really “immerse” yourself in the clinical experience during these valuable attachments. This includes staying at the weekend if you can. You may be able to arrange to continue with your SSC work on the Friday whilst staying at the DGH. However if the particular SSC requires that you return to campus, then the DGH consultants are aware of this requirement. Your attendance at the DGH will be monitored by the supervising consultant. Those students undertaking CHDA at PRUH and UHL, and those students undertaking RSH at PRUH, QEH and UHL, do not require this three week placement as they receive equivalent clinical experience at these hospitals. Enjoy the Year! 12 Holidays FIRST ROTATION Week 1 Start Date 10-Sep-12 2 3 4 5 6 7 8 9 10 11 12 17-Sep-12 24-Sep-12 01-Oct-12 08-Oct-12 15-Oct-12 22-Oct-12 29-Oct-12 05-Nov-12 12-Nov-12 19-Nov-12 26-Nov-12 13 03-Dec-12 SSCs, Community Study & Assessments SSC Start date 14/09/12 Reading week Community Study (Stream A) 21/09/12 Community Study day (Stream B) – 07/12/12 SSC 1 Submission date 07/12/12 10-Dec-12 17-Dec-12 Christmas Holiday 24-Dec-12 SECOND ROTATION New Year's Day Bank Holiday 1 2 3 4 5 6 7 8 9 10 11 12 13 Easter Monday Third Rotation Early May Bank Holiday 1 2 3 4 5 6 7 8 (31-Dec-12) (01-Jan-13) 02-Jan-13 07-Jan-13 14-Jan-13 21-Jan-13 28- Jan-13 04-Feb-13 Careers Day Fri 11/01/13 Stream A ½ Day Global Health ½ day Tropical Health Fri 18/01/13 Stream B ½ day Global Health ½ day Tropical Health Fri 08/02/13 11-Feb-13 18-Feb-13 25-Feb-13 04-Mar-13 11-Mar-13 18-Mar-13 25-Mar-13 (01-Apr-13) 02-April-13 08-Apr-13 15-Apr-13 22-Apr-13 29-Apr-13 (06-May-13) 07-May-13 13-May-13 9 10 11 20-May-13 (27-May-13) 28-May-13 03-Jun-13 10-Jun-13 12 17-Jun-13 13 24-Jun-12 01-Jul-13 Spring Bank Holiday Health promotion and elective portfolio planning (A&B) Community Study (Stream A) 04/01/12 08-Jul-13 Community Study (Stream A) 15/02/13 Community Study day (Stream A) – 15/03/13 Community Study day (Stream B) – 22/03/13 Submission of Elective portfolio 29/03/13 Community Study presentations (Stream A) – 12/04/13 Community Study presentations (Stream B) – 19/04/13 Consolidation and review Stream A 26/04/13 Consolidation and review Stream A 03/05/13 Consolidation and review Stream B 10/05/13 Consolidation and review Stream B 17/05/13 Written Assessment – See virtual campus for Exam Dates Part A OSCE – Timetable published 2 weeks before on the VC Re-sit Written Assessment/ Part B OSCE – Final Exam results to be published 15-Jul-13 13 6. DEADLINES AND DATES Item Application for Elective attachments in twinned institutions Elective Proposal Form Elective Portfolio Completed logbook Mitigating Circumstances (Assessments) Form* for Written Examinations Elective emergency contact details Mitigating Circumstances (Assessments) Form for OSCE Mitigating Circumstances (Assessments) Form* for Resit Written Examinations Publication of MBBS Part 4 Results Elective period Deadline End of November 2012 (see dates on VC) Early Feb– See dates on VC/Elective Handbook 29/03/13 Rotation 1- 3rd Dec Rotation 2 – 25th March Rotation 3 - 25th June 7 days before exam. If exam is taken you must submit the form 7 days after exam. Mid July 2013 - See dates on VC/Elective Handbook 7 days before exam. If exam is taken you must submit the form 7 days after exam. 7 days before exam. If exam is taken you must submit the form 7 days after exam. Please refer to Virtual Campus Examination Information page See VC & Elective Handbook 14 Submitted to / Location Academic Centre Academic Centre Academic Centre Academic Centre Academic Centre Academic Centre Academic Centre Academic Centre Guy’s Exam Noticeboard 7. COURSE OUTLINE • The Phase 4 course extends over 41 weeks. There will be a total of 4 weeks holiday: 2 weeks at Christmas and the New Year, and two after the completion of Phase 4, in addition to Bank Holidays. There is no holiday at Easter. • Each rotation lasts 13 weeks: 12 weeks teaching and a final reading week in week 13 (Rotation 1 & 2). Rotation 3 lasts 13 weeks: 12 weeks teaching and written assessment in Week 13. There is no SSC in Rotation 3 • Fridays (except for Community Study Days as outlined below) are for Student Selected Components but are also designated for teaching and consolidation, you can expect to have some timetabled sessions on these Fridays. • After the final rotation, there are two further weeks for assessment, to include the OSCE and the resit end of block written examinations. • Symposia: first symposia Monday afternoon, otherwise weeks 1-12 on most Wednesday mornings. Most symposia are block specific for all students on all campuses. • Seminars: Mondays, Tuesdays and Thursdays for one hour (2 hours for PBL in the EMTL Block at King's College Hospital campus), and are block specific; for CHDA at GST, KCH and PRUH, seminars are all delivered in weeks 1, 2, and 12 of the Block. For timetables see the Virtual Campus and Coursebooks. • Community Study days will take place on the following Fridays: Rotation 1 - Week 2 (Stream A) & Week 13 (Stream B). Rotation 2 - Weeks 1 and 11 (Stream A) and weeks 6 and 12 (Stream B). Rotation 3 – CS Presentation Week 2 (Stream A) – HP & CS Presentation Week 3 (Stream B). All students will also attend the Community Study symposium on the morning of week 1, rotation 2 (6th Jan 2012). Outline Timetable 13 weeks • 2 weeks Child Health, Development and Ageing Reproductive and Sexual Health 13 weeks Child Health, Development and Ageing Emergency Medicine, Trauma and Locomotion 13 weeks 1 week 1 week Part B OSCE• Re-sit written examinations• Emergency Medicine, Trauma and Locomotion Reproductive and Sexual Health Week Week Week starting starting starting 01/07/13 08/07/13 15/07/13 Part A OSCE Introductory Day Emergency Medicine, Trauma and Locomotion Reproductive and Sexual Health Holiday Introductory Day Child Health, Development and Ageing Rotation THREE 02/04/13-28/06/13 Part A OSCE Rotation TWO 02/01/13-29/03/12 Introductory Day Rotation ONE 10/09/12-07/12/12 1 week Each rotation begins with an introductory programme, scheduled for the first day of each rotation. On this day, the whole year will assemble in the morning before splitting into the three group blocks. The timetable for each introductory day applies for all three rotations, and is as follows: 15 Timetable for Introductory Days Morning programme: Rotation 1 (Monday 10/09/12): 09:00am – 1pm Introduction, Greenwood Lecture Theatre, Weston St, Guy’s; follow-up sessions in Anatomy Lecture Theatre (Hodgkin) and Harris Lecture Theatre (Hodgkin) and for CHDA Waterloo Campus (CHDA students will be split into two groups –see Introduction Timetable and attachment). Rotation 2 (Wednesday 02/01/12): 8.30am – 1pm Introduction, Greenwood Lecture Theatre, Weston St, Guy’s; follow-up sessions Anatomy Lecture Theatre, Tower Lecture Theatre & Greenwood LT. Rotation 3 (Tuesday 02/04/12): 8.30 am – 1pm Introduction, Greenwood Lecture Theatre, Weston St, Guy’s; follow-up sessions in Anatomy Lecture Theatre, Harris Lecture Theatre (Hodgkin) & New Hunts House Lecture Theatre 2. Afternoon programme: Rotations 1, 2 and 3: from 2pm First symposium of each course block. See Symposium timetable (available on the VC) for full details. You should make sure you have the following: • MBBS Phase 4 Student Handbook – only available on the VC • MBBS Phase 4 Logbooks (CHDA, EMTL, RSH) - Distributed on Rotation 1 intro day. • MBBS Core Curriculum (available from the Virtual Campus) • MBBS Phase 4 Community Study Guide – Distributed on Rotation 1 intro day. • MBBS Elective Handbook (available from the Virtual Campus) 16 8. PHASE 4 KEY CO-ORDINATORS Head of Phase 4 Phase 4 Academic Centre Contact Dr Simon Hannam Department of Paediatrics King’s College Hospital Denmark Hill London SE5 9RS 020 3299 4000 ext 4644 Selina McClure Phase 4 Undergraduate Officer Academic Centre 2nd Floor Henriette Raphael House Guy’s Campus London SE1 1UL 020 7848 6720 FAX 020 7848 6730 [email protected] [email protected] Deputy Head of Phase 4 Dr Rachael Morris-Jones Dermatology Consultant Kings College Hospital London SE5 9RS 020 3299 4000 ext ext 4634 [email protected] Lead Co-ordinator for Community Study/Health Promotion & SSCs SSC Academic Centre Contact Dr Ann Wylie Paul Jones Undergraduate Officer for Phase 4 (SSCs) 2nd Floor Henriette Raphael House Guy’s Campus London SE1 1UL 020 7848 6711 FAX 020 7848 6730 [email protected] Department of Primary Care and Public Health Sciences 4th Floor, Capital House, 42 Weston Street LONDON SE1 3QD 0207 848 8705 FAX 020 7848 8705 [email protected] Phase 4 Administrator: Simon Power Tel 0207 848 8689 [email protected] Co-ordinator for Elective Dr Anthea Tilzey C/o Academic Centre 2nd Floor Henriette Raphael House Guy’s Campus London SE1 1UL FAX 020 7848 6730 [email protected] 17 Phase 4 Block Leaders and Student Co-ordinators Child Health Development and Ageing Block Paediatrics and Child Health Sub-block Medicine and Psychiatry of Old Age Sub-block Dr Simon Waller Consultant Paediatric Nephrologist Evelina Children's Hospital Guy's and St Thomas' NHS Trust Lambeth Palace Road London, SE1 7EH Dr Thomas Ernst Consultant acute physician and geriatrician St Thomas’ Hospital Tel: 020 7188 2516 [email protected] Administrator: 0207 188 4586 (Sec) 0207 188 4585 0207 188 3026 bleep 1341 Sandra Gray Tel: 020 7188 2515 [email protected] [email protected] Emergency Medicine, Trauma and Locomotion Block Dr Chris Lacy A&E Department King’s College Hospital Denmark Hill London SE5 9RS 020 3299 1941 Secretary: Sophy Dunn 020 3299 1584 [email protected] [email protected] Reproductive and Sexual Health Block Ms Deborah Bruce Annelie Mojzis Department of Women’s Health 10th Floor, North Wing St. Thomas’ Hospital London SE1 7EHF Undergraduate Teaching Administrator/PA to Ms Bruce: [email protected] [email protected] 020 7188 3631 FAX 0207 620 1227 Medical Student Co-ordinators GST Campus GST Campus KCH Campus (CHDA & EMTL Loco) (EMTL Anae & A&E) (EMTL & CHDA) Maria Fernandes Site Secretary and Co-ordinator Sub Dean For Teaching Office Prideaux Building, Block 9 St. Thomas Hospital Lambeth Palace Road SE1 7EH Tel: 020 718 85183 [email protected] Farhana Begum Sheinaz Mahomedally Anaesthetics Dept MBBS Curriculum Administrator Guy's & St Thomas' NHS 2nd Floor Borough Wing 2nd Floor, Weston Education Centre Great Maze Pond Denmark Hill Campus London. SE1 9RT. Tel: 0207 848 5224 Tel: 020 7188 0645 (Int: 80645) email: [email protected] [email protected] QEH Campus (EMTL & RSH) UHL Campus Joanna Woollard Education Centre Stadium Road Woolwich London SE18 4QH 0208 836 6788 Fax: 020 8836 6785 [email protected] Samantha Newman Education Centre University Hospital Lewisham High St. Lewisham London SE13 6LH 020 8333 3000 ext. 8734 PRUH Campus Shayron Hegarty (RSH & CHDA) TBC (EMTL) The Education Centre Princess Royal University Hospital Farnborough Common Orpington BR6 8ND 01689 864347 [email protected] TBC 18 [email protected] Phase 4 Examiners Head of Examinations Deputy Head of Examinations Rob Feneck Anaesthetics Dept. East Block, St Thomas' Hospital, Lambeth Palace Road, London SE1 7EH Dr Simon Hannam Department of Paediatrics King’s College Hospital Denmark Hill London SE5 9RS 020 3299 4000 ext 4644 [email protected] c/o [email protected] Phase 4 Examinations Academic Centre Contact OSCE Co-ordinator and Administrator Philip Wright Academic Centre 2nd Floor Henriette Raphael House Guy's Campus London SE1 1UL 020 7848 6723 FAX 020 7848 6730 [email protected] Co-ordinator: Dr Vip Gill Administrator: Mr James Hollands Chantler Clinical Skills Centre Ground Floor Shepherd’s House Guy's Campus London SE1 1UL 020 7848 6101 FAX 020 7848 6730 [email protected] Block Senior Examiners Child Health, Development and Ageing Block Written Assessment OSCE Dr Simon Hannam Dr Simon Hannam Emergency Medicine, Trauma and Locomotion Block Written Assessment OSCE Dr Arsenyj Powroznyk Dr Chris Lacy Reproductive and Sexual Health Block Written Assessment OSCE Mr Mike Marsh MS Deborah Bruce 19 Course Organisers by Block and Campus Child Health, Development and Ageing Block Module KCH GST PRUH UHL Child Health Dr S Hannam Dr S Waller Dr M De Silva Dr J Lawrence Neonatology Dr S Hannam Dr G Lee Dr M De Silva Dr J Lawrence Child Psychiatry Dr S Bernard Dr S Bernard Dr S Bernard Dr S Bernard Community Paediatrics Dr M Davie Dr R Healy Dr S Sharma Dr G Siggers Dermatology Dr R Morris-Jones Dr Clive Archer Dr K Watson Dr P Banerjee Medicine of Old Age Dr R Pathansali Dr T Ernst Dr B Kessel Dr Patel Dr V Mak Dr C Sebastian Dr C Goddard Dr T Beynon Dr L Exton Dr K Emmitt Psychiatry of Old Age Dr N. Funnell Palliative Care Dr P Edmonds Emergency Medicine, Trauma and Locomotion Block Module KCH GST UHL PRUH QEH Emergency Medicine Dr TJ Lasoye Dr B Christian Mr N Harrison Dr Sam Thenabadu Dr F Ohanusi Anaesthetics Dr S Peat Dr V Gill Dr G Mathew Dr Andrew Turvey Dr S Gupta Pain Dr S Peat Dr J Azzopardi Dr G Mathew Dr Sam Thenabadu Dr S Gupta Orthopaedics Mr M Wilkinson Mr I Jones Dr J Bird Mr Max Edwards Mr A Tindall & Mr A Dutta Dr T Garrood Rheumatology Dr P Gordon Dr G Yanni Dr Sarah Medley Dr C Mathews Reproductive and Sexual Health Block Module KCH GST PRUH UHL QEH Obstetrics & Gynaecology Mr M Marsh Ms Deborah Bruce Miss K. Omar Ms R Cochrane Mr N Perks Genitourinary Medicine Dr A MenonJohansson Dr A MenonJohansson Dr A MenonJohansson Dr A MenonJohansson Dr J Russell Breast Medicine Dr J Marsden Mr H Hamed Mr P Sinha Dr H Hamed Mr B Kald Family Planning Ms M Nowicki Ms M Nowicki Ms M Nowicki Ms M Nowicki Ms M Nowicki 20 9. CHILD HEALTH, DEVELOPMENT AND AGEING BLOCK (CHDA) 9.1 An Overview of the Block 23 9.2 Course Organisers and Contact Details 24 9.3 Block Aims and Objectives 26 9.4 Orientation 33 Guy’s/St Thomas’ Campus 33 King’s College Hospital Campus 34 Princess Royal University Hospital Campus 35 University Hospital Lewisham Campus 36 9.5 Outside and Overseas Attachments 37 9.6 Symposia Information 38 9.7 Aims and Objectives for Symposia 38 9.8 Seminar Titles 41 9.9 Aims and Objectives for Seminars (Medicine and Psychiatry of Old Age) 42 (For Paediatrics & Child Health Seminar Aims and Objectives please refer to Paediatrics Seminar Guide) 9.10 Recommended Reading and Computer-Aided Learning 21 46 9.1 An Overview of the Block Introduction The Child Health Development and Ageing (CHDA) course arose from a shared vision of the similarities in a number of respects between the clinically disparate specialties of geriatric medicine and paediatrics. The course incorporates dermatology - a clinical specialty highly relevant across the age spectrum - and palliative medicine. At King’s College Hospital, Guy’s and St. Thomas’s and Princess Royal University Hospital there are two introductory seminar/symposia weeks and one final seminar/symposia and revision week. The remaining 9 weeks of the block consists of 3 weeks of paediatrics (including hospital paediatrics, community child health and the care of the newborn) and child psychiatry based at GST or KCH; for those students based at KCH and GST, a 3-week placement in paediatrics at a local DGH, or at a hospital in the Overseas Exchange Programme, or at a hospital arranged independently; and 3 weeks of Medicine and Psychiatry of Old Age. Students at University Hospital Lewisham & Princess Royal Hospital (Orpington) have a fully integrated block, with seminars throughout the 12 weeks, and equivalent paediatric experience obtained during 8 weeks on campus, as well as 4 weeks of Medicine and Psychiatry of Old Age. The Block has a series of seminars covering Medicine and Psychiatry of Old Age, Paediatrics, Dermatology, Child Psychiatry and Palliative Medicine. The symposium programme is integrated across the CHDA block as a whole. Thus the changes in drug handling (pharmacokinetics) across the age spectrum from neonate to extreme age are considered in the Therapeutics Across the Ages symposium jointly run by a geriatrician and a paediatrician. Similarly, communication problems and abuse, violence and neglect are all considered from a multidisciplinary standpoint. It is expected that students will not only acquire the attitudes, knowledge and skills appropriate to the clinical disciplines but also the attitudes and knowledge relevant to the consideration of ageing and its implications. The Medicine & Psychiatry of Old Age The Medicine and Psychiatry of Old Age module brings the medicine and psychiatry of old age together. It includes a small but crucial component of palliative medicine. The strength of this joint approach between medicine and psychiatry is that it not only enables overlap areas to be taught jointly (e.g. seminars on delirium, and the law) but also ensures that the two subjects are taught in an integrated manner. The core curriculum includes a variety of conditions that students should be familiar with. This familiarity can be achieved by self-directed learning, clerking patients and presenting cases to teachers as well as by attending bedside teaching sessions. The sub-block aims to strike a balance between clinical teaching and self-directed activities. In addition to the skills logbook, where formal assessment of clinical skills will be documented, students will be given guidance as to the range of cases they should see. Medicine and Psychiatry of Old Age is taught in the seminars symposia and, importantly, in the clinical setting including the ward, outpatient clinics, Day Hospitals and community teams. Dr Thomas Ernst, Consultant acute physician and geriatrician Paediatrics, Child Health & Child Psychiatry Whether you choose to become a GP, work in an A&E, as a surgeon or even a Paediatrician - at some point in your career you will have to look after children. This block offers you the only real focused opportunity to develop the skills you need to do this before you qualify. Children differ from adults in many ways. It is not just the difference in physiology, pharmacokinetics and spectrum of pathology that you need to be aware of. Children need their doctors to understand them in the context of their families and society and to consider their developmental, social and educational needs. You also need to develop skills to communicate with both children and their often anxious parents. During your attachment in Paediatrics you will spend time in Neonatology, Community Paediatrics, Child Psychiatry, and Dermatology. Learning about children's medicine starts with an in-depth knowledge of basic child sciences and a clear understanding of how and why children, especially babies, differ from adults. Once the first two years of life are past most children in developed countries live healthy lives but they can easily be blighted by conditions that are readily preventable through accident control, immunisation, wholesome food, parental education and clean water. The way we teach paediatrics and child health is changing. The emphasis is on knowing where to look rather than keeping vast stores of knowledge in one's head. We will try to point the way through formal teaching. We hope you will appreciate that child health is best promoted through teamwork and that you learn much from therapists and nurses. Your real teachers are children and their parents. Learn how to listen to them. Dr Simon Waller Consultant Paediatric Nephrologist & Lead for undergraduate Paediatric teaching Dr Simon Hannam, Department of Neonatal Paediatrics, KCH and head of phase 4 22 9.2 Course Organisers and Contact Details Paediatrics and Child Health GST KCH 020 7188 7188 020 7737 4000 Dr Simon Waller Dr Simon Hannam [email protected]. 020 3299 4000 uk ext 4644 simon.hannam@ 0207 188 4586 (Sec) nhs.net PRUH 01689 863000 Dr Menaka de Silva [email protected] UHL 020 8333 3000 Dr Joanna Lawrence Direct line: 0203 192 8760 [email protected] Sec: Ms Sue Crome Direct line: 0203 192 6763 [email protected] Sheinaz Mahomedally sheinaz.mahomedally @nhs.net 020 7848 5224 Child Psychiatry GSTT 0203 228 2570 KCH 0203 228 2570 PRUH UHL Sarah Bernard, Sarah Bernard, Sarah Bernard, Sarah Bernard, [email protected] k [email protected] .uk [email protected] KCH 020 7737 4000 PRUH 01689 863000 UHL 020 8333 3000 Dr Max Davie 0203 049 6004 [email protected] Dr Sujata Sharma 020 8466 9988 Sujata.Sharma@ bromleypct.nhs.uk Dr G Siggers Sec Sharon Nelson Georgie.siggers@lewishamp ct.nhs.uk [email protected] hs.uk Community Paediatrics GST 020 7188 7188 Dr Ros Healy 0203 049 8143 ros.healy@ southwarkpct.nhs.uk Sec. Teresa Edwards Tel: 0207 138 1566 Teresa.edwards@lewishamp ct.nhs.uk Dermatology GST 020 7188 7188 Dr Clive Archer [email protected] KCH 020 3 299 4238 PRUH 01689 863000 UHL 020 8333 3000 Dr Rachael Morris-Jones rachael.morris-jones@ nhs.net Dr Karen Watson 01689 865070 [email protected] Dr Pui Banerjee [email protected] Sec: Rebecca Riley [email protected] 020 8333 3000 ext 6181 Medicine of Old Age GST 020 7188 7188 KCH 0203 299 6071 PRUH 01689 863000 UHL 020 8333 3000 Dr Rohan Pathansali [email protected] Dr Belinda Kessel 01689 865851 [email protected] Dr Mehool Patel [email protected] Dr Tom Ernst Tel: 020 71882516 Email: [email protected]. uk Neonatology GST 020 7188 7188 KCH 020 7737 4000 PRUH 01689 863000 UHL 020 8333 3000 Dr Geraint Lee Dr Simon Hannam Dr Menaka de Silva Dr Joanna Lawrence Sec: Jill Faal ext 6609 Sec: Val Albert ext 8177 23 [email protected] 020 3299 4000 ext 4644 [email protected] [email protected] Tel: 0208 333 3000 ext 8760 [email protected] Sec: Ms Sue Crome Direct line: 0203 192 6763 [email protected] Psychiatry of Old Age GST 020 7188 7188 Dr Vivenne Mak 020 7411 6201 vivienne.mak@ slam.nhs.uk Palliative Medicine GST 020 7188 7188 Dr Teresa Beynon Teresa.Beynon@gstt. nhs.uk KCH 020 7737 4000 PRUH 01689 863000 UHL 020 8333 3000 Dr Nicola Funnell [email protected] Sec: Jean Anderson 020 32281620 Dr Cherian Sebastian 0208 462 3183 Cherian.Sebastian@Oxleas. nhs.uk Dr Cait Goddard KCH 020 7737 4000 PRUH 01689 863000 UHL 020 8333 3000 Dr Rachel Burman [email protected] Dr Elizabeth Jones 01689 865667 [email protected] Dr Katie Emmitt katie.emmitt@ nhs.net 020 8333 3017 UHL Student Coordinator Samantha Newman 020 8333 3000 ext 8734 samantha.newman@ nhs.net PRUH Student Coordinator Shayron Hegarty 01689 864347 [email protected] 24 [email protected] hs.uk 9.3 Block aims and objectives Paediatrics & Child Health Paediatrics & Child Health 1. Attitudes You should develop appropriate attitudes during the course, which will include: a child-centred approach respecting the developing rights through childhood 2. By the end of the paediatric course you should be able to: recognise when a child is ill explain the importance of prevention in child health demonstrate the skills of obtaining a history from parent and child adapt clinical examination skills to the needs of the child describe the difference between the child and adult patient sharing with the patients an advocacy role recognise the importance of the stages of child development connect the clinical situation with basic sciences (especially genetics and embryology) analyse the role of the family, society and environment plan a management strategy for the individual child patient 3. Emergencies You should read about the initial management of the following paediatric emergencies during your paediatric firms. You should have a chance to see some of these during your time on take. cardio-respiratory arrest dehydration (secondary to gastroenteritis, diabetic ketoacidosis) acute asthma burns upper respiratory tract obstruction (croup) the severely injured child (accident, child septicaemia (including meningococcal) abuse) meningitis accidental poisoning status epilepticus cardiac failure coma 4. Skills and procedures You should observe the following You should be competent in the following skills: take a history from a parent and child Examine a baby * Does not include newborn check examine a child Perform and interpret a basic developmental assessment of an infant or young child Explain a common complaint to a child Try to follow your patient through the investigations or treatment so you can appreciate the impact that these have on the child and the family as well as familiarising yourself with techniques setting up of an IV infusion insertion of a nasogastric tube accurate measurement of height and weight administration of nebulised bronchodilators lumbar puncture ultrasound examination of abdomen and head CT, MRI scan renal isotope scan tracheal intubation insertion of a chest drain 5. Preventive Paediatrics It is important for you to understand the principles and methods in child surveillance and prevention such as immunisation and screening. You should have the opportunity to participate in a developmental assessment session, immunisation clinic and to discuss the importance and difficulties involved in child protection. 25 6. Core curriculum presentations You should try to see examples of the following conditions. Using your contact with the child as the centre of your learning, expand your knowledge of the epidemiology, pathology, clinical features and management by reading around the subject. Try to clerk as many patients as possible, preferably one of each of the following although some of the neonatal cases may not be directly accessible to you. There will be children with other conditions and by clerking these also it will help you in your skills of history taking, clinical examination and creating organised notes. respiratory distress syndrome tonsillitis (82) oesophageal atresia +/- tracheo-oesophageal febrile child (121) fistula diaphragmatic hernia chickenpox (102) chronic lung disease of prematurity bronchiolitis herpes simplex stomatitis (102) asthma (3, 4) febrile convulsions (69) cystic fibrosis (3,4) infectious mononucleosis (60, 82) innocent murmur AIDS heart failure epilepsy (69) patent ductus arteriosus ventricular septal defect coarctation of aorta cerebral palsy (95) spina bifida Fallot's tetralogy arrhythmias (95) developmental delay feeding difficulties (134) (126) learning difficulties (126) brain tumours failure to thrive: starvation (124) vomiting (18) diarrhoea (23) coeliac disease constipation (24) faecal incontinence (27) recurrent abdominal pain (10, 11) urinary tract infections (31, 32,33,36) diabetes mellitus (1B) short stature (125) hypothyroidism delayed puberty (125) acute otitis media (75, 76) recurrent otitis media (75,76) deafness (78) delayed speech (126) Squint (87) arthritis (92, 93) eczema (104) enuresis (32) vesico-ureteric reflux nephrotic syndrome (10B) acute renal failure chronic renal failure hypertension (2B) rickets (91, 95) impetigo (105) infestations (lice, scabies) (100) osteomyelitis sickle cell disease (5B) iron deficiency (5B) idiopathic thrombocytopenic purpura leukaemia haemophilia child abuse (120, 94, 109, 124) neglect congenital dislocation of hip (95) behavioural difficulties anorexia nervosa psychological response to illness 26 Child Psychiatry 1. Attitudes: Throughout the course, you should aim to be non -judgmental in understanding how a child’s emotional and behavioural status can result from abnormalities of the inter-relationship within the child’s genetic loading, development, family functioning, education and leisure/social activities. This bio-psycho- social model should be considered 2. Knowledge: By the end of the course, you should be able to describe: the assessment of childhood psychiatric/behavioural disorder the epidemiology of childhood psychiatric disorder Neurodevelopmental disorders including ADHD, ASD, Tic disorders OCD, behaviourand epilepsy Emotional and behavioural disorders including mood disorder, eating disorders, conduct disorder) child abuse and its impact (120) interventions service development Communication with children/adolescents of different ages 3. Skills: You should observe: Important features in taking a history from parents, children, adolescents and a family interview Dermatology 1. Knowledge By the end of the course you should be able to • describe the: • • normal skin anatomy and physiology • 2. Skills By the end of the course you should be able to: • take a dermatological history • take a drug history in relation to a skin disorder • Examine the skin for a common condition 3. Core curriculum presentations Nail disorders (97) Hair loss (98) Hairiness (99) Pruritus (100) Pigmented skin leisions (pigmentary disorders, moles and melanomas) (101) scientific basis and pathogenesis of core skin conditions principles of treatment of the skin disease the management of a patient with skin disease • explain to a patient how to apply a skin preparation • give health advice on the risks of excess sun exposure 27 Acute rashes (102) Chronic rashes (103) Eczema and dermatitis (104) Skin infections (105) Bruising and purpura (106) Lumps in the skin (107) Medicine & Psychiatry of Old Age 1. Attitudes During the course, you should: • develop a positive attitude to ageing and older people • recognise the value of older people’s experience • appreciate the importance of equal right of access to health and local authority services • be aware of the potential for health improvement in older people 2. Knowledge By the end of the course, you should be able to: (a) Service Provision • list the health care professionals who comprise the multidisciplinary team • describe the roles of these individuals with reference to common clinical/situational problems e.g. patients with stroke or fractured neck of femur • describe the objectives and components of an effective service for meeting the health care needs of elderly patients • describe the interfaces between primary and secondary health care services for elderly patients (b) Gerontology • describe the present and future population structure with regard to age and predict the implications of these changes for health care delivery • outline the epidemiology of prevalent age related disorders • discuss the main theories of ageing and the physiological and biochemical changes in cell biology associated with ageing • list the physiological changes seen in organs with ageing and differentiate where possible from pathology • outline (a) the concepts of functional reserve and increased variability as applied to ageing; (b) the causes, presentation and management of elder and carer abuse (c) Clinical medicine • recognise the non-specific presentation of disease and the, often different, specific presentations of disease in later life 3. Core curriculum presentations You should try to see examples of the following conditions: Delirium (64) Dementia (70) Anxiety and depression (56, 57) Falls, blackouts, syncope and their sequelae • be aware of societal ageism and paternalism be aware of patients' and relatives' reactions to loss of function and bereavement • recognise the importance of physical and psychological care for patients with advanced incurable diseases and their carers • • • • recognise the presence of multiple pathology and co-existence of chronic diseases be aware of the effect of environment on presentation and management recognise common syndromes with which patients present rather than restricting the approach to the diagnoses that are made after full assessment (d) Primary/secondary care interface • describe the main community based agencies in both public and voluntary sectors which provide services for older people, what services they provide and how these services can be accessed • describe the roles of the GP and primary health care team members in co-ordinating hospital discharge • describe the indications for referral to hospital based services: acute admission, outpatient consultation, Day Hospital and domiciliary visiting • clerk a new referral to the Day Hospital or Community Mental Health Team and contribute towards the formulation of a problem list and plan of management. This patient should be reviewed with a member of the multidisciplinary team after at least two visits • visit a community based facility for elderly patients • describe the principles of management of dying patients • describe the presentations and management of carer fatigue • describe the meaning of the terms disability, impairment and handicap and how disease processes lead to disability, impairment and handicap 28 Weight loss (19) Common infective presentations (6,7) Mobility problems (68) Functional problems Ankle swelling (9, 50) Chronic skin ulceration (48, 49) Weakness, tiredness and fatigue (60) (63, 65, 69) Bowel and bladder problems (31,32, 33,34) Breathlessness (3,4) 4. Skills By the end of the course you should be able to: In addition, you should: • take a history and examine an older patient and include an assessment of function • take a history from a third party on behalf of an elderly patient • formulate a problem list and management plan from presentation to discharge • perform a full examination & systematic assessment of a patient with depression • perform a full examination & systematic assessment of a patient with dementia • observe members of the core multidisciplinary team consider the discharge arrangements for patients needing an occupational therapy home visit before discharge and home care services after discharge. • have contributed towards a multidisciplinary needs assessment of a patient prior to long term placement including discussion with the patient concerning the patient's wishes and alternative strategies Vertical Strand disciplines: an all age perspective Communication Skills You should be able to: communicate with the young, their parents, elderly people and their relatives develop good listening skills and empathic responses explore the implications of different courses of treatment and check for understanding. use appropriate verbal and non-verbal communication skills i.e.: effective listening, questions styles and empathic responses develop flexibility of every day use of language to match the child and parents and use or suggest aids to help with explanation and follow up support break news of serious illness and treatment to patients communicate effectively in clinical teams Knowledge 1. Clinical Genetics You should be aware of genetic conditions that affect children and adults, including late onset genetic disorders and the genetic basis of common diseases. Areas to be covered include: Assessment of children with developmental delay. Unusual modes of inheritance and their clinical significance in paediatric disease, including chromosome microdeletions, mosaicism and imprinting. The use and limitations of genetic testing for diagnosis. Counselling and ethical issues surrounding testing for genetic disease in children. Issues surrounding pre-symptomatic testing for genetic disease - e.g. Huntingtons disease. The Genetic basis of common diseases – e.g. breast cancer. New approaches to treatment for disease – stem cells and cloning. 2. Clinical Pharmacology & Therapeutics You should be able to describe the following: changes in pharmacokinetics and pharmacodynamics across the ages the application of these changes to prescribing the factors leading to the excess prevalence of adverse reactions in older patients the completion of a Yellow Card report to the Committee on Safety of Medicines a prescribing checklist the role of non pharmacological treatments in physical and mental illnesses, giving examples 3. Clinical Sciences the embryology of kidneys, heart and enteric system in relation to paediatric nephrology, heart murmurs and paediatric surgery forensic pathology: sudden infant death syndrome (SIDS) and infanticide nutrition and aspects of care gerontology: socio-demographic issues of ageing 29 4. Ethics, the law & older people confidentiality and patient autonomy informed consent, capacity and competence advance directives/living wills medical intervention in advanced physical and mental illness euthanasia Power of Attorney Court of Protection Mental Health Act (relevant sections) 5. • • • • Palliative Medicine symptom control care of the dying patient, focusing on elderly patients ethical issues at the beginning and end of life communication skills - checking understanding and giving information sensitively 6. • • • • • • Pathology & Laboratory Sciences nutrition: bone chemistry, bacteriology of gut, iron deficiency anaemia abuse, violence and neglect: forensic pathology dermatology: simple histopathology of core presentations bacteriology and virology of common infections; common immunisations basic haematological knowledge of sickle cell disease and childhood leukaemia the correlation of autopsy with pre-mortem findings in the elderly 7. Primary Care and the Community Study The community study offers students an opportunity to study the following topics from the perspectives of the child’s family and primary care: Impact of new baby on mother and family – social, cultural and psychological factors. Infant feeding including breast feeding and weaning. Child growth and developmental progress – the 6 week check and use of parent held record Immunisation Parental stress – presentation of children in A+E ; emergency care - lay and professional perspectives Non-accidental injury in primary care Links to core curriculum Professional attitudes (6) Communication skills (7) Knowledge: infant feeding problems (134); non-accidental injury (120); failure to thrive (124); developmental delay (126); acute rashes (102) (immunisation) 8. Public Health 1. Epidemiology of common diseases describe the basic epidemiological features of the following conditions; Paediatrics: infectious disease, neural tube defects, asthma, sudden infant death; Medicine & Psychiatry of Old Age: stroke, dementia, osteoporosis; Dermatology: skin cancer demonstrate a clear understanding of the following epidemiological terms when applied to the above diseases – incidence, prevalence, crude mortality, age-sex specific death rates, standardised mortality ratios, standardised death rates, population attributable risk, population attributable risk fraction, identify modifiable social and environmental risk factors for these diseases (eg. poverty, occupation, housing, indoor air quality, outdoor air quality, smoking, obesity, diet, exercise) interpret Standardised Mortality Ratios, odds ratios, relative risks, population attributable risks, population attributable risk fractions and other epidemiological data as they relate to these diseases And in addition for Paediatrics interpret data on perinatal mortality, neonatal mortality and infant mortality to identify what measures can be taken to improve outcome 30 2. Screening apply the WHO (Wilson and Junger) criteria for screening to the following programmes and discuss, using their knowledge from their clinical teaching whether these programmes are likely or unlikely to fulfil the criteria: Paediatrics: neonatal screening; Medicine & Psychiatry of Old Age: osteoporosis identify social and health service factors associated with low uptake of screening and strategies that can be adopted to improve uptake outline how screening programmes can be audited and evaluated interpret data concerning the sensitivity, specificity and positive predictive value of tests used for the above screening programmes and demonstrate an understanding of how they influence what information should be given to patients if they undergo screening tests 3. Health promotion describe primary, secondary and tertiary prevention of the following conditions, demonstrating an understanding of measures that can be taken at an individual and population level to reduce the incidence and/or prevalence of: Paediatrics: accidents, infectious disease, sudden infant death syndrome, exposure to environmental tobacco smoke; Medicine & Psychiatry of Old Age: accidents (including falls); Dermatology: skin cancer and in addition for Paediatrics describe the health benefits of breast feeding and discuss what measures can be taken at an individual and population level to increase breast feeding rates 4. Infectious diseases Paediatrics: describe the rationale behind the current immunisation programme in children. explain the importance of herd immunity describe how diseases are notified and how this information can be used to monitor the epidemiology of notifiable diseases identify the major steps required in controlling an outbreak of meningitis in children describe the epidemiology and public health measures required to prevent spread of threadworm, head lice, scalp ringworm, scabies 5. Health Services • describe current important demographic changes in the UK and internationally • discuss how demographic changes in the UK could impact on the prioritisation of health services in the UK • list factors that should be considered when deciding whether to invest resources in a new drug treatment or health service Students are reminded that the public health sciences does not wish to overburden students with factual knowledge. However students are expected to be able to apply basic epidemiological, public health, sociological and economic principles to the conditions above using their medical knowledge to identify the issues that might be of relevance for that condition. 31 9.4 Orientation The blocks and campuses to which you have been allocated are displayed on the Phase 4 Virtual Campus before the start of each rotation. • This section shows progression through the Block and any relevant sub-blocks and disciplines. •. More detailed timetables will be posted on the Virtual Campus and students will also be notified by email. Please ensure that you check both regularly. http://virtualcampus.kcl.ac.uk/ and click on MBBS 4 for up-to-date course information Guy’s and St Thomas’ Campus The rotation has seminar blocks in weeks 1& 2, and week 12. Weeks 3-11 consist of clinical teaching: 3 weeks of Medicine and Psychiatry of Old Age; and 6 weeks of Paediatrics, consisting of 3 weeks of Paediatrics at GST; and 3 weeks of Paediatrics at a District General Hospital or approved self-arranged placement. The Block has teaching at both Guy’s and St Thomas’ hospitals but the timetable is designed to ensure a minimum of crossing between hospitals during any one day. Group and Firm allocations Students will be assigned to a Paediatric firm (A-E), and a Group (1-3). Groups 1, 2 and 3 define which of the periods of 3 weeks out of the 9 you will spend in Medicine and Psychiatry of Old Age: Group 1 (A1-E1) = 1st 3 weeks, Group 2 (A2-E2)= 2nd 3; and Group 3 (A3-E3) = 3rd 3 weeks Group allocations weeks 3-5 weeks 6-8 weeks 9-11 PAEDS DGH group 1 (A-E1) MPOA MPOA PAEDS group 2 (A-E2) DGH MPOA group 3 (A-E3) PAEDS DGH Dermatology Dermatology will be organised in relation to tutorial groups A1, B3 etc Week 1-2 Rotation 1 Seminar Block Tues 10/09/1221/09/12 24/09/12 12/10/12 Rotation 2 Seminar Block Thurs 03/01/1311/01/13 14/01/1302/02/13 Rotation 3 Seminar Block Tues 02/04/1313/04/13 15/04/1303/05/13 6-8 15/10/12 02/11/12 04/02/1322/02/13 9-11 05/11/12 23/11/12 25/02/1315/03/13 12 Seminar Block 26/11/12 03/12/12 Seminar Block 18/03/13 25/03/13 Tue 07/05/1324/05/13 Tues 28/05/13 14/06/13 Seminar Block 17/06/13 24/06/13 3-5 13 32 Group 1 Group 2 Group 3 Medicine and Psychiatry of Old Age Paediatrics DGH/ Peripheral attachment Medicine and Psychiatry of Old Age Paediatrics Paediatrics DGH/ Peripheral attachment DGH/ Peripheral attachment Medicine and Psychiatry of Old Age Rotation 1& 2- Reading week; Rotation 3 Written Assessment King’s College Hospital Campus The rotation has seminar blocks in weeks 1& 2, and week 12. Weeks 3-11 consist of clinical teaching: 3 weeks of Medicine and Psychiatry of Old Age; and 6 weeks of Paediatrics, consisting of 3 weeks of Paediatrics at KCH; and 3 weeks of Paediatrics at a District General Hospital or approved self-arranged placement. group 1 group 2 group 3 Group allocations weeks 3-5 weeks 6-8 weeks 9-11 MPOA PAEDS DGH DGH MPOA PAEDS PAEDS DGH MPOA Dermatology Dermatology outpatients will be on Tuesdays, either in the morning or the afternoon. Week 1-2 Rotation 1 Seminar Block Tues 10/09/1221/09/12 24/09/12 12/10/12 Rotation 2 Seminar Block Thurs 03/01/1311/01/13 14/01/1302/02/13 Rotation 3 Seminar Block Tues 02/04/1313/04/13 6-8 15/10/12 02/11/12 04/02/1322/02/13 9-11 05/11/12 23/11/12 25/02/1315/03/13 12 Seminar Block 26/11/12 03/12/12 Seminar Block 18/03/13 25/03/13 Tue 07/05/1324/05/13 Tues 28/05/13 14/06/13 Seminar Block 17/06/13 24/06/13 3-5 13 15/04/1303/05/13 Group 1 Group 2 Group 3 Medicine and Psychiatry of Old Age Paediatrics DGH/ Peripheral attachment Medicine and Psychiatry of Old Age Paediatrics Paediatrics DGH/ Peripheral attachment DGH/ Peripheral attachment Medicine and Psychiatry of Old Age Rotation 1& 2- Reading week; Rotation 3 Written Assessment Peripheral Attachments in Paediatrics Students will be given information by e-mail and referred to the relevant pages of the Virtual Campus for further information. 33 Princess Royal University Hospital Campus Rotation 1 10/09/1207/12/12 Mon 10/09/12 Rotation 2 02/01/1329/03/12 Weds 02/01/13 Rotation 3 02/04/1328/06/13 Tues 02/04/13 Seminars From Tue 11/09/12 From Thurs 03/01/13 From Thurs 04/04/13 Symposia (Wednesday) From Wed 12/09/12 From Mon 07/01/13 From Wed 03/04/13 Clinical Rotation and Induction at PRUH 24/09/12 14/01/13 15/04/13 Course dates Introductory Day (Guy’s Campus) 34 Time and Venue Morning Programme (see VC for details) Afternoon Symposium: from 2pm (see VC for timetable) Seminars take place in weeks 1, 2, and 12. Please see your seminar timetable for further details Students to attend Wednesday morning symposia at GST, KCH or UHL (see VC for timetable). Report to the Education Centre, Princess Royal University Hospital for 8.15am University Hospital Lewisham Campus Rotation 1 10/09/1207/12/12 Mon 10/09/12 Rotation 2 02/01/1329/03/12 Weds 02/01/13 Rotation 3 02/04/1328/06/13 Tues 02/04/13 Seminars From Tue 11/09/12 From Thurs 03/01/13 From Thurs 04/04/13 Symposia (Wednesday) Clinical Rotation From Wed 12/09/12 11/09/1230/11/12 From Mon 07/01/13 03/01/1322/03/12 From Wed 03/04/13 02/04/1321/06/13 Course dates Introductory Day 35 Time and Venue Morning Programme (see VC for details) Afternoon Symposium: from 2pm (see VC for timetable) Seminars take place in the Owen Centre from 9am weeks 1, 5, 9 and 12 (and Wednesday’s weeks 4, 7, 10). See VC for Symposia timetable Meet with Community Paeds Lead at 8:45am, Owen Centre, UHL 9.5 Peripheral and Overseas Attachments A three week peripheral attachment will be part of the Child Health, Development & Ageing Block (CHDA) for the Paediatrics module for students based at KCH and GST. This will either be a placement at a DGH* allocated by the Academic Centre, or at an overseas twinned institution via the Exchanges Office, or an independently arranged placement (the deadline for these latter two options was earlier in 2010/11). Students based at UHL and PRUH obtain similar clinical experience at those campuses. *Placements will be at one of the following hospitals: William Harvey Ashford, Darent Valley, Mayday Croydon, Eastbourne, Maidstone, Queen Elizabeth the Queen Mother Margate, Maritime Medway, Pembury, Queen Mary’s Sidcup, Conquest St Leonard’s, Queen Elizabeth Woolwich, Worthing. Health-screening and Immunisation requirements for DGHs Most DGHs require you to present them with evidence of relevant vaccinations/status: .HepB, HepB surface antigen, Rubella & MMR vaccinations. Hep C, HIV, VzV,& TB Status. You cannot commence on the wards without health clearance. You must therefore make an appointment with Occupational Health at the beginning of the year, to make sure that this information is immediately available for DGHs. Students must also contact the DGH at least 4 weeks before your placement to see if there are any forms or additional screening is required. Failure to do this will result in you missing your attachment, and therefore failing the block. We advise you to bring a spare copy of your status with you on induction day. Occupational Health currently test for Hepatitis B antibodies, Rubella antibodies, and evidence of T.B. vaccination. Chicken pox antibodies are only tested for if the student does not have a positive history of the disease. Please ensure that you regularly check the DGH section on the Virtual Campus and your email for up-to-date details on what is required for your allocations 36 9.6 Symposia In the Child Health, Development and Ageing block, your first symposium will be on the introductory day of the rotation. Following that, you will have a symposium every Wednesday morning but please note that some may fall on a Wednesday afternoon or a Monday – please ensure you see the Virtual Campus for an up-to-date timetable. Topics covered by the CHDA symposia are: Communicating with Children, the Elderly and Relatives Clinical Ethics and Law Violence, Abuse and Neglect Child Development Therapeutics Across the Ages Genetics Care of the Child with Surgical Illness: Aspects of Paediatric Surgery The Dying Patient Nutrition The Management of Disability in Children and Adults Dermatology 9.7 Aims and Objectives for Symposia By the end of each symposium you should have achieved the learning objectives listed; (CC Presentations: Core Curriculum Presentations) • Mutually agree the next stage in management Communication • Use every day language at a level the child will understand and check for understanding Organisers: Ms E Gill • Appropriately use aids to help understanding CC Presentations: All CHDA • Elicit the child’s and parent/s concerns • Encourage the child to ask questions To be able to: • Allow parent/s time to talk about concerns and • Elicit relatives’ own beliefs and wishes, acknowledge such concerns demonstrating appropriate questions styles, • Reach a stage of mutual agreement with child good listening skills and empathic responses and parent/s as to what will happen next • Explain the implications of different courses of • Refer to relevant literature/research regarding treatment and checking for understanding communicating with the young, elderly and • Allow time for relatives to absorb information relatives and use of silence • Acknowledge and share patients' known Clinical Ethics and Law wishes, if any, with relatives • Mutually agree the next stage of decision Organiser: Mr P Haughton making and treatment CC Presentations: All CHDA • Explore a common childhood problem with parents and child To be able to: • Elicit concerns and anxieties • Discuss the normative dimensions of clinical • Use appropriate verbal and non-verbal decisions, so that (a) identify which aspects of communication skills i.e. effective listening, decisions are technical in nature and which are questions styles and empathic responses ethical; (b) assess how technical and ethical • Demonstrate flexibility of every day use of aspects relate to each other language to match the child's and parent/s and use or suggest aids to help with explanation • Develop and acquire skills in analysing the and follow up support normative dimension of clinical decisions • Check for understanding with both child and (identifying moral principles and rules; critically parents analysing moral arguments) 37 • Develop and acquire skills in exploring and justifying personal decisions regarding ethical issues as they arise in specific clinical contexts Genetics Organiser: Dr Dragana Josifova At the end of the block, students should have achieved the following: To be able to take a full family history To use family history to identify common patterns of inheritance, and their importance in the clinical setting (autosomal dominant, autosomal recessive, X-Linked inheritance, mitochondrial inheritance) To understand types of mutations and the clinical implications of these To understand imprinting and mosaicism in relation to genetic disease To understand the uses and limitations of DNA testing in clinical genetics To understand the approach to clinical dysmorphology, and the importance of making the correct diagnosis for genetic counselling To be aware of late onset genetic disorders for which testing is possible, and the implications of such testing for the at-risk individual To understand the role of Clinical Genetics in counselling patients affected by common multifactorial diseases, with emphasis on assessment of cancer risk Violence, Abuse and Neglect Organiser: Dr Bola Adeyemi CC Presentations: 120, 124, 126, 134 Aim: To recognise and respond to the effects of family violence. To know: • What constitutes abuse • Types and ranges of abuse (including domestic violence and elder abuse) • Underlying principles – welfare of child, Convention on the Rights of the Child • How to recognise abuse (signs and symptoms) • Vulnerability to abuse and risk factors within the child and within the family • What to do within the health system • Multiagency and legal framework • Consequences of violence and abuse – short and long term • Principles of management and treatment • Ethical/confidentiality issues • Need for prevention Therapeutics across the Ages Organisers: Prof S Jackson CC Presentations: All CHDA Care of the Child with Surgical Illness: Aspects of Paediatric Surgery Organiser: Miss M Agrawal CC Presentations: 10, 13, 18, 24, 39, 71, 72, 73, 124, 134 • Describe the changes in pharmacokinetics from birth to old age • List the factors that would determine the dose, dose regimen and packaging requirements in both children and elderly patients • Comment critically on inpatient prescription sheets and be able to write prescriptions for commonly prescribed medications • Describe the implications of the Medicines Act as they relate to prescribing • Differentiate the legal categories of drugs and give examples of each category To be able to describe: • The differences between children and adults in terms of common surgical problems • The presentation, management and long-term effects of common congenital malformations • List the items on a prescribing checklist Child Development Organiser: Dr Max Davie CC Presentations: 95, 126 • Understanding factors which influence developmental progress • Forming a picture of developmental expectations • Recognising when to be concerned: ‘red flags’ • Knowing what questions to ask 38 The Dying Patient Organiser: Dr P Edmonds CC Presentations: 127, 135 The Management of Disability in Children and Adults Organiser: Dr A Sharma CC Presentations: 32, 56, 64, 65, 68, 126 Aim: To describe the physical and psychosocial needs of dying patients and their carers, and clinical and organisational strategies to meet those needs. To be able to: • List the common causes of death in the UK • Identify the symptoms and signs that suggest that a patient is in the last days of life • List common symptoms in the last week of life • Describe the indications for use of syringe drivers, and be able to convert a patient from oral morphine to subcutaneous diamorphine • Outline factors suggesting that a carer is ‘at risk’ following a bereavement To be able to describe: • The consequences of disability • The process of rehabilitation, including the WHO definitions of impairment/disability (ability)/ handicap/participation The prevalence, process of identification and management of common impairments leading to disability • The roles and functions of members of the multi-disciplinary team Dermatology - Clinical Demonstration Organisers: Dr R Morris-Jones and Dr Clive Archer Clinical Nutrition Organiser: Dr John Jackman CC Presentations: 19, 29, 124, 134 Aim: CC Presentations: 48, 97, 103, 104, 105, 107 • To consolidate the clinical skills required to examine the skin and to demonstrate physical signs of common dermatoses in hand picked patients (Guy’s St. Thomas’ & King’s students only) • To consolidate clinical and investigative skins (UHL students only • To become familiar with the principles of topical therapies • To address any gaps in core knowledge at the end of the course to know the major nutritional issues faced in medical practice, through focusing on four clinical situations. Objectives - by the end of the session students should: be able to make informed decisions about nutrition in dying patients, patients with swallowing difficulties and patients with intestinal failure. Know the principles and practicalities of providing parenteral nutrition Understand the medical and social consequences of excess nutritional intake Students will learn through participation in four study sessions: Intestinal failure and the issues surrounding parental nutrition Managing nutrition in the terminally ill patient with difficulty swallowing The medical and social issues associated with obesity 39 9.8 Seminar Titles *Child Health & Paediatrics • Dehydration & Fluid Balance 18, 23, 35, 1B • The Child with Wheeze and Cough 4, 6 • The Acutely Infected Child 1, 7, 61, 79 • Growth 124, 125, 19, 23, 99 • Neurological problems in childhood 62, 69, 132, 131, 130 • Heart Problems 3 • Problems with Micturition & Defaecation 24, 25, 27, 31, 32, 33, 36 • Paediatric Haematology 106, 127, 135, 5B Cutaneous Infections, Acne, and Roseacea 103 Benign and Malignant Tumours of the Skin 101, 107 Allergic Conditions and Photosensitivity 100, 102 The Skin and Systemic Disease 105 Introduction to Blistering Disorders 102 Medicine & Psychiatry of Old Age Assessment of the older person (medical aspects) and atypical presentation of disease 65 Assessment of the older person (psychiatric aspects) 64 Symptom Control (Palliative Medicine) 127 Ageing, Disease and Disability Healthy ageing versus disease Delirium 64 Dementia: clinical features and brain changes 70 Dementia: behavioural problems and impact on carers and services 70 Bowel and Bladder problems 31, 32, 33, 34 Functional mental illness Anxiety and Depression 56, 57, 128 Law and the older person Ageing in the 21st century: evidence from sociology, demography, social policy and economics Psychological approaches to management of disorders 70, 12 *Neonatology • Common problems of the Normal Neonate 134 • Low birth weight babies (preterm and SGA babies) 134 *Child Psychiatry • Deliberate Self Harm 51, 56, 59 • Neuro-psychiatry 59, 126 • Emotional and Behavioural Disturbance 55, 56, 57 • Mind and Body in Paediatrics, 11, 17, 24, 27, 60, 62, 104 **Dermatology Introduction to dermatology Eczema and Psoriasis Cutaneous infections Skin tumours The skin and systemic disease. * For Seminar Aims & Objectives, please refer to Paediatrics and Child Health Study Guides (the ‘blue book’) ** Seminar Aims & Objectives are available on the VC 40 9.9 Aims and Objectives for seminars Medicine & Psychiatry of Old Age By the end of each seminar session you should have achieved the following educational objectives: Medicine & Psychiatry of Old Age By the end of each seminar session you should have achieved the following educational objectives: Assessment of the older person (medical • to list the common presentations of medical aspects) and atypical presentation of disease problems that lead elderly patients to lose their • to list the common problems that may be independence identified on history taking that may or may not be • to describe the ways in which elderly patients may presenting complaints present differently compared with younger adults • to list the common problems that may be • to list the key professionals providing assessment identified on examination that may or may not be of older patients both in the hospital and presenting complaints community settings Assessment of the older person (psychiatric aspects) • to know 3 categories of the history/mental state examination that often require greater attention than in younger people • to know at least 3 sources of information (other than that from the patient) that aid the diagnostic process • to know 7 aspects of the social history relevant to older people with mental disorders • to know 3 tests of frontal lobe function used in bedside testing • to list at least 2 techniques for introducing cognitive testing to older people without upsetting or annoying them • to test memory, orientation (time and place), concentration, praxis and calculation • to describe the principle of confidentiality in respect of informant history Symptom Control (Palliative Medicine) Aim: For students to develop an understanding of • to be aware of the range of options available for symptom management, including symptom assessment in palliative medicine, pharmacological and non-pharmacological including psychosocial issues. strategies • to list the basic principles underlying effective symptom control 42 Ageing, Disease and Disability • to describe normal ageing changes in the kidney, liver, cardiovascular, musculo-skeletal, thermoregulatory and immune systems and the brain • to list criteria for the definition of normal ageing • to describe the concept of ‘reserve’ • to understand the WHO criteria for handicap, impairment and disability • to describe two examples of how normal ageing and disease interact to produce symptoms Delirium • to indicate 3 cardinal features and a further 3 symptoms and signs of the syndrome • to list at least 6 main categories of disease that might lead to delirium in an older person • to list 3 common iatrogenic causes of delirium • to describe the approximate prevalence of the syndrome in a) older medical in-patients and b) older post-operative surgical patients • to list 2 possible pathophysiological mechanisms of delirium • to describe general measures that may reduce the frequency and impact of delirious phenomena in individual patients • to list 4 indicators that might distinguish delirium from dementia • to describe the 3 advantages and 3 disadvantages each of using lorazepam and haloperidol in delirium in an older person • to know that delirium may not reverse for many months Dementia: clinical features and brain changes • to list the features that make up the syndrome of dementia • to describe the common causes of dementia • to describe the histopathological features differentiating the common forms of dementia • to list the investigations that may be performed in a patient presenting with the syndrome of dementia • to describe the assessment of a patient referred for cholinesterase inhibitor therapy for Alzheimer’s disease Dementia: behavioural problems and impact on carers and services • to list at least 5 behavioural problems in dementia that have impact on carers, indicate why this impact is felt, and estimate their frequency • to list 3 categories of intervention with behavioural problems in dementia, and an example of each, together with its advantages and disadvantages • to describe the epidemiology of caring: gender, age, and rates of depressive and other psychological indices of stress in carers • to list the 3 most common requests of carers • to define the word "need" in at least 2 ways • to describe the approximate current financial costs of caring for dementia in the UK- direct and indirect and compare that with expenditure on anti-dementia medication • to describe 3 different types of respite care Atypical Presentation of Disease to list 4 common non-specific presentations of illness in old age to list 4 common medical conditions that commonly present in a non-specific manner in older patients 43 Falls, Dizziness, Blackouts • to recognise the key features in a history to suggest locomotor, cardiovascular and CNS causes for falls • to list 10 common causes of falls • to explain the causes of instability and gait disorder in older people • to summarise the clinical and haemodynamic presentation of patients with carotid sinus syndrome • to plan a strategy for the investigation of patients presenting with falls • to list major complications resulting from falls • to describe the roles of the physiotherapist and the occupational therapist in the management of patients who fall • to list other key professionals and their roles in preventing falls in older people Bowel and Bladder problems • to describe the physiology of micturition and defaecation • to describe the prevalence of urinary and faecal continence problems in adults • to identify the key features on history and examination of stress and urge urinary continence problems • to summarise the role of urodynamics in the investigation of urinary continence problems • to describe the key features of a management strategy for both urge and stress continence problems • to list the indications for and complications associated with the use of urethral and suprapubic urinary catheters • to list 3 common causes of faecal continence problems • to describe the management options available to help patients with established faecal continence problems Functional mental illness • to describe 3 differences and 3 similarities between schizophrenia-like disorders in younger and older people • to describe the prevalence of schizophrenia-like disorders in the community • to describe 3 common delusions in older people with schizophrenia-like disorders in older people Anxiety and Depression • to list at least 6 major symptoms of a depressive syndrome in an older person • to describe the prevalence of depressive syndromes in older people a) in the general population b) general practitioner's surgeries, c) under home care services d) in medical wards e) in old people's homes f) after stroke • to quote the current suicide rate for young and old men, and young and old women, in the UK • to list at least 3 ways in which depression might more typically present in older rather than younger people • to quote the relative risk of dying within 1 year in older people versus those without such a syndrome 44 • to list 4 factors epidemiologically associated with • to list the names, class, and 3 adverse consequences each of at least 3 different oral and 3 different depot medications used in schizophrenia-like disorders in older people • to rehearse 3 general reasons for intervention and 3 reasons not to intervene in schizophrenia-like disorders in older people • to describe a simple protocol for the medical management of the first moderate depressive disorder in a 75 year old man • to list 3 advantages and 3 disadvantages of ECT in severe depression in an older person • to list 3 similarities and 3 differences between depressive and anxiety states • to list at least 5 anxiety syndromes (e.g. agoraphobia, social phobia) in older people • to list 1 advantage and 452 disadvantages to using benzodiazepines in the management of anxiety in old age Law and the older person • to define mental capacity • to understand the meaning of consent to treatment • to understand the use of the Mental Health Act for older people and to describe Sections 2, 3 and 25 • to understand the use of Common Law to enable treatment for those who cannot consent • to describe safeguards for the use of the Mental Health Act and Common Law • to describe continuing powers of attorney and enduring powers of attorney Ageing in the 21st century: evidence from sociology, demography, social policy and economics The aim of this session is to outline the key challenges of an ageing population, and the implications for health in the next 30 years. By the end of the seminar students will be able: • to describe future trends in mortality, morbidity and dependency • to describe future trends in family formation, dissolution and living arrangements relevant to older people • to describe how the interaction of these trends will affect future formal and informal sources of care • to describe the social and economic implications of such trends • to describe their impact on the role of the welfare state in the 21st century • to answer the question “can we continue to afford the present Welfare State” with supporting arguments Psychological approaches to management of disorders • to list at least 3 medical conditions common in older people in which psychological management is at least as important as medical management • to list at least 3 aspects of "person-centred care" of dementia • to describe a simple behavioural programme for agoraphobia in an older person, and list 2 ways in which it might be easier and 2 ways it might be more difficult to execute than in a younger person • to describe at least 3 different coherent psychological interventions that might be applicable to an older person with a moderate depressive syndrome • to describe at least 3 features of grief management • to list 3 ways in which the settings in which the students are working with older people (e.g. wards, clinics) might have adverse psychological consequences for the older people and for the students 45 9.10 Recommended Reading and Computer-aided learning Please refer to VC 46 10. EMERGENCY MEDICINE, TRAUMA AND LOCOMOTION BLOCK (EMTL) 10.1 An Overview of the Block 49 10.2 Course Organisers and Contact Details 50 10.3 Block Aims and Objectives 51 10.4 Orientation 56 Guy’s/St Thomas’ Campus 56 King’s College Hospital Campus 57 Queen Elizabeth Hospital Campus 58 University Hospital Lewisham Campus 59 10.5 Symposia Information 60 10.6 Aims and Objectives for Symposia 60 10.7 Seminar Titles 63 10.8 Aims and Objectives for Seminars 63 10.9 Recommended Reading and Computer-Aided Learning 69 47 10.1 An Overview of the Block During this Block, you will learn from specialists in Anaesthetics, Emergency Medicine, Intensive Care, Orthopaedics, Trauma, Rehabilitation and Rheumatology. A large component of the course will be offered as 'hands on' experience. This will enable you to gain the diagnostic and practical experience necessary to manage patients requiring emergency treatment following a wide range of traumatic and acute medical conditions, diagnose and manage chronic diseases affecting the locomotor system, and to understand the principles of anaesthetics, pain management and Intensive Care Medicine. The course is divided into two six-week sub-blocks. The Emergency Medicine sub-block consists of three weeks of Emergency Medicine and three weeks of Anaesthetics which includes sessions in pain management and Intensive Care Medicine. The Locomotion subblock is a fully integrated course covering Rheumatology, Trauma and Orthopaedics. In the Emergency Department a day and evening 'shift system' will be used in the course to provide students with experience of a range of acute presentations. Seminars will be timed to fit in with overlapping shifts. The seminars and symposia cover areas relevant to the course content, and will cover basic science topics in histopathology, anatomy, therapeutics clinical biochemistry, integrated with the clinical disciplines such as radiology. On completion of this Block you will have gained the knowledge, skills and confidence required to manage a wide range of potentially difficult situations you will face in your future practice. Dr Chris Lacy Department of Emergency Medicine 48 10.2 Course Organisers and Contact Details ED GST 020 7188 7188 Dr Shumontha Dev shumontha.dev @gstt.nhs.uk KCH 020 3299 9000 Dr Tunji Lasoye 020 3299 3235 [email protected] Anaesthetics GST 020 7188 7188 Dr Vip Gill 020 7188 0645 [email protected] QEH 020 8836 6788 Mr Ferdinand Ohanusi UHL 020 8333 3030 Mr Nigel Harrison [email protected] PRUH [email protected] 0208 836 4364/ 4366, bleep 651 KCH 020 3299 9000 Dr Sue Peat 020 3299 3358 sue.peat@ nhs.uk EMD PA : Janet Forest 020 8333 3058 QEH 020 8836 6788 Dr Sanjay Gupta 020 8836 5986 [email protected] et UHL 020 8333 3030 Dr George Mathew PRUH [email protected]. uk Sec: Val smith 0208 333 3413 Dr Robert Feneck 020 7188 0653 [email protected] m Pain GST 020 7188 7188 Dr Joseph Azzopardi Joseph.Azzopardi@ gstt.nhs.uk Orthopaedics GST 020 7188 7188 Mr Ioan Jones 020 7188 4474 [email protected] s.uk KCH 020 3299 9000 Dr Sue Peat 020 3299 3358 [email protected] KCH 020 3299 9000 Mr Mike Wilkinson 020 3299 3649 michael.s.marsh@ kcl.ac.uk QEH 020 8836 6788 Dr Sanjay Gupta 020 8836 5986 [email protected] QEH 020 8836 6786 Mr Dutta 020 8836 4159 [email protected] [email protected] 49 UHL 020 8333 3030 Dr George Mathew George.mathew1@n hs.net PRUH UHL 020 8333 3030 Mr Jonathan Bird 020 8333 3000 Jonathan.bird@n hs.net PRUH Rheumatology GST 020 7188 7188 Dr Toby Garrood [email protected] KCH 020 7737 4000 Dr Patrick Gordon 020 3299 1735 [email protected] GST Administrator Maria Fernandes 020 7188 5183 [email protected] KCH Administrator Sheinaz Mahomedally [email protected] UHL 020 8333 3030 Dr Ghada Yanni 020 8333 3030 ext 6215 [email protected] UHL Student Coordinator Samantha Newman 020 8333 3000 ext 8734 samantha.newman@ nhs.net PRUH 020 7848 5224 PRUH Administrator 50 QEH 020 8836 6788 Dr Catherine Mathews 020 8836 5025 catherinemathews@ nhs.net QEH Administrator Joanna Woolard 0208 836 6788 [email protected] 10.3 Block aims and objectives Aims The aims of the Emergency Medicine, Trauma and Locomotion course are to ensure that you understand: • the presentation and management of patients with common and life threatening emergencies including those with critical injuries • the management of patients who need high dependency care and anaesthesia • the features of pain and pain control • the presentation, assessment and management of patients with disorders affecting the locomotion system including rehabilitation Objectives • • • To achieve competence in skills needed for the practice of emergency medicine, trauma and locomotion subjects To acquire the core knowledge required for the practice of emergency medicine, the understanding of pain control, and the management of locomotion disorders To demonstrate appropriate attitudes in the management of emergency patients, patients with locomotion disabilities, and their relatives and carers 1. Attitudes By the end of the course, you should have achieved the following: • awareness of the moral and ethical • responsibilities involved in individual patientcare in the provision of emergency medicine, and management of disability awareness of the need to manage patients in the context of self-care, and care by others in the context of the injured patient and those with disability and dependency needs • awareness of personal limitations, a willingness to seek help when necessary and to work as a member of a team in the context of the Accident and Emergency Department and in the care of patients with disability 2. Knowledge By the end of the course you should be able to describe: (a) Locomotion system • The clinical science, presentation, pathology and management of disorders of locomotion that relate to the musculo-skeletal system •The anatomy of the limbs, back and joints (b) Emergency Medicine and high dependency care Core clinical presentations: • back pain and sciatica (89) • neck pain (90) • musculoskeletal deformity (91) • acute joint pain (92) • chronic joint pain (93) • osteoporosis (6B) • The presentation, pathology, basic sciences and • clinical management of common and life • threatening emergencies. • • The following core clinical presentations: • • chest pain (1) • • circulatory collapse (2) • 51 substance abuse and alcoholism (52) acute headache (61) loss of consciousness (63) confusion (64) acute loss of function (65) fits and convulsions (69) head injury (71) chest injury (72) abdominal injury (73) acute red eye (83) • • • • acute and chronic breathlessness (3) acute and chronic wheezing (4) haemoptysis (5) upper respiratory infections (coughs, colds and sore throats) (7) • acute abdominal pain (10) • haematemesis and malaena (20) • acute and chronic swelling of limbs (9, 50) • acute poisoning/suicide and attempted suicide (51) 3. Skills • • • • • • • • By the end of the course you should be able to: (a) Emergency medicine: • take a history from a patient with a serious illness attending the ED • assess a patient with a medical emergency • assess a patient with limb trauma • suture • undertake basic life support • ALS (a) demonstrate understanding of the ALS algorithm - (i.e. discriminate between a shockable and non-shockable rhythm and know use of 1 adrenaline and atropine in a cardiac arrest scenario), (b) demonstrate safe defibrillation on a mannikin, (c) demonstrate bag valve mask ventilation on a mannikin • demonstrate bag valve mask ventilation of the lungs on a patient • insert a laryngeal mask airway • insert a cannula and set up an intravenous infusion • make a preoperative assessment and explain peri-operative care, including pain relief (b) Locomotion: • take a history from a patient with musculoskeletal symptoms including assessment of function • examine the back and neck (including neurology) • examine the musculo-skeletal system of the limbs in an adult (GAL system) 4. Investigation and Procedures sudden loss of vision (85) eye trauma (88) fractures and limb trauma (94) bruising and purpura (106) burns (108) facial pain (81) neck pain (90) cancer pain and palliation (135) examine the main joints in an adult: (a) hip, (b) knee, (c) ankle and foot, (d) shoulder and elbow, (e) hand Phase 3 General Skills – revision You should be able to: • measure BP using a sphygmomanometer • measure peak expiratory flow using a Wright’s peak flowmeter • demonstrate basic airway skills • take a 12 lead electrocardiogram • take a venous blood sample • do blood stick testing • test urine with labsticks and interpret the result • give an intravenous injection • set up a blood infusion • insert a urinary catheter into a male • demonstrate knowledge of sterile techniques, including scrubbing up for theatre There are many other skills in the EMTL Block that you will be expected to have acquired and also many that you will witness. The list in the logbook will identify the full range of skills you should practise in EMTL. You should observe and be able to explain the reasons for undertaking the following: You should observe and understand the following management procedures: • • Use of life support systems - IPPV • Insertion of a CVP line • Insertion of an arterial line • Lumbar puncture • Use of transducers • Insertion of a chest drain • Insertion of an epidural catheter • Patient controlled analgesia, e.g. syringe driver • • • • Laboratory tests on blood, urine and other body fluids Emergency medicine: blood gas analysis, acid-base balance, coagulation profiles Neuromusculoskeletal: auto-immune profiles X-rays: demonstrating fractures, pneumothorax, haemothorax, bone and joint diseases Radionuclide scanning: bone and dexa 52 • scans, CT and MRI scans. (To recognise on head scans: midline shift, intracranial bleeds and infarcts, and, on MRI scans, gross spinal compression) Physiological measurements for high dependency patients to include: fluid balance charting, arterial, CVP, pulse oximetry waveforms, ECG monitoring • • • • Feeding by percutaneous gastrostomy (PEG) Application of and removal of plaster cast and backslab Joint aspiration and injection Soft tissues injection Vertical Strand Disciplines You should be able to describe or outline details of the following: 1. Clinical Pharmacology & Therapeutics (a) Emergency medicine, anaesthetics, critical care, pain control • resuscitation and Emergency Drugs with reference to cardiac arrest, CCF, asthma, hypovolaemia • use of oxygen, adrenaline, atropine, inotropes • oxygen therapy • acute respiratory failure • fluid therapy • pain relief • sedation • management of nausea and vomiting • basic pharmacology: principles of pharmacokinetics and pharmacodynamics • corticosteroids, bronchodilators, anti-histamines • poisoning and antidotes • thrombolytics, anticoagulants, vasodilators • antibiotics: effective and appropriate prescribing • antiseptics • local anaesthetics • wound care and dressings • immunisation and tetanus prophylaxis (b) Locomotion • drugs used in treatment of musculo-skeletal conditions and arthropathies: NSAIDS, gold, penicillamine, azathioprine, methotrexate, corticosteroids and anti-malarials • drugs used in management of osteoporosis: bisphosphonates, calcium and vitamin D • antibiotic prophylaxis for orthopaedic surgery • pain control in chronic conditions 2. Clinical Sciences anatomy of locomotion system (spine and joints) forensic pathology: trauma pain: anatomy, physiology 3. Ethics & Law In relation to: (a) Emergency Medicine Consent and capacity issues End of life decisions Mental Health Act Children’s Act and NAI (b) Chronic diseases (rheumatological) 53 4. Palliative Medicine • • pain in advanced disease breaking bad news 5. Pathology & Laboratory Sciences The pathological processes concerned in and the role of the clinical laboratory disciplines in the diagnosis and management of: (a) Emergency Medicine • respiratory failure • shock • systemic infections • organic brain failure • acute poisoning • head injury • meningitis, encephalitis and cerebral abscess • use of blood products and management of massive transfusion • thrombosis prophylaxis (b) Locomotion • infective, neoplastic, metabolic and other inflammatory disorders involving the musculoskeletal system 6. Primary Care and the Community Study The community study enables students to consider emergencies and related issues from the perspectives of patients and primary care. common emergencies in pregnancy, puerperium and infancy presenting in primary care stresses of parenting, and support available in the community non-accidental injury and child protection issues interactions between the mother/baby, and Health Services – particularly GP services, Emergency Department Services, Out of Hours Emergency Services, and Community Health Services, including consideration of “appropriate” and “inappropriate” use of emergency services Links to core curriculum Professional attitudes (6) Communication skills (7) Knowledge: non-accidental injury (120) 7. Radiology/Imaging Fractures and dislocations bone and joint diseases e.g. arthritis and osteoporosis use of imaging in truncal trauma use of imaging in head injury 8. Public Health 1. Epidemiology of common diseases describe the basic epidemiological features of the following conditions: Emergency Medicine: accidents, low back pain, osteoporosis demonstrate a clear understanding of the following epidemiological terms when applied to the above diseases – incidence, prevalence, crude mortality, age-sex specific death rates, standardised mortality ratios, standardised death rates, population attributable risk, population attributable risk fraction, identify modifiable social and environmental risk factors for these diseases (eg. poverty, occupation, housing, indoor air quality, outdoor air quality, smoking, obesity, diet, exercise) interpret Standardised Mortality Ratios, odds ratios, relative risks, population attributable risks, population attributable risk fractions and other epidemiological data as they relate to these diseases 54 2. Health promotion describe primary, secondary and tertiary prevention of the following conditions, demonstrating an understanding of measures that can be taken at an individual and population level to reduce the incidence and/or prevalence of: accidents, disasters 3. Health Services describe current important demographic changes in the UK and internationally discuss how demographic changes in the UK could impact on the prioritisation of health services list factors that should be considered when deciding whether to invest resources in a new drug treatment or health service Students are reminded that the public health sciences does not wish to overburden students with factual knowledge. However students are expected to be able to apply basic epidemiological, public health, sociological and economic principles to the conditions above using their medical knowledge to identify the issues that might be of relevance for that condition. 55 10.4 Orientation • • •. The blocks and campuses to which you have been allocated are displayed on the Phase 4 Virtual Campus before the start of each rotation. This section shows progression through the Block and any relevant sub-blocks and disciplines. Any changes to the timetable will be posted on the Virtual Campus and students will also be notified by email. Please ensure that you check both regularly. See http://virtualcampus.kcl.ac.uk/and click on MBBS 4 for up-to-date course information Guy’s and St Thomas’ Campus Students will be issued with a detailed site-specific timetable at the beginning of their rotation. The Block is divided into two 6-week sub-blocks: one covering Emergency Medicine which consists of three weeks of A&E and three weeks of Anaesthetics and the other sub-block covering Locomotion, consisting of a 6-week integrated course of Rheumatology, Orthopaedics and Trauma. The Emergency Medicine sub-block divides students into two groups. The Locomotion sub-block divides students into 4 firms. Week 1-3 4-6 7-9 Rotation 1 Tuesday 11/09/12 – 28/09/12 01/10/12 – 19/10/12 22/10/12 – 09/11/12 Rotation 2 Thursday 03/01/1318/01/13 21/01/13 – 08/02/13 11/02/13 – 01/03/13 Rotation 3 Thursday 04/04/13 – 19/04/13 22/04/13 – 10/05/13 13/05/13 31/05/13 Emergency Medicine Groups Group A Group B Emergency Medicine 13 12/11/12 – 30/11/12 03/12/12 04/03/13 22/03/13 25/03/12 03/06/13 21/06/13 Firm C1 Firm C2 Firm D1 Firm D2 Loco Loco Loco Loco Anaesthetics Anaesthetics Emergency Medicine Emergency Medicine Loco Loco 10-12 Locomotion Firms Loco Firm Firm Firm A1 A2 B1 Locomotion Firms Anaesthetics Loco Firm B2 Anaesthetics Emergency Medicine Group C Group D Emergency Medicine Groups Rotation 1& 2- Reading week; Rotation 3 Written Assessment 24/06/13 56 King’s College Hospital Campus Students will be issued with a detailed site-specific timetable at the beginning of their rotation. The Block is divided into two 6-week sub-blocks: one covering Emergency Medicine which consists of three weeks of A&E and three weeks of Anaesthetics and the other sub-block covering Locomotion, consisting of an integrated 6-week course of Rheumatology, Orthopaedics and Trauma. The Emergency Medicine sub-block divides students into two groups. The Locomotion sub-block divides students into 4 firms. Week 1-3 4-6 7-9 Rotation 1 Tuesday 11/09/12 – 28/09/12 01/10/12 – 19/10/12 22/10/12 – 09/11/12 Rotation 2 Thursday 03/01/1318/01/13 21/01/13 – 08/02/13 11/02/13 – 01/03/13 Rotation 3 Thursday 04/04/13 – 19/04/13 22/04/13 – 10/05/13 13/05/13 31/05/13 Emergency Medicine Groups Group A Group B Emergency Medicine 13 12/11/12 – 30/11/12 03/12/12 04/03/13 22/03/13 25/03/12 03/06/13 21/06/13 Firm C1 Firm C2 Firm D1 Firm D2 Loco Loco Loco Loco Anaesthetics Anaesthetics Emergency Medicine Loco 10-12 Locomotion Firms Loco Loco Loco Firm Firm Firm A1 A2 B1 Locomotion Firms Firm B2 Emergency Anaesthetics Medicine Anaesthetics Emergency Medicine Group C Group D Emergency Medicine Groups Rotation 1& 2- Reading week; Rotation 3 Written Assessment 24/06/13 57 Queen Elizabeth Hospital Campus Students will be issued with a detailed site-specific timetable on arrival at QEH. On the first day of your Attachment, please report to Joanna Woolard in the Education Centre (located at the West Entrance of the Hospital opposite the Conference Centre) at 9.30am The Block is divided into two 6-week sub-blocks: one consists of three weeks of A&E and three weeks of Anaesthetics and the other sub-block consists of an integrated course of Rheumatology, Orthopaedics and Trauma. Week Rotation 1 Rotation 2 Rotation 3 1-3 Tuesday 11/09/12 – 28/09/12 01/10/12 – 19/10/12 22/10/12 – 09/11/12 Thursday 03/01/1318/01/13 21/01/13 – 08/02/13 11/02/13 – 01/03/13 Thursday 04/04/13 – 19/04/13 22/04/13 – 10/05/13 13/05/13 31/05/13 4-6 7-9 10-12 13 12/11/12 – 30/11/12 03/12/12 04/03/13 22/03/13 25/03/12 03/06/13 21/06/13 Emergency Medicine Groups Groups A&B Groups C&D Students 1-8 Students 9-16 Emergency Anaesthetics Medicine Locomotion Groups Groups 1-8 Students 17-32 Locomotion Anaesthetics Emergency Medicine Emergency Medicine Anaesthetics Locomotion Groups 1-8 Students 1-16 Locomotion Groups 24/06/13 Groups A&B Emergency Medicine Groups C&D Emergency Medicine Groups Rotation 1& 2- Reading week; Rotation 3 Written Assessment 58 Anaesthetics University Hospital Lewisham Campus Students will be issued with an Induction Pack on the first day of the clinical rotation (collect from Samantha Newman at 9:30am in the Education Centre, UHL). The Block is divided into two 6-week sub-blocks: one consists of three weeks of A&E and three weeks of Anaesthetics and the other sub-block consists of an integrated course of Rheumatology, Orthopaedics and Trauma. Week 1-3 4-6 7-9 Rotation 1 Tuesday 11/09/12 – 28/09/12 01/10/12 – 19/10/12 22/10/12 – 09/11/12 Rotation 2 Thursday 03/01/1318/01/13 21/01/13 – 08/02/13 11/02/13 – 01/03/13 Rotation 3 Thursday 04/04/13 – 19/04/13 22/04/13 – 10/05/13 13/05/13 31/05/13 12/11/12 – 30/11/12 04/03/13 22/03/13 03/06/13 21/06/13 Group A Emergency Medicine Anaesthetics Emergency Medicine Rheumatology, Orthopaedics, Trauma Emergency Anaesthetics Medicine Anaesthetics Emergency Medicine Rotation 1& 2- Reading week; Rotation 3 Written Assessment 10-12 13 Group B Anaesthetics Rheumatology, Orthopaedics, Trauma Princess Royal University Hospital Campus Students will be issued with a detailed site-specific timetable on arrival at PRUH. On the first day of your Attachment, please report to Andrew Jones in the Education Centre (located at the West Entrance of the Hospital opposite the Conference Centre) at 8.30am The Block is divided into two 6-week sub-blocks: one consists of three weeks of A&E and three weeks of Anaesthetics and the other sub-block consists of an integrated course of Rheumatology, Orthopaedics and Trauma. Week Rotation 1 Rotation 2 Rotation 3 1-3 Tuesday 11/09/12 – 28/09/12 01/10/12 – 19/10/12 22/10/12 – 09/11/12 Thursday 03/01/1318/01/13 21/01/13 – 08/02/13 11/02/13 – 01/03/13 Thursday 04/04/13 – 19/04/13 22/04/13 – 10/05/13 13/05/13 31/05/13 4-6 7-9 10-12 13 12/11/12 – 30/11/12 03/12/12 04/03/13 22/03/13 25/03/12 03/06/13 21/06/13 Emergency Medicine Groups Groups A&B Groups C&D Students 1-8 Students 9-16 Emergency Anaesthetics Medicine Locomotion Groups Groups 1-8 Students 17-32 Locomotion Anaesthetics Emergency Medicine Emergency Medicine Anaesthetics Locomotion Groups 1-8 Students 1-16 Locomotion Groups 24/06/13 Groups A&B Emergency Medicine Groups C&D Emergency Medicine Groups Rotation 1& 2- Reading week; Rotation 3 Written Assessment 59 Anaesthetics 10.5 Symposia In the Emergency Medicine, Trauma and Locomotion block, your first symposium will be on the introductory day of the rotation. Following that, you will have a symposium every Wednesday morning. Please see the Virtual Campus for an up-to-date symposia timetable for your EMTL block. Topics covered by the EMTL symposia are: The Multi-trauma Patient Anatomy and Radiology of the Joints Rheumatoid Arthritis The Failing Joint Control of Chronic Pain Anaesthetic Discoveries Communication: Dealing with Crisis Back Pain Ethics & Law Neurological Gait Deliberate and Accidental Self-Harm Rehabilitation and Real Life 10.6 Aims and Objectives for Symposia By the end of each symposium you should have achieved the following learning objectives: (CC Presentations: Core Curriculum Presentations) The Multi-trauma patient Organisers: Dr Nigel Harrison /Dr P Gordon/ Dr T Lasoye CC Presentations: 2, 63, 71, 72 To be able to: • Describe the principles of treating the multiply injured patient in the A&E Department • Recognise the importance of pre-hospital and immediate hospital treatment in the golden hour • Describe the function and roles of a trauma team • Outline the primary and secondary survey • Describe the biomechanics of injury and forensic pathology Rheumatoid Arthritis Organiser: Dr P Gordon CC Presentations: 92, 93 To be able to describe: • The pathology, recognise the clinical features and management of inflammatory arthritis. • The impact of the disease on the health service both in hospitals and in the community • Management of rheumatoid arthritis; nonsteroidal anti-inflammatory drugs, COX-2 inhibitors, disease modifying drugs, steroids, physiotherapy, occupational therapy, and surgery The Failing Joint Organiser: Mr M Wilkinson CC Presentations: 93 To be able to describe: • The nature of the disease/wear process which leads to joint failure • The anatomy and function of typical joints (eg. hips and knee) then the pathological processes involved • The size of the problem in the general population and the costs to the individual and society in general • The treatment options: conservative/therapeutics Anatomy and radiology of the joints Organisers: Prof Harold Ellis CC Presentations: 89 To be able to: • List the advantages and limitations of standard radiography • Define the A.B.C.S. of plain film examination • Describe the histology of the different joint types • Describe the anatomical features of clinical relevance at the shoulder, knee, hip and spine 60 • The indications for surgery and the nature of the surgical options Preassessment: To understand the importance of the preoperative assessment process To know the ASA and Mallampati classifications To know the importance of Body mass index Control of Chronic pain Organiser: Dr Stephanie Jarrett CC Presentations: 81, 89, 93, 135 Equipment: To know and recognise the equipment for delivering oxygen to a patient To know the some of the differences between a child and adult airway To know the basic differences in anaesthetic circuits To know the basic technique and complications for inserting a central venous line and how monitoring is interpreted To know the basic technique and complications in inserting neuraxial blocks To be able to describe chronic pain as a multi-factorial symptom, including biological, psychological and social factors To understand the differences between acute and chronic pain, requiring different approaches To revise the basic pathophysiological mechanisms of chronic pain To be able to obtain a basic chronic pain history, understanding the differences between nociceptive, neurogenic, and neuropathic pain, how these can overlap and how it is possible to have pain of unknown origin To appreciate that neuropathic pains are often not sensitive to opiates To understand the role of medical interventions in chronic pain To know how to initiate and titrate oral Morphine for cancer pain To understand the role played by patients’ beliefs about their pain To be aware of the importance of good communication in enabling patients to best manage their chronic pain Resuscitation: To know and understand Basic and Advanced Life support algorithms (not taught in the symposium) T o appreciated some of the ethical and legal issues around resuscitation To know what is meant by the ‘do not resuscitate’ policy Communication: dealing with crisis Organiser: Ms E Gill CC Presentations: All EMTL Anaesthesia - What You Need to Know! Organiser: Dr Vip Gill To understand the principles of: • Ensuring a patient gets assessed appropriately (ie. knows triage system) • The use of skills to calm an angry friend • Ensuring safety of self, patient and staff • Using rapport and empathy skills and demonstrating emotional support for the patient • Giving information, using silence appropriately and clarifying and checking for understanding • Using support for emotional state of patient and companions • Offering an explanation for what is happening in a sensitive way Drugs: • To understand the basic theory of mechanism of action of general and local anaesthetics • To be able to give an example of a commonly used inhalational and intravenous anaesthetic • To be able to draw and understand the general structure of a local anaesthetic To be able to classify different local anaesthetics To understand what determines the duration of action and potency of a local anaesthetic To know the toxic doses of commonly used local anaesthetic drugs Concepts: To understand the concepts of the ‘triad of anaesthesia’ and ‘depth of anaesthesia’ To be able to make an assessment of anaesthetic risk To understand what is meant by ‘fitness for surgery’ Back pain Organiser: Ms K Payne CC Presentations: 89, 90 Physiotherapy perspective 61 • To understand the role of physiotherapy in the management of back pain and its relevance to medical practice • To be aware of biomechanical vs structural diagnostic terms • To gain insight into the physical assessment and management of back pain via practical demonstration • To understand the impact of psychosocial factors on prognosis • To be aware of the physical treatment options available and their evidence base Aim: To provide the student with an overview of medical and psychiatric aspects of management of deliberate self-harm and attempted suicide. Objectives: To understand the following basic information in relation to deliberate self harm and attempted suicide: • major epidemiological and aetiological factors • techniques of assessment of the patient presenting with deliberate self harm or attempted suicide • acute medical and psychiatric management • uses of common law and statute law Neurological Gait Organiser: Dr J Lin CC Presentations: 95 Rehabilitation and real life Organiser: Prof L Turner-Stokes Dr Julian Harriss CC Presentations: 67, 68, 95, 96 • To be able to recognise common disorders of gait • To be able to describe the functional anatomy of the neurological systems which are impaired in gait disorders • To be able to describe the role of the multidisciplinary rehabilitation team in the management of gait disorders • To be able to describe the four constructs of rehabilitation – pathology, impairment, disability and handicap • To be able to describe the link between impairment and disability • To be able to describe the link between disability and handicap • To develop general applications of this learning experience to any situation involving impairment • To be able to describe the clinical relationships of the anatomy and function of the spine and spinal cord Deliberate and Accidental Self-harm Organisers: Dr G Ranjith CC Presentations: 51 62 10.7 Seminar Titles Emergency Medicine Sub-Block: Anaesthetics/Pain Emergency Drugs Preoperative assessment and preparation for surgery Acute pain relief 90, 92, 135 Care of the unconscious patient 63 Oxygen Therapy and ventilatory support Multiple organ failure and patient at-risk teams Acid Base Balance, fluids and electrolytes Emergency Medicine BLS/ALS 2, 8 Shock 2, 20, 72, 73 Head injury 63, 64, 71 Drugs and poisoning 51, 52, 63, 64 Alcohol 52 Burns 108 Wounds and wound closure 49 Locomotion Sub-Block: Orthopaedics Infections and tumours Paediatric Orthopaedics: CDH to slipped femoral epiphysis 95 Hip and Knee surgery 92, 93 Foot and ankle surgery 92, 93 Hand surgery 92, 93 Shoulder and elbow surgery 92, 93 Trauma Fractures and methods of management Complications of fractures 94 Distal Limb injuries 94 94 Rheumatology (GST & UHL students only) Musculoskeletal history, examination and imaging Seronegative inflammatory arthropathies and crystal arthritis 91, 92 Regional pain, back pain and soft tissue rheumatic diseases 89, 90, 91 Osteoarthritis and metabolic bone disease 91 Connective tissue diseases (Systemic Lupus Erythematosus, Scleroderma) 92 Polymyalgia Rheumatica, giant cell arteritis and vasculitis 92, 61, 62 10.8 Aims and Objectives for seminars By the end of each seminar session you should have achieved the following educational objectives: Anaesthetics/Pain Emergency Drugs By the end of the session you will be able to: List the essential emergency drugs used in clinical practice Define the actions of these drugs and their basic pharmacology Preoperative assessment and preparation for surgery By the end of the session you should be able to: List the universal questions asked to patients before a general anaesthetic List the conditions needing further investigation Reproduce the physiological data required for safe general anaesthesia Reproduce the treatment of chronic conditions in the perioperative period (diabetes, hypertension) List the indications for the use of each drug and their routes and methods of administration Explain the need for investigations (blood tests, ECGs, X-rays) Describe the process of anaesthesia and appropriate analgesia Identify problems and when to consult an anaesthetist 63 Acute pain relief By the end of the session you should be able to: Describe how to assess pain List the standard methods of acute pain relief which are available and be able to describe them to a surgical patient Care of the unconscious patient By the end of the session you should be able to: Outline principles of assessment and airway management in unconscious patients List the components of the Glasgow Coma Score List the precautions to be taken when looking after an unconscious patient Oxygen Therapy and ventilatory support a) Oxygen Therapy i) Knowledge Objectives By the end of the session you should be able to: List the common indications for oxygen therapy Draw the haemoglobin oxygen dissociation curve List the main factors which shift the curve to the left Give the formula for the calculation of oxygen delivery Describe in which patients a fixed performance mask should be used List the main hazards of oxygen therapy ii) Skills Objectives Differentiate between arterial blood gases taken from patients with Type I and Type II respiratory failure Identify the commonly used fixed performance and variable performance face masks Multiple organ failure and patient-at-risk teams i) Knowledge Objectives By the end of the seminar you should be able to: Summarise the important pathophysiologic mechanisms that lead to the development of multiple organ failure List the clinical features of multiple organ failure Compare and contrast the haemodynamic and metabolic effects of: i) Adrenaline ii) Noradrenaline iii) Dobutamine iv) Dopamine v) Dopexamine Acid Base Balance, fluids and electrolytes i) Knowledge Objectives By the end of the seminar you should be able to: List the common causes of metabolic and respiratory acidosis and alkalosis List the causes of hyperkalaemia, hypokalaemia, hypernatraemia and hyponatraemia List the main pharmacological properties, including side effects, of the principal groups of analgesic drugs List the physiological monitors required when caring for an unconscious patient List the methods of assessing recovery from unconsciousness b) Ventilatory Support i) Knowledge Objectives After the seminar you should be able to: List the main indications for mechanical ventilation Understand the meaning of the abbreviations PEEP and CPAP Explain how oxygenation can be improved by the application of PEEP/CPAP Explain the difference between volume and pressure controlled ventilation Give the formula for calculating minute ventilation ii) Skills Objectives Suggest appropriate modifications to ventilator settings when given a selection of blood gases and clinical scenarios Define ARDS List the common conditions associated with ARDS Compare the advantages and disadvantages of TPN versus enteral nutrition List the clinical abnormalities which are present in patients at risk of developing multiple organ failure Identify patterns of acid base abnormalities Explain the management of patients with hyperkalaemia, hypokalaemia, hypernatraemia and hyponatraemia Show knowledge of how to prescribe IV fluids ii) Skills Objectives 64 Define the complications and presenting features of hyperkalaemia, hypokalaemia, hypernatraemia and hyponatraemia Interpret arterial blood gases and basic serum biochemistry Adequately ventilate a mannikin with a bag valve mask Outline the algorithms for the management of cardiac arrest including the use of adrenaline and atropine Demonstrate safe defibrillation of a mannikin Emergency Medicine BLS/ALS By the end of the session you should be able to: Describe the assessment of a collapsed patient Demonstrate basic life support competently, both single handed and in pairs Discriminate between shockable and nonshockable rhythms Shock By the end of the session you should be able to: Define shock Describe the clinical findings in shock Outline the pathophysiology of shock List the common causes of shock Head injury By the end of the session you should be able to: Describe the pathophysiology of severe head injury Describe the assessment of the head injured patient and the clinical tools for evaluation Demonstrate understanding of the priorities in head injury management Drugs and poisoning By the end of the session you should be able to: List the common drugs taken in overdose, both accidental and deliberate Outline the management priorities for poisoned patients Alcohol By the end of the session you should be able to: Describe the pathophysiological and pharmacological effects of alcohol both acute and long term Outline the major complications of alcohol abuse Evaluate the interventions available to prevent abuse including community agencies Burns By the end of the session you should be able to: Describe the pathophysiology of burns Describe the epidemiology of burns Assess the burnt area List the common complications of burns Wounds and wound closure By the end of the session you should be able to: Evaluate the need for wound closure in a given wound Describe different types of wounds Describe the principles behind local anaesthetic administration 65 Evaluate a given set of clinical observations as to the severity of shock Determine the management priorities in a given shock scenario List the common investigations and evaluate their importance Outline the management plan in a given scenario Describe the epidemiology of head injury Determine the likely substances ingested in common given scenarios Describe the common antidotes Demonstrate understanding of the role of the National Poisons Centre Describe the management of acute alcohol withdrawal in a dependent patient Demonstrate how to assess alcohol use and its effect on the patient Determine the management priorities in severely burned patients Evaluate the common treatments for burns Demonstrate competence in managing burns in a given scenario Demonstrate competence in suturing a simulated wound List the common complications of wound closure Describe the appropriate dressing for a range of wounds Orthopaedics Infections and Tumours By the end of the seminar you should be able to: Understand the principles behind musculoskeletal infections and tumours Describe the clinical presentation (i.e. history and findings on examination) of musculoskeletal infections and tumours Paediatric Orthopaedics By the end of the seminar you should be able to: Understand the principles of common paediatric orthopaedic disorders Describe the clinical presentation of common paediatric orthopaedic disorders Hip and Knee Disorders By the end of the seminar you should be able to: Understand the principles of common disorders of the hip and knee Describe the clinical presentation (i.e. history and findings on examination) of disorders of the hip and knee Foot and Ankle Disorders By the end of the seminar you should be able to: Understand the principles of common disorders of the foot and ankle Describe the clinical presentation of disorders of the foot and ankle Hand Disorders By the end of the seminar you should be able to: Understand the principles of common disorders of the hand Describe the clinical presentation of disorders of the hand Shoulder and Elbow Disorders By the end of the seminar you should be able to: Understand the principles of common disorders of the shoulder and elbow Describe the clinical presentation of disorders of the shoulder and elbow Trauma Fractures and methods of management By the end of the session you should know: How to diagnose a fracture How to select an appropriate method of management Complications of fractures By the end of the session you should know: The common complications that occur following fractures Distal limb injuries By the end of the session you should know: How to assess a patient presenting with a hand injury How to assess a patient presenting with a foot injury Plan the appropriate investigations of such infections and tumours Understand the principles of treatment of musculo-skeletal infections and tumours Plan the appropriate investigations of common paediatric orthopaedic disorders Understand the principles of treatment of common paediatric orthopaedic disorders Plan the appropriate investigations of disorders of the hip and knee Understand the principles of treatment of disorders of the hip and knee Plan the appropriate investigations of disorders of the foot and ankle Understand the principles of treatment of disorders of the foot and ankle Plan the appropriate investigations for hand disorders Understand the principles of treatment of hand disorders Plan the appropriate investigations for shoulder and elbow disorders Understand the principles of treatment of shoulder and elbow disorders How fractures are stabilised How complications can be missed How complications are managed 66 How to manage common soft tissue and bony hand and foot injuries Rheumatology Musculoskeletal history, examination and imaging i) Aims You should learn how to take a history, examine and investigate a patient with musculoskeletal complaints. ii) Knowledge Objectives iii) Skills Objectives By the end of the session you should: By the end of the session you should be able to: Know the symptoms that characterise Perform a screening examination of the inflammatory and mechanical joint diseases musculoskeletal system such as the GALS Know the principles of joint examination and method how to perform a more detailed examination of the musculoskeletal system Know the basic investigations that are commonly used in the diagnosis and assessment of rheumatic diseases Seronegative inflammatory arthropathies and crystal arthritis i) Aim To introduce you to various inflammatory arthropathies that are seronegative for rheumatoid factor. ii) Objectives By the end of the session students should: Know the association between HLA-B27 and Know the clinical features of ankylosing seronegative arthritis spondylitis, reactive arthritis and psoriatic Be familiar with the clinical features, arthritis investigations and management of gout and pseudogout Regional pain, back pain and soft tissue rheumatic diseases i) Aims You should be familiar with the clinical features, investigations and management of regional pain, back pain and soft tissue rheumatism. ii) Objectives By the end of the session you should: Learn to distinguish inflammatory from Learn the management of mechanical back mechanical back pain pain and sciatica Be able to recognise the clinical features and Learn the clinical features, investigations and predisposing factors of mechanical back pain management of patients with common soft and sciatica tissue rheumatic diseases such as adhesive Be able to arrange appropriate investigations capsulitis and tenosynovitis for back pain and sciatica Osteoarthritis and metabolic bone disease i) Aims You should learn the clinical features, pathologies, investigations and management of osteoarthritis and metabolic bone diseases. ii) Objectives By the end of the session you should: Learn the epidemiology, clinical, pathological Learn the clinical features, investigations and and radiological features of osteoarthritis management of osteomalacia and Paget's Know the management of osteoarthritis disease Learn the causes, assessment and management of osteoporosis Connective tissue diseases (Systemic Lupus Erythematosus, Scleroderma) i) Aims To introduce you to connective tissue diseases as multi-system disorders. You should be familiar with the main clinical features and learn how to investigate connective tissue diseases especially systemic lupus erythematosus and scleroderma. ii) Objectives By the end of the session you should: Understand the clinical implications of different Learn the main systemic manifestations of auto-antibodies especially anti-nuclear connective tissues diseases antibodies Learn the preliminary investigations in connective tissue diseases 67 Polymyalgia Rheumatica, giant cell arteritis and vasculitis i) Aims To learn the clinical manifestations, differential diagnoses and management of polymyalgia rheumatica, giant cell arteritis and common forms of vasculitis. ii) Objectives By the end of the session you should: Be able to recognise the presenting features of Know the management of polymyalgia polymyalgia rheumatica and temporal arteritis rheumatica and temporal arteritis Appreciate the differential diagnoses of Learn the main clinical features of different polymyalgia rheumatica and exclude these by vasculitidies eliciting the relevant clinical history, identifying the clinical signs and organising appropriate investigations 68 10.9 Recommended Reading and Computer-aided learning Please refer to the VC for reading list Internet Resources 1. Arthritis Research Campaign http://www.arthritisresearchuk.org/ 3. British Society for Rheumatology http://www.rheumatology.org.uk/ 4. Royal College of General Practitioners http://www.rcgp.org.uk/ 5. National Osteoporosis Society http://www.nos.org.uk/ 6. Annals of Rheumatic Diseases http://ard.bmj.com/ 7. Cochrane Library http://www.cochrane.co.uk/ 8. National Library of Medicine http://www.nlm.nih.gov/ 9. New England Journal of Medicine http://content.nejm.org/ 10. Doctor on line http://www.arthritis.co.za CD-rom: Interactive Hand. <www.primalpictures.com> CD-rom: Interactive Knee. <www.primalpictures.com> CD-rom: Interactive Foot and Ankle. <www.primalpictures.com> CD-rom: Shoulder. <www.primalpictures.com> CD-rom: Spine. <www.primalpictures.com> CD-rom: Hip. www.primalpictures.com • Internet Resources Anaesthesia Online (includes Medline access http://www.priory.com/anaes.htm South Eastern School of Anaesthesia www.sesa.org.uk 69 11. REPRODUCTIVE AND SEXUAL HEALTH BLOCK(RSH) 11.1 An Overview of the Block 72 11.2 Course Organisers and Contact Details 73 11.3 Block Aims and Objectives 74 11.4 Orientation 80 Guy’s/St Thomas’ Campus 80 King’s College Hospital Campus 81 Princess Royal University Hospital Campus 82 Queen Elizabeth Hospital Campus 82 University Hospital Lewisham Campus 83 11.5 Outside and Overseas Attachments 84 11.6 Symposia Information 85 11.7 Aims and Objectives for Symposia 85 11.8 Seminar Titles 88 (For RSH Block Seminar Aims and Objectives please refer to ‘RSH Block – Seminar Guidelines’ booklet) 11.9 Recommended Reading and Computer-Aided Learning 70 89 11.1 An Overview of the Block Welcome to the Reproductive and Sexual Health Block. During this Block, students will be based at KCH, GST, UHL, QEH or PRUH. During this Block we hope that you will acquire core knowledge and skills relevant to obstetrics and gynaecology, genitourinary medicine, and breast medicine. As far as possible we have ensured that the same experience will be gained on the different campuses. With regards to obstetrics and gynaecology, at Guy’s and St Thomas’, King’s and Lewisham we have persevered to maintain a firm structure. Students based at KCH and GST will spend three weeks at a peripheral hospital. The reasons for the peripheral attachments are: the support for them from previous students and our concern that the core curriculum, particularly in gynaecology, will not be able to be delivered on the teaching hospital site, primarily because of sub-specialisation amongst the consultants. Those students based at PRUH, QEH and UHL will obtain similar broad clinical experience at this campus. As with the other Blocks there will be a symposium every Wednesday morning and there will be three seminars (tutorials) throughout each week. The subjects of the seminars across all campuses will be identical. Fridays are for Student Selected Components, although in Term 2 we expect you stay at your peripheral attachment on Fridays as you do not have to return to campus to complete your elective portfolios. If you encounter any problems during your attachment please approach your course organiser. We hope that you will enjoy your time in the Reproductive and Sexual Health Block, and although reading around subjects is important, the best place to learn clinical medicine is where the patients are, namely the wards and the clinics. Ms Deborah Bruce Department of Women’s Health 71 11.2 Course Organisers and Contact Details Obstetrics & Gynaecology Ms Deborah Bruce 020 7188 3631 [email protected] k Undergraduate Teaching Administrator: Mrs Annelie Mojzis 020 7188 3631 [email protected] Mr Mike Marsh 020 3299 3629 [email protected] Miss Kazal Omar Tel: 016 8986 4892 [email protected] Mrs Ruth Cochrane 020 8333 3066 [email protected] Secretary: Ms Agatha Palmer 020 3299 3629 [email protected] Administrator: Shayron Hegarty Tel: 016 8986 4347 [email protected] Student Coordinator: Samantha Newman 020 8333 3000 ext 8734 [email protected] Course Administrator: Pat Riddle 020 3299 3546 [email protected] QEH Mr Nigel Perks 020 8836 4500 [email protected] Medical Undergraduate Administrator: Joanna Wollard 020 8836 6788 [email protected] Genito-Urinary Medicine GSTT 020 7188 7188 KCH 020 7737 4000 PRUH & UHL QEH Mr Anatole Menon-Johansson [email protected] Mr Anatole Menon-Johansson [email protected] See Guy’s/St Thomas’ Dr Judy Russell 0208 836 5765 [email protected] PA: Davina Austin-Harvey [email protected] PA: Davina Austin-Harvey [email protected] Administrator: Dr Hannah.Alexander [email protected] Administrator: Dr Hannah Alexander [email protected] Breast Medicine GSTT 020 7188 7188 KCH 020 7737 4000 PRUH 01689 863000 UHL 020 8333 3000 Mr Hisham Hamed [email protected] 020 7188 4245 Dr Jo Marsden [email protected] Mr Prakesh Sinha Tel: 016 8986 4441 [email protected] Mr Hisham Hamed 020 7955 5000 ext 3776 020 8333 3000 ext 3161/8508 [email protected] QEH Mr Bengt Kald [email protected] [email protected] 72 Family Planning / Reproductive Health GSTT 020 7188 7188 Dr M Nowicki KCH 020 7737 4000 As GSTT PRUH 01689 863000 As GSTT UHL 020 8333 3000 As GSTT QEH Student Coordinator Joanna Woollard Tel: 020 8836 6788 [email protected] PRUH Student Coordinator Shayron Hegarty 016 8986 4347 [email protected] UHL Student Coordinator Samantha Newman 020 8333 3000 ext 8734 [email protected] t [email protected] 020 3049 4006 73 11.3 Block aims and objectives Objectives During the Reproductive and Sexual Health course, you should: • Achieve core knowledge • Demonstrate core professional values Obstetrics & Gynaecology 1. Aims The aims of the course in Obstetrics and Gynaecology are to: • Understand the disease of women with regard to prevention, recognition, and management of gynaecology disease 2. Attitudes By the end of the course you should be able to: • recognise patients’ rights in all respects, and particularly in regard to confidentiality and informed consent 3. Knowledge You should be able to describe: (a) The clinical presentations relevant to obstetrics and gynaecology as follows: acute abdominal pain (10) pelvic mass (14) uterovaginal prolapse (26) acute retention of urine (30) urinary frequency and urgency (31) urinary incontinence (32) pain of micturition (33) vaginal discharge (109) amenorrhoea (112) disorders of menstruation (113) dymenorrhoea and pelvic pain (114) unwanted pregnancy and termination (116) painful sexual activity (117) 4. Skills By the end of the course to be able to: • take a comprehensive gynaecological history including breast, genito-urinary medicine and sexual histories • take a comprehensive obstetric history • examine a pregnant woman • perform a competent breast examination • perform a bimanual pelvic examination • • Recognise and manage psychological problems in human reproduction, including psychosexual disorders Understand normal pregnancy and labour • Appreciate that a person’s sexuality is complex and personal and a person’s privacy must be respected with regard to history taking and examination at all times failure to conceive (118) contraception (119) genital ulcers and warts (122) abnormal vaginal bleeding in the first 24 weeks of pregnancy (110) abnormal vaginal bleeding after 24 weeks of pregnancy (111) normal pregnancy (115) (b) The symptomless problems relevant to obstetrics and gynaecology: high blood pressure (2B) anaemia, including haemoglobinopathy (5B) osteoporosis (6B) abnormal cervical smear (7B) proteinuria (10B) • • • • insert a Cusco speculum, examine the cervix, and take a cervical smear and endocervical swab catheterise a female patient explain to a patient the use of pessaries and suppositories participate in a normal delivery Sexual and Reproductive Health (Family Planning) 1. Aims The aims of the family planning course are to ensure that you are able to: identify the family planning and sexual health needs of patients during their work as preregistration house officers and to respond to these or refer appropriately 74 provide basic information on contraception, genital infection, and management of the unplanned pregnancy in a non-judgmental manner promote sexual health when appropriate and in a sensitive manner 2. Attitudes You should recognise and practice the following: • the importance of a non-judgmental approach towards a range of sexual lifestyles and the termination of pregnancy 3. Knowledge You should be able to describe: • all currently available methods of contraception • medical therapies which might put a patient at risk of pregnancy or a complication of their contraceptive method. This will include: the prescription of antiepileptics or anti retrovirals to those on the combined pill; major surgical operations or immobilisation in those on the combined pill; e.g. when a broken leg is set in plaster or strict bed rest is advised. 4. Additional Skills • Take a sexual history relevant to a family planning consultation • Discuss the advantages and disadvantages of the combined oral contraceptive, injectable and implant contraceptives, male and female barriers, intrauterine contraceptives and emergency conraception • the responsibilities of doctors in relation to confidential information • appropriate conduct during intimate examinations (see Code of Practice for student examination of patients, page 4) • Contraceptive methods which cause or exacerbate medical conditions. This will include: pelvic pain in a patient using the IUD for contraception; severe migraine/DVT/PE in a patient on the combined oral contraceptive • General issues which relate to sexual and reproductive health (SRH) and which are also relevant to other specialties • the legal issues which relate to the provision of contraception to those under the age of consent and the barriers experienced by clients in accessing sexual health services • Demonstrate condom use to a patient An understanding of the diagnosis and management of common HIV related complications • • A recognition of psychosexual problems An understanding of the basis of psychiatric aspects of patients with genitourinary diseases and/or HIV Sexual Health and HIV 1. Aims • An understanding of the aetiology, clinical presentation, diagnosis and management of common sexually acquired infections 2. Attitudes To show the following: • A recognition of the range of sexual behaviour • An awareness of sexuality and sexual orientation • An understanding of confidentiality as applied to patients attending a GUM service 3. Knowledge (a) The clinical presentations relevant to genitourinary medicine/HIV: • genital ulcers and warts (12, 20) • pelvic mass (14) • urinary frequency and urgency (31) • pain on micturition (33) • testicular pain (37) • testicular swelling (38) • vaginal discharge (109) • urethral discharge (123) • dysmenorrhoea and pelvic pain (114) • painful sexual activity (117) (c) The clinical presentations related to HIV medicine: • acute and chronic breathlessness (3) • haemoptysis (5) • acute headache (61) • fits and convulsions (69) • memory loss (70) • weight loss (19) • diarrhoea (23) • skin infections (105) • fever (121) • the dying patient (127) (b) The core knowledge related to HIV medicine should include: • the natural history and epidemiology of HIV 75 infection the diagnosis and management of common HIV-related opportunistic infections and tumours • the principles of antiretroviral and prophylactic therapy in HIV infection 4. Additional skills To be able to: • take an appropriate sexual history in a variety of clinical situations • perform a male and female genital examination • discuss the relevant issues with patients undergoing HIV testing • • • offer basic health education and promotion to patients presenting with sexually-acquired infections utilise clinical skills gained in Phase 3 to assess patients presenting with acute HIVrelated complications Breast Medicine 1. Aims The aims of the course in Breast Medicine are to be able to: • take a clinical history from a patient presenting with breast symptoms • carry out a competent clinical examination of the breasts and axillae 2. Objectives • To achieve core knowledge 3. Core Clinical presentations lump in breast (40) mastalgia (41) nipple discharge (42) The symptomless problems relevant to breast medicine are: abnormal screening mammogram (8B) family history of breast cancer (11B) epidemiology of benign and malignant breast disease clinical presentation of breast disease pathology of breast disease investigation of breast problems • understand breast disease with regard to screening, diagnosis and management give information to patients with breast disease, including giving bad news • To demonstrate core professional skills imaging of the breast - including X-ray, mammography, and ultrasound breast cancer screening - theory, practice, advantages/disadvantages staging of breast cancer treatment of breast cancer palliative and terminal care (127, 135) genetics of breast cancer (136) psychological aspects of breast cancer breast infection Vertical Strand Disciplines Communication skills You should be able to: demonstrate effective patient centred interviewing using communication skills learnt earlier in the course physically examining patients taking into account the need for sensitivity, explanation and privacy explain common medical and surgical procedures, investigations and treatments in language patients understand and check for understanding 76 Knowledge 1. Clinical Genetics You should be aware of different issues involved in pregnancy where there is a family history of a genetic disease. These include: Patterns of inheritance and interpretation of pedigrees Methods of assessment of risk of inherited disease in a pregnancy. The techniques for genetic testing, their uses and limitations in pregnancy. Chromosome abnormalities and their clinical implications. Screening for genetic disease in pregnancy. Counselling and ethical issues arising from testing in pregnancy. Pre-implantation genetic diagnosis, its uses and limitations. 2. Clinical Pharmacology & Therapeutics (a) Obstetrics, New-born, and Gynaecology • Drugs and teratogenesis • Prophylaxis for pregnancy • Use of drugs in pregnancy • Management of medical disorders in pregnancy • Drugs and induction of labour • Analgesia in labour • Drugs and lactation • Ergometrine • Hormone replacement therapy • Fertility Drugs • Contraception (b) Sexual Health / HIV • Principles of antibacterial therapy • Principles of anti-retroviral therapy • Treatment of gonorrhoea • Treatment of chlamydia trachomatis • Anti-retroviral therapy 3. Clinical Sciences • Embryology relating to newborn variations and neonatal problems • Preterm and babies with low weight for gestational age (LWGA) • Anatomy of pelvis • Physiology of pregnancy • Fetal physiology and teratogenesis • Physiology of parturition • Adaptation to extra-uterine life and prematurity • Forensic pathology: abortion, maternal death 4. Ethics & Law relating to Human Reproduction • Ethical debates about, and the legal status of, the embryo and fetus • The maternal-fetal relationship: ethical tensions • Abortion: professional guidelines, legal requirements and debates about the use of tissue from aborted fetuses • Sterilisation: ethical and legal issues • Pre and post-natal screening and testing: ethical issues concerning informed consent and the determination of the future interests of the child • Assisted conception: legal boundaries and ethical disputes, resource allocation • Benefits and dangers of genetic testing and screening after birth: risks of unwelcome information and of genetic stigmatisation • Genetic counselling relating to the above issues 77 5. Palliative Medicine To know about: • HIV • Palliation of advanced breast & gynaecological cancers (135) 6. Pathology & Laboratory Sciences To be able to give an account of the role of the clinical laboratory disciplines in the diagnosis and management of: Tumours of the cervix, endometrium, myometrium and ovaries particularly the histopathology and cytology, including cervical screening Infections of the pelvis Breast tumours and breast screening Sexually transmitted diseases presenting as vaginal and urethral discharge AIDS and HIV Basic abnormalities of pregnancy Haematological abnormalities in pregnancy including haemolytic disease of the newborn, anaemia and thrombocytopenia Thrombosis and disseminated intravascular coagulation 7. Primary Care and the Community Study The Community Study enables students to study pregnancy and the puerperium from the perspectives of patients and primary care: Antenatal care in the community Common health problems in pregnancy presenting in the community Women’s views on and experiences of antenatal care, antenatal screening and delivery Post-natal physical health and illness, including breast problems the 8 week postnatal examination Family planning choices Post-natal mental health and illness The impact of having a baby on the mother and her family in terms of daily activities, roles, selfimage and changing relationships. Primary care and community sources of support and resources for the mother and family. Links to core curriculum Professional attitudes (6) Communication skills (7) Knowledge: normal pregnancy (115); depression (post-natal depression) (56); contraception (119); fever (puerperal infection) (121); pain in breast (41) 8. Radiology & Imaging Ultrasound scanning and fetal monitoring Mammography 9. Public Health 1. Epidemiology of common diseases describe the basic epidemiological features of the following conditions: sexually transmitted disease, breast cancer, cervical cancer demonstrate a clear understanding of the following epidemiological terms when applied to the above diseases – incidence, prevalence, crude mortality, age-sex specific death rates, standardised mortality ratios, standardised death rates, population attributable risk, population attributable risk fraction, identify modifiable social and environmental risk factors for these diseases (eg. poverty, occupation, housing, indoor air quality, outdoor air quality, smoking, obesity, diet, exercise) interpret Standardised Mortality Ratios, odds ratios, relative risks, population attributable risks, population attributable risk fractions and other epidemiological data as they relate to these diseases describe the epidemiology of maternal mortality and measures taken to collect information regarding maternal deaths describe the epidemiology of teenage pregnancy in the UK, identifying local and national measures that can be taken to reduce teenage pregnancy 78 2. Screening apply the WHO (Wilson and Junger) criteria for screening to the following programmes and discuss, using their knowledge from their clinical teaching whether these programmes are likely or unlikely to fulfil the criteria: cervical screening, breast screening, antenatal screening identify social and health service factors associated with low uptake of screening and strategies that can be adopted to improve uptake outline how screening programmes can be audited and evaluated interpret data concerning the sensitivity, specificity and positive predictive value of tests used for the above screening programmes and demonstrate an understanding of how they influence what information should be given to patients if they undergo screening tests 3. Health promotion describe primary, secondary and tertiary prevention of the following conditions, demonstrating an understanding of measures that can be taken at an individual and population level to reduce the incidence and/or prevalence of: sexually transmitted disease, unplanned pregnancy, neural tube defects, intrauterine growth restriction, perinatal mortality; 4. Infectious diseases describe the epidemiology and prevention of sexually transmitted disease 5. Health Services describe current important demographic changes in the UK and internationally discuss how demographic changes in the UK could impact on the prioritisation of health services in the UK list factors that should be considered when deciding whether to invest resources in a new drug treatment or health service Students are reminded that the public health sciences does not wish to overburden students with factual knowledge. However students are expected to be able to apply basic epidemiological, public health, sociological and economic principles to the conditions above using their medical knowledge to identify the issues that might be of relevance for that condition 79 11.4 Orientation The blocks and campuses to which you have been allocated are displayed on the Phase 4 Virtual Campus before the start of each rotation. • This section briefly outlines progression through the Block and any relevant sub-blocks and disciplines. • Any changes to the timetable will be posted on the Virtual Campus and students will also be notified by email. Please ensure that you check both regularly. http://virtualcampus.kcl.ac.uk/vc/medical.htm and click on MBBS 4 for up-to-date course information Guy’s and St. Thomas’ Campus Students are allocated to rotation sets. Students will rotate through the following modules: Module 1 Genitourinary Medicine 2 Obstetrics and Gynaecology 3 Breast Medicine 4 Outside Attachment in Obstetrics & Gynaecology Week Rotation 1 Rotation 2 Rotation 3 Set Set A B Tuesday Thursday Thursday B 1 OG 11/09/12 03/01/13 04/04/13 2 17/09/12 07/01/13 08/04/13 GU GU 3 24/09/12 14/01/13 15/04/13 P B 4 01/10/12 21/01/13 22/04/13 P OG 5 08/10/12 28/01/13 29/04/13 P OG Tuesday 6 15/10/12 04/02/13 OG OG 07/05/13 7 22/10/12 11/02/13 13/05/13 OG OG 8 29/10/12 18/02/13 20/05/13 OG OG Tuesday 9 05/12/12 25/02/13 OG P 28/05/13 10 12/12/12 04/03/13 03/06/13 OG P 11 19/12/12 11/03/13 10/06/13 OG P 12 26/12/12 18/03/13 17/06/13 OG OG 13 03/12/12 25/03/13 24/06/13 Key GU OG B P Set Set C D OG OG Set E OG Set F OG Set G OG Set H OG Set I OG Set J OG Set K OG GU OG B OG OG GU OG OG B P GU P P P B GU OG OG OG OG GU OG OG OG OG GU OG OG OG P GU P P P OG GU OG OG OG P GU OG OG OG P OG OG P P P OG OG OG OG B OG P OG B P P P B OG OG OG P P OG P P OG OG OG P P OG B OG OG P P OG OG OG OG OG OG OG OG Rotation 1& 2- Reading week; Rotation 3 Written Assessment OG B OG OG OG B P P OG Peripheral Attachments in Obstetrics and Gynaecology Students will be given information by e-mail and referred to the relevant pages of the Virtual Campus for further information. 80 King’s College Hospital Campus Students will receive their own individual timetable. Students will rotate through the following modules: Module Gynaecology Genitourinary Medicine Breast Medicine/Outpatient Gynaecology Outside Attachment in Obstetrics & Gynaecology Week Rotation 1 Rotation 2 Rotation 3 Tuesday Thursday Thursday 1 11/09/12 03/01/13 04/04/13 2 17/09/12 07/01/13 08/04/13 3 24/09/12 14/01/13 15/04/13 4 01/10/12 21/01/13 22/04/13 5 08/10/12 28/01/13 29/04/13 Tuesday 6 15/10/12 04/02/13 07/05/13 7 22/10/12 11/02/13 13/05/13 8 29/10/12 18/02/13 20/05/13 Tuesday 9 05/12/12 25/02/13 28/05/13 10 12/12/12 04/03/13 03/06/13 11 19/12/12 11/03/13 10/06/13 12 26/12/12 18/03/13 17/06/13 13 03/12/12 25/03/13 24/06/13 1 2 3 4 Rotation 1& 2- Reading week; Rotation 3 Written Assessment For the first day of each module, students are to report to Mr Mike Marsh, Seminar Room, 9th Floor, Ruskin Wing, King's College Hospital. For details on HIV/GUM week (week 2) please refer to the relevant section of your introductory handout. Peripheral Attachments in Obstetrics and Gynaecology Students will be given information by e-mail and referred to the relevant pages of the Virtual Campus for further information. 81 Princess Royal University Hospital Campus Students should report to the Education Centre at 8.30am on the first day where there will be a short induction tour and students will receive individual timetables and information relevant to their rotation. Students will rotate through the following modules: Module 1 Genitourinary Medicine (at GST) ) – Weeks 1 & 2 2 Obstetrics and Gynaecology 3 Breast Medicine Week Rotation 1 Rotation 2 Rotation 3 Tuesday Thursday Thursday 1 11/09/12 03/01/13 04/04/13 2 17/09/12 07/01/13 08/04/13 3 24/09/12 14/01/13 15/04/13 4 01/10/12 21/01/13 22/04/13 5 08/10/12 28/01/13 29/04/13 Tuesday 6 15/10/12 04/02/13 07/05/13 7 22/10/12 11/02/13 13/05/13 8 29/10/12 18/02/13 20/05/13 Tuesday 9 05/12/12 25/02/13 28/05/13 10 12/12/12 04/03/13 03/06/13 11 19/12/12 11/03/13 10/06/13 12 26/12/12 18/03/13 17/06/13 13 03/12/12 25/03/13 24/06/13 Rotation 1& 2- Reading week; Rotation 3 Written Assessment Queen Elizabeth Hospital Campus Students will be issued with a detailed site-specific timetable on arrival at QEH. Please report to the Education Centre (located at the West Entrance of the hospital opposite the Conference Centre) at 9.15 am on the first day of your clinical rotation. The first Tuesday and Thursday of each rotation will be induction days. Students will rotate through the following modules: Module 1 Genitourinary Medicine (at GST) – Weeks 1 & 2 2 Obstetrics and Gynaecology 3 Breast Medicine Week Rotation 1 Rotation 2 Rotation 3 Tuesday Thursday Thursday 1 11/09/12 03/01/13 04/04/13 2 17/09/12 07/01/13 08/04/13 3 24/09/12 14/01/13 15/04/13 4 01/10/12 21/01/13 22/04/13 5 08/10/12 28/01/13 29/04/13 Tuesday 6 15/10/12 04/02/13 07/05/13 7 22/10/12 11/02/13 13/05/13 8 29/10/12 18/02/13 20/05/13 Tuesday 9 05/12/12 25/02/13 28/05/13 10 12/12/12 04/03/13 03/06/13 11 19/12/12 11/03/13 10/06/13 12 26/12/12 18/03/13 17/06/13 13 03/12/12 25/03/13 24/06/13 Rotation 1& 2- Reading week; Rotation 3 Written Assessment 82 University Hospital Lewisham Campus Students will be given their own individually designed and tailored timetables on the first clinical day. Students will rotate through the following modules: Rotation 1 10/09/1207/12/12 Mon 10/09/12 Rotation 2 02/01/1329/03/12 Weds 02/01/13 Rotation 3 02/04/1328/06/13 Tues 02/04/13 Clinical Rotation 11/09/1230/11/12 03/01/1322/03/12 02/04/1321/06/13 Seminars From Tue 11/09/12 From Thurs 03/01/13 From Thurs 04/04/13 Symposia (Wednesday) From Wed 12/09/12 From Mon 07/01/13 From Wed 03/04/13 Course dates Introductory Day 83 Time and Venue Morning Programme (see VC for details) Afternoon Symposium: from 2pm (see VC for timetable) Collect individual timetables on first clinical day. Meet Samantha Newman at 9:30am in the Education Centre to collect Induction Packs Seminars take place in weeks 3 - 12 inclusive. Please see UHL timetable for details See VC for Symposia timetable 11.5 Outside and Overseas Attachments A three week peripheral attachment will be part of the Reproductive and Sexual Health Block for the Obstetrics and Gynaecology module for students based at KCH and GST. This will either be a placement at a DGH* allocated by the Academic Centre, or at an overseas twinned institution via the Exchanges Office, or an independently arranged placement (the deadline for these latter two options was earlier in 2009). Students based at PRUH and UHL obtain similar clinical experience at these campuses. *Placements will be at one of the following hospitals: St Richard’s Chichester, Eastbourne, Queen Elizabeth the Queen Mother Margate, Maritime Medway, Poole, Queen Mary’s Sidcup, Queen Elizabeth Woolwich, Worthing. Health-screening and Immunisation requirements for DGHs Most DGHs require you to present them with evidence of relevant vaccinations/status: .HepB, HepB surface antigen, Rubella & MMR vaccinations. Hep C, HIV, VzV,& TB Status. You cannot commence on the wards without health clearance. You must therefore make an appointment with Occupational Health at the beginning of the year, to make sure that this information is immediately available for DGHs. Students must also contact the DGH at least 4 weeks before your placement to see if there are any forms or additional screening is required. Failure to do this will result in you missing your attachment, and therefore failing the block. We advise you to bring a spare copy of your status with you on induction day. Occupational Health currently test for Hepatitis B antibodies, Rubella antibodies, and evidence of T.B. vaccination. Chicken pox antibodies are only tested for if the student does not have a positive history of the disease. Please ensure that you regularly check the DGH section on the Virtual Campus and your email for up-to-date details on what is required for your allocations 84 11.6 Symposia Information In the Reproductive and Sexual Health block, your first symposium will be on the introductory day of the rotation. Following that, you will have a symposium every Wednesday morning. Please see the Virtual Campus for an up-to-date symposia timetable for your RSH block. Topics covered by the RSH symposia are: Reproductive & Sexual Health History and Examination Clinical Aspects of Breast Diseases Pregnancy in Perspective Termination of Pregnancy Clinical Ethics and Law Prescribing and Breastfeeding in Pregnancy Abnormal Cervical Smear / Pelvic Pain Gynaecological Cancers How to Practice Medicine and Stay Out of Jail Genetics 11.7 Aims and Objectives for Symposia By the end of each symposium you should have achieved the following learning objectives: • Discuss the importance of the Triple Approach Reproductive and Sexual History and Pelvic to breast diagnosis Examination • Discuss the different treatment pathways for malignant breast disease Organiser: Ms Deborah Bruce • Understand how radiological and pathological CC Presentations: None techniques can be used together for the diagnosis of breast problems To learn about the key issues in taking: A gynaecological history A breast health history Pregnancy in Perspective An obstetric history A sexual history Organsier: Prof A Shennan / Mr M Marsh A psychosexual history CC Presentations: 115 To be able to: Perform a pelvic examination and take a To be able to discuss and describe: cervical smear • The aim of caring for pregnant women in the Understand the correct procedure for community examining a pregnant abdomen • A woman’s perspective of pregnancy Clinical Aspects of Breast Diseases Organisers: Dr C Peacock/Mr H Hamed CC Presentations: 40, 41, 42 Termination of pregnancy Organisers: Dr Itty Samuel CC Presentations: 116, 119 To be able to: • Take an appropriate history from a patient presenting with a breast lump • Discuss the concerns/fears that a patient may have when presenting with a breast lump • Carry out a clinical examination of the breast • Describe (briefly) the epidemiology of termination of pregnancy in the UK • Explain the law in relation to the termination of pregnancy in the UK • Describe the role of contraceptive services in the prevention of unplanned pregnancy To be able to: Opportunity to Explore personal feelings around Termination of Pregnancy • Describe the techniques of termination of pregnancy according to duration of pregnancy Clinical Ethics and Law Organiser: Mr P Haughton CC Presentations: All RSH • To be able to discdouguss the normative dimensions of clinical decisions, so that 85 (a) they are able to identify which aspects of decisions are technical in nature and what are ethical and (b) they are able to assess how technical and ethical aspects relate to each other • To develop and acquire skills in analysing the normative dimension of clinical decisions (identifying moral principles and rules; critically analysing moral arguments) • To develop and acquire skills of exploring and justifying personal decisions regarding ethical issues as they arise in specific clinical contexts • To be able to discuss the interface between clinical topics and ethical issues • The main problems which may face a patient as a result of commencing anti-HIV (antiretroviral) treatment Prescribing in Pregnancy Breastfeeding Organiser: Dr S Clarke CC Presentations: 115 and List the differential diagnosis of pelvic pain List the sequelae associated with different causes of pelvic pain Take a relevant history from a woman with pelvic pain Describe how different elements of the history discriminate between causes of pelvic pain Describe different findings on examination which discriminate between different causes of pelvic pain Explain indications for carrying out further investigations and how these investigations are useful Describe appropriate management for each cause of pelvic pain Identify which causes of pelvic pain are preventable and strategies to prevent them Gynaecological cancers Organiser: Dr G Culora / Dr A Winship CC Presentation: 113, 114 during To be able to: • Describe the presentation and management of the most important gynaecological cancers (invasive cervical squamous carcinoma, endometrial adenocarcinoma, and surface epithelial tumours of the ovary) • Describe the basic clinical pathology, including the principles of tumour staging • Describe the role of imaging (MRI and other modalities) in the pre-treatment staging of gynaecological cancer and in follow up • Describe the relative roles of surgery, radiotherapy and chemotherapy in the management of these cancers •Talk to and learn from the experiences of cancer patients under current therapy To be able to describe: • pharmocokinetics and pharmakodynamics in pregnancy • Importance of good prescribing in pregnancy •Common disorders and prescribing principles • Drug and alcohol misuse in pregnancy and whilst breast-feeding • Epilepsy and asthma medication during pregnancy and with breastfeeding •Management of thrombo-embolic disease in pregnancy Abnormal Cervical Smear and Pelvic pain Organiser: Dr Ali Kubba CC Presentations: 7b, 114, 117 How to practise medicine and stay out of jail Organiser: Ms R Cochrane CC Presentations: 111, 113, 115, 119 To be able to: • List the pros and cons of cervical screening • Explain the objectives of the National Cervical Screening Programme • Describe the cervical transformation zone and explain its significance • Define dyskaryosis and explain its significance • Describe patient attitudes to cervical screening, their response to both a normal and abnormal smear results and to discuss informed consent in relation to this test • Explain the importance of HPV in cervical pathology • Explain the importance of colposcopy to detect and treat cervical pathology Describe the health promotion opportunities in a cervical screening consultation Describe the epidemiology of pelvic pain To be able to: • Describe the concepts of risk management in general, including good note-keeping, the use of agreed protocols, informed consent, preventative action in high-risk cases • Describe the mechanisms for dealing with difficult cases and complaints • Discuss the skills relating to risk management Genetics Organisers: Dr Dragana Josifova CC Presentations: 11b At the end of the symposium, students should have achieved the following: 86 To be able to estimate risk of fetal abnormality in a pregnancy from family history of genetic disease and other relevant information To understand the uses and limitations of DNA testing in pregnancy To understand the concept of linkage and its uses in pre-natal diagnosis To understand the uses and limitations of different invasive tests in pregnancy, including chorionic villous biopsy, amniocentesis and cord blood sampling To understand the use of ultrasound scanning in the pre-natal diagnostic setting To understand the issues involved in screening tests in pregnancy To be aware of the different forms of chromosomal abnormalities that can arise, their clinical effects and significance to other family members To understand the ethical issues surrounding different aspects of pre-natal testing for genetic disease Medical disorders in pregnancy Organiser: Dr K Harding At the end of the symposium students will be able to describe A systematic approach to women with medical disorders How to counsel women prior to pregnancy to achieve optimum outcome The long term affect of illness on reproductive health To demonstrate an understanding of how pregnancy affects maternal physiology and the impact on maternal health Examples of models of illness will include diabetes, maternal cardiac disease, sickle cell disease and cancer 87 11.8 Seminar Titles Obstetrics • Maternal physiology in pregnancy and labour 115 • Pre-pregnancy counselling 115, 11(B) • Anaemia in pregnancy 115, 5 • Hypertension and Proteinuria in pregnancy 2(B), 10 • Antepartum haemorrhage 2, 10, 111, 5(B) • The anomaly scan and prenatal diagnosis 115, 116, 11(B) • The Booking visit / Normal antenatal care 115 • Monitoring the fetus 115 • The management of labour/delivery 115 • The third stage and puerperium 115, 134 • Prematurity (non-core) • Preterm birth (non-core) • Medical disorders in pregnancy • Domestic violence Gynaecology • Menstrual disorders 113, 114, 5(B) • Subfertility 19, 53, 54, 112, 113, 118 • Urinary problems 28, 30, 31, 32, 33 • Uterovaginal prolapse 26 • Dysmenorrhoea: Chronic pelvic pain and endometriosis 11, 113, 114 • Acute pelvic pain including cysts 10, 110, 112 • Pelvic mass 10, 11, 12, 13, 115 • Amenorrhoea 112, 113, 115, 118 • Miscarriage and ectopic pregnancy 112, 113 • Menopause and osteoporosis 1, 89, 91, 112, 6(B) • Female genital mutilation Gynaecology oncology Genitourinary & psychosexual medicine • HIV infection: Clinical manifestations of early disease and the principals for antiretroviral therapy 3, 5, 6, 16, 17, 19, 23, 62 • HIV infection: Clinical Manifestations of advanced disease 61 • Sexual History Taking (Communications Skills and Genitourinary Medicine/The pre and post HIV test discussion) 56, 57 • Genital Ulcer disease/Genital Dermatoses 48, 105, 106, 109, 122 • Female Genital Mutilation (None) • Psychosexual Medicine 56, 57 2 Breast medicine • Imaging, diagnosis and screening 40, 41, 42, 43 • Pathology and natural history of breast cancer • Treatment of breast cancer For Seminar Aims & Objectives please refer to the RSH Block - Seminar Guidelines booklet 3 11.9 Recommended Reading and Computer-aided learning Please refer to the Reading List online. https://readinglist.kcl.ac.uk/module.cgi?module=117MBBS4 4 12. VERTICAL STRAND DISCIPLINES 12.1 An Overview 91 12.2 Course Organisers and Contact Details 94 12.3 Recommended Reading and Computer-aided Learning 95 5 12.1 Vertical Strand Disciplines: An Overview Clinical Genetics In Phase 4, you should be able to apply the knowledge of basic genetics and modes of inheritance gained in Phase 2 to clinical situations. The Clinical Genetics course consists of 2 genetics symposia included in the CHDA and RSH blocks. The symposia are a balance of clinical lectures and small group tutorials. These cover the important areas within clinical genetics which are applicable to all branches of medical and surgical practice. Attendance at 1 genetics outpatient clinic in the RSH block is optional. Some important aspects of clinical genetics, especially the basic approach to a genetic consultation and the communication skills used, can only be learnt in the genetics clinic. Only one student can sit in on each consultation which is also a one to one tutorial. The student should therefore book in advance by signing up online. Details of available clinics/relevant links will be emailed and posted on the VC. Alternatively, telephone the department on 0207 188 1364, or come in person to reception in the Department of Genetics on the 7th Floor of New Guys House. A range of SSCs are also available in Genetics. Each SSC consists of individually supervised project, and provides the opportunity to participate in on general and specialist genetics clinics. Dr Dragana Josifova Department of Genetics Guy’s Hospital Clinical Pharmacology and Therapeutics Understanding the principles of clinical pharmacology is essential for safe and effective clinical practice. You should learn the general principles of the subject, and how these are applied in the management of common clinical conditions. In Phase 4, there will be three relevant symposia, one in each block (on drugs at the extremes of age, drugs in pregnancy, and on the therapeutic aspects of movement). In learning about therapeutics of common acute and chronic diseases you should integrate your knowledge of the mechanism of drug action (basic pharmacology) with relevant pathophysiology. Think about therapeutic goals (e.g. alleviating symptoms, slowing disease progression etc) for classes of patients and for individual patients. Learning clinical pharmacology is effective only if accompanied by clinical experience: it is a practical subject and the patient is the best teacher. Always take a drug history, always read the prescription chart of in-patients and review medications being taken by outpatients. Learn about these drugs as you encounter them and you will rapidly build up your knowledge of drugs used in current practice. For each such drug, learn about clinical use, mechanisms of action, adverse effects and contraindications, relevant pharmacokinetics (i.e. relevant to clinical use, route of administration and frequency of administration) and clinically important drug interactions. Special situations (e.g. the use of drugs at extremes of age, in pregnancy, or in-patients with coexisting disease of major organ systems) are particularly relevant in the context of Phase 4. Prof Jim Ritter & Dr Albert Ferro Department of Clinical Pharmacology St Thomas’ Hospital Communication Skills The integrated Communication Skills course reinforces the value and need for effective communication in healthcare and encourages ethical communication practice. You have already acquired core skills in communicating with patients and will be expected to develop and add to these skills throughout Phase 4. Two symposia offer communication skills training: one in the Child Health, Development and Ageing Block entitled Communicating with the Young, Elderly and Relatives, and one entitled Dealing with Crisis in the Emergency Medicine, Trauma and Locomotion Block. An introductory session in the Reproductive and Sexual Health Block will cover communication relating to taking sexual histories and intimate examinations. Sessions will involve small group work, directed reading, video and role-play using actors. Additional sessions on communication skills will be available during Phase 4 through a 6 rolling programme. These will be offered on a sign up basis in the Skills Centre, and will be shared with nursing students nearing finals and newly qualified nurses. You will need to check the notice board in the reception of the Chantler Clinical Skills Centre for topics and to sign up. Ms Elaine Gill Chantler Clinical Skills Centre Shepherd’s House Guy's Campus Ethics and Law Phase 4 has a substantial ethical element. Key concepts acquired in the Practice of Medicine course (Phases 1&2) are put into effect. Thus while the focus in the early years was understanding concepts such as personal autonomy, capacity, competence and liberty, in Phase 4 the aim is to apply them in practice. The formal delivery of Ethics takes place through the symposia programme as well as informally within the context of clinical learning and reflection. Topics covered include the ethical and legal issues within such topics as abortion, decision making with the young and elderly, HIV, screening, sub-fertility, suicide, and transplantation. Ethics will be assessed in the OSCE. Peter Haughton Department of Medical and Dental Education 4th floor, Henriette Raphael House Guy’s Campus Palliative Medicine In Phase 4 students will be introduced to the clinical aspects of the care of patients with advanced disease, building on the teaching that students have had in the previous three years. The focus of Palliative Medicine in Phase 4 is on the care of the dying patient, the principles of symptom control and the pharmacology of drugs to treat pain and other symptoms. This is undertaken through symposium teaching (care of the dying patient, chronic pain), a seminar (symptom control) and the opportunity to join a clinical session (either in outpatients or on a ward round.) These aspects of Phase 4 will be assessed in the written papers and OSCE. Dr Polly Edmonds Palliative Care Team King’s College Hospital Pathology and Laboratory Sciences The aim of the pathology teaching in Phase 4 is to build on your basic science knowledge derived from the Scientific Basis of Disease Course in Phase 2, the general clinical pathology learned in Phase 3, and apply this to further clinical settings. You should aim to increase your understanding of the pathological processes of patients you encounter, develop data interpretation skills, and begin to appreciate the optimum use of clinical laboratory services. Histopathology and the other laboratory sciences will be integrated into Phase 4 symposia with contributions from the following specialties: histopathology, cytopathology, forensic pathology, embryology, chemical pathology, haematology, infection, immunology and toxicology. 7 Primary Care, the Community Study and applied health promotion Primary Care, the Community Study, applied health promotion and consolidation and reveiw Please note you will be issued with a specific handbook at the Phase 4 opening session in September. In Phase 4, you will participate in a Community Study where, in pairs, you will visit a pregnant woman and her family to follow progress from pregnancy to the birth and early months of the child. The Community Study aims to provide you with an opportunity to develop a relationship with a family over time enabling you to: Study the impact of pregnancy, childbirth and a new baby on the physical, social and psychological health of a mother and her family. Learn about the growth and development of a baby in the early months of life. Make links with hospital based learning by looking at several core curriculum topics, relevant to all three rotations, from the perspectives of the woman, her family, primary care and the community. Reflect on and discuss related social and ethical issues. Develop communication skills and professional attitudes Be aware of the role of health promotion during this time The study occupies four Fridays and students are allocated to either Steam A or B. You will be advised of the actual dates but in principle stream A students Friday week 2 rotation 1, Week 1 rotation 2, week 11 rotation 2 and week 1 rotation 3 ( assessments). Stream B Week 13 rotation 1, week 6 rotation 2, week 12 rot 3 and week 2 rotation 3( assessment). During each day, you and your partner will visit the mother and baby in the morning, followed by a tutorial with your GP, and then meet for an afternoon seminar in the SLC except on day 2. A reading list will be provided as preparation for the first and second seminars. In addition you will in pairs review a l health promotion intervention and report this review in presentation format to your assigned practice on your assessment morning. In order to help with this, and to prepare for relevant sections of the Elective SSC, a symposium will be held early morning 4th Jan 2012. You will be allocated time during your community days for the health promotion review. The study will be assessed in the Student Learning Centres with students presenting in pairs their learning from the study. This will take place in April 2012 with the seminar leader. In addition there will be end of phase 4 OSCE stations based on the study. The sessions with your GP tutor will be the only contact that you have with primary care in Phase 4. As GPs deal with many of the problems pertaining to maternal and child health, this provides a valuable opportunity for you. Also, this is the only part of the course in which you will have the opportunity to study a patient over an extended period of time. The Consolidation and review sessions will be in Rotation 3 on two Fridays and will enable you to self select topics to revisit enabling you to hone and practise your skills with patients in various settings covering a range of conditions associated with Phase4, and use the mini-Cex with your GP tutor. Ann Wylie, Senior Teaching Fellow Department of Primary Care and Public Health Sciences Guy’s Campus 8 12.2 Course Organisers and Contact Details Module Clinical Pharmacology and Therapeutics Communication Skills Ethics and Law Genetics Course Organiser Dr Jackson [email protected] Ms Elaine Gill 020 7848 6350/3 [email protected] Ms Bernadette O’Neill 020 7848 6354 bernadette.o’[email protected] Peter Haughton 020 7848 6993 [email protected] Dr Dragana Josifova [email protected] Palliative Medicine Dr Rachel Burman [email protected] Primary Care and the Community Study Dr Ann Wylie 020 7848 8075 [email protected] 9 12.3 Recommended Reading and Computer-aided learning Clinical Pharmacology and Therapeutics Recommended Reading: A Textbook of Clinical Pharmacology. (4th ed). 1999. Ritter JM, Lewis LD, Mant TG, Arnold. London. British National Formulary Pharmaceutical Society of Great Britain. Available from the Academic Centre and on-line at www.bnf.org Communication Skills • Recommended to purchase: Silverman J, Kurtz S & Draper J [1998] Skills for Communication with Patients. Radcliffe Medical Press • Reference : Doyal L, & Wilsher D. [1994] Witholding and Withdrawing Life Sustaining Treatment from Elderly People: Towards Formal Guidelines. British Medical Journal Vol. 308: 1689-1692 Lipp [2nd ed. 1995] Respectful treatment Maguire P [2000] Communication Skills for Doctors. Arnold Murray Parkes C, Markus A (eds) [1998] Coping with Loss: helping patients and their families. BMJ Publishing Platt F W, & Gordon GH [1999] Field Guide to the Difficult Patient Interview. Lippincot, Williams and Wilkinson (especially Part III – Dealing with Patient Emotions). Ostergaad, MS. [1998] Childhood Asthma: parents’ perspective – a qualitative interview study. Family Practice 15: 153-157 Stewart K [1995] Discussing cardio-pulmonary resuscitation with patients and relatives. Postgraduate Medical Journal 71: 585-589 Ethics and Law New Dictionary of Medical Ethics. 1997. Boyd Pinching and Higgs (Eds). BMJ. Medicine, Patients and the Law, 2nd ed. 1992. M Brazier: Penguin Causing Death and Saving Lives. 1990. J Glover, Penguin The Value of life, An Introduction to Medical Ethics, 1985. J Harris: RKP Should the Baby live? 1985. Kuhse & Singer: Oxford Pathology Histopathology General and systematic pathology. 3rd ed. 2000. Underwood J. Churchill Livingstone. Microbiology Notes on Medical Bacteriology (Student notes): JD Sleigh & MC Timbury, 5th edition, 1998 Microbiology in Clinical Practice: DC Shanson, 3rd edition, 1999 Human Virology: 2nd ed. 2000 L Collier & J Oxford, Principles and Practice of Infectious Diseases: Mandell, Bennett & Dolin, 5th edition, 2000 Haematology Essential Haematology. Hoffbrand AV, Pettit JE. 4th edition 2001. Blackwell Scientific Publications Paediatric Haematology. Lilleyman, Hann & Blanchette. 2nd edition 1999. Churchill Livingstone ABC of Transfusion. Contreras. 3rd edition 1998. BMJ Books Clinical Haematology. Wintrobe MM. 10th edition, 1999. Lea & Febiger, Philadelphia Chemical Pathology Clinical Chemistry (4th ed.) 2000. Marshall W J. Mosby. Lecture Notes on Clinical Chemistry. 5th ed. 1993 Whitby LG, Percy-Robb IW & Smith AF. Blackwell, Oxford. A Workbook of Clinical Chemistry, case presentations and data interpretations. 1994. Mayne PD, Day AP, Arnold E. Cases in Chemical Pathology - A diagnostic approach. 4th ed. 1999. Walmsley RN, Watkinson LR, Koay ES. 10 Disorders of Fluid and Electrolyte Balance. 1984. Walmsley RN, Guerin MD. Immunology Medical Immunology for Students. Playfair JHL and Lydyard PM (1995) Churchill Livingstone Essentials of Clinical Immunology (4th ed) 1999. Chapel H, Haeney M, Misbah S and Snowden N. Blackwell Scientific Publications. (also available on-line at www.netlibrary.com) Medical Immunology (7th ed): 1997. Stites DP, Terr AI (1987) Appleton and Lange Immunisation against infectious diseases. 1996. HMSO Primary Care and the Community Study The Pregnancy Book 1999 published by the Health Education Authority Birth to Five 1999 published by the Health Education Authority Public Health Medicine Essential public health medicine. 2nd ed. 2000 Donaldson & Donaldson. Lecture notes on epidemiology and public health medicine. 4th ed. 1996. Farmer & Miller Clinical epidemiology: the essentials. 3rd ed. 1996. Fletcher, Fletcher & Wagner Clinical epidemiology: a basic science for clinical medicine. 1991. Sackett et. al. 11 13. STUDENT SELECTED COMPONENTS For details of SSC assessment, merits, credits and annual progression requirements please consult the SSC regulations on the Virtual Campus. Students in Phase 4 are expected to complete two SSCs. In rotation 1 you will take a taught SSC, a library project, a self designed SSC or a language SSC. In rotation 2 you will complete the Elective Portfolio. Guidelines for the portfolio can be found in the Elective Handbook which will be available in the first rotation. For students who are repeating Phase 4: You are required by the King’s College London Regulations to repeat the year in its entirety and that includes the 2 SSCs. If you have already completed your Elective at the end of last Phase 4 then you will need to do an alternative SSC in rotation 2 instead of the Elective Portfolio SSC. We advise you to choose a clinically based SSC in any Phase 4 subject with which you have found difficulty in the past. You are advised to discuss this with your Clinical Adviser and with Rachael-Morriss Jones, Deputy Head of Phase 4 as soon as possible in rotation 1. Elective Portfolio SSC The elective SSC has a total value of 2 SSC units. In rotation 2 of phase 4 you will complete the elective portfolio SSC which is worth 1 SSC unit. You should start to think about your elective at the beginning of Phase 4 and read the elective handbook which contains essential information about planning your elective, travel advice and writing your elective portfolio. You should make two appointments to see your Clinical Advisor during the second rotation. At the first appointment you should discuss your provisional plans and your Advisor should sign the Elective Proposal Form, which should be submitted by early Feb 2013 (Check VC/Elective Handbook for date details). At the second appointment you should discuss a draft of your Elective Portfolio. The Elective Portfolio must be submitted to the Academic Centre by early April ((Check VC/Elective Handbook for date details), unless there are mitigating circumstances in which case you should discuss beforehand with the Academic Centre and your Clinical Advisor. Please consult your Elective handbook for more details. Primary Care and Community Study Days In Phase 4, you will participate in a Community Study (see section on Vertical Strands for more information). The 4 Fridays that this takes place on are not SSC days and your supervisor will be aware that teaching should not be scheduled on these days. Due to the large size of the student body the cohort will be split into one of two groups for your Community Study. The group that you are allocated to will depend on your SSC allocation and you should check that your supervisor is aware of these days when you start the SSC. Group A: Community study days on 23rd September 2011, 6th January 2012, 16th March 2012 and 13th April 2012. Group B: Community Study days on 9th December 2011, 10th February 2012, 23rd March 2012 and 20th April 2012. 12 14. ASSESSMENTS AND EXAMINATIONS What will the Phase 4 exams be like? There will be two types of examination in Phase 4: written papers at the end of the third Block as an objective in-course assessment and a comprehensive Objectively Structured Clinical Examination (OSCE) at the end of Phase 4. Written examination There will be three 2 ½ -hour written papers at the end of the third Block which will include all the subjects taught in Phase 4. This will include single best answer questions and extended matching questions. Questions may include photographs, clinical histories or investigation results as the introduction and then a series of choices for you to choose the best one. There will be no negative marking for incorrect answers. These assessments are not competitive but the graded marks you will be awarded will reflect your performance against a standard set by the Board of Examiners. The content of the papers is based on the core curriculum for the subjects taught in the Blocks including the symposia as well as the vertical strands: public health medicine, pathology, communication, ethics and law, therapeutics, palliative medicine, genetics and clinical science with which they are integrated. A comprehensive knowledge of the common or ‘dangerous if missed’ conditions is expected by your examiners. We hope that very few or no candidates will fail to reach the standard to pass in the written examinations. It will be compulsory to take these examinations. Success in all these written examinations grants exemption from the end of Phase 4 written examinations in July 2012. OSCE There will be a 22 station (19 active stations) part A OSCE over 6 days - from Wednesday 4th July to Wednesday 11th July 2012 with a part B OSCE (24 active stations) around 10 days later (actual date TBC). The End of Phase 4 OSCE will test the skills taught in Phase 4 and will involve material from all the constituent subjects of this year including the Community Study. You are expected to be signed-up for all the skills in each of the Phase 4 skills log-book, and ensure you hand in your completed books at the required deadline.. If you lose your log-book please contact the Phase 4 Academic Centre contact or the Head of Phase 4 ASAP. YOU ARE REMINDED TO PHOTOCOPY YOUR LOGBOOK. What if you fail to achieve the standard to pass in the Block examinations? If you do not reach the pass mark in one or more of written examination(s), you will not be exempt from the written examination for that Block or Blocks in July. If you fail any July examination you will fail the year.. In exceptional circumstances, with documentary evidence of incapacitating illness, you may be allowed to miss a written examination and take it at the next available opportunity i.e. in July. What if you fail to achieve the standard to pass the OSCE? If you do not reach the minimum competence level for the OSCE you will fail the year. In exceptional circumstances, with documentary evidence of an incapacitating illness which might prevent you from sitting the OSCE at the correct time, attempts will be made to allocate you to a session late in the OSCE week. If this is not possible, a replacement OSCE will take place after the July written examinations. Failure to take or pass the OSCE will necessitate your failing the year.. 13 What if you do really well in one Block but badly in another? There is no process for carrying over marks between the Blocks. You must achieve the pass mark for all three written examinations. However the vertically integrated subjects of public health medicine, palliative medicine, pathology, communication, ethics and law, therapeutics, genetics and clinical science will be tested within each of the papers. What if you do really well in these examinations? Excellent performance will be rewarded by a nomination for a commendation in that subject. . Full information about the regulations governing the assessment in Part 4 can be seen in the Part 4 Marking Guide which is can be found on the Virtual Campus. Will you get any feedback on your performance? Yes, details of your performance in the subjects of the examinations will be reported back to you. Although the pass mark is not calculated in a competitive way, it can be useful for you to know how well you performed compared with your peers. We will supply you with a centile score for each subject and an accumulation of the scores on questions which test elements from the vertical strands following the last Block examination in the year. We hope that this will be a guide to your future studying tactics. If you felt that you worked really hard but achieved only low centile scores it would be worth discussing your study methods with your Clinical Adviser or book an appointment with the Education Advisers. 14.1 PHASE 4 MARKING SCHEME 2012-13 The Phase 4 Marking Scheme is available each year in the Exam Information section of the Virtual Campus. You should familiarise yourself with these at the beginning of the year. 14.2 REGULATIONS FOR THE DEGREES OF BACHELOR OF MEDICINE AND BACHELOR OF SURGERY (MB BS) 2012-13 The regulations governing the MBBS degree programme that you are currently following are updated each year and placed on the Virtual Campus in the Exam Information section. You should familiarise yourself with these at the beginning of the year. 14.3 MITIGATING CIRCUMSTANCES You will find full information on the mitigating circumstances regulations here: either http://www.kcl.ac.uk/college/policyzone/index.php?id=280. http://www.kcl.ac.uk/college/policyzone/assets/files/students/MCF_11_12_Final.pdf Please note that the School Examination Board deems any student who attended an assessment to have declared themselves fit to take that assessment. It is therefore only in extremely rare cases that retrospective withdrawal is approved. All students are expected to take responsibility for judging whether they are genuinely unfit to take an assessment, seeking appropriate pastoral and regulatory guidance over any concerns and following the appropriate procedures. 14.4 ACADEMIC REGULATIONS The College’s full set of Academic Regulations is available here: http://www.kcl.ac.uk/about/governance/regulations/acregs. These should be read in conjunction with the MBBS Marking Scheme, Regulations and your handbooks and logbooks. 14 15. EXAMPLE QUESTIONS There are a number of question formats, which may be used in the End of Block and End of Year Written examinations. To illustrate the types of questions and to provide you with some potentially lifesaving revision of road knowledge and skill here are some examples of these formats. Single-Best-Answer questions Another format of this type of question with an initial stem followed by a series of words or phrases is the Single-Best-Answer question. These are particularly useful for testing decisions between fairly close options and for descriptions of photographs or figures. One answer only is awarded marks and if more than one answer is given by candidates then zero is awarded even if one of the answers would have been correct. This is why it is essential that you read the questions very carefully. Example of Single-Best-Answer question: 4. When you are driving at 70 mph, which ONE of the following stopping distances (a combination of both thinking distance and braking distance) is most likely: (a) (b) (c) (d) (e) 18 car lengths 6 car lengths 9 car lengths 24 car lengths 13 car lengths 4. Answer Key (d) 5. Following a collision of two cars on a motorway, one car is lying on its side on the grass verge. You are a medical student travelling in a car 500m back. Your driver stops on the hard shoulder and you note that no one seems to be coming to help. Your driver is phoning the emergency number, your highest priority is to: (a) (b) (c) (d) (e) maintain the airways of any casualties record the positions of the cars and any casualties ensure your own safety light cigarettes for casualties who are suffering from shock claim a fee for medical assistance from casualties’ insurance company 5. Answer Key (c). Hopefully you had to really think whether to opt for (a) or (c). This type of question often contains close options where you need to analyse the introductory stem very carefully for evidence to help make you decision. The above example clearly states that no one else is helping and your colleague is making the essential call. It also easy to put a series of these Single-Best-Answer questions together following an introductory case description or a series of photographs or xrays. Extended Matching Questions This format uses an initial list or menu of options from which you choose after reading a number of clinical vignettes or questions. Continuing with our road travel revision but keeping the concept of a menu in mind, here is an example of an Extended Matching Question: Example of Extended Matching Question: Theme: food for travelling Options: (a) beef-burger and chips (b) vegetarian salad (c) sushi 15 (d) (e) (f) (g) (h) (i) (j) (k) (l) croissants and strong coffee seafood pasta hot curry and rice fruit salad chicken soup and bread roll steak and kidney pie cheese roll bar of chocolate all day full English breakfast Instructions: For each of the situations described below choose the SINGLE most likely food from the above list of options. Each option may be used once, more than once or not at all. In each of the situations you are a driving up a long motorway with a close friend who is making a telephone call during a stop at the service area. You are in a very long queue to order food and you had forgotten to ask your friend what he/she wanted. You do not have time to leave the queue and your friend cannot be signalled to in the telephone box. Choose the food for your friend which is most likely to be acceptable. 1. a 2. a 3. a 4. a 5. This is the first date with your friend who you met at an animal rights campaign meeting. Your friend is so anxious about obesity that previously you had wondered about an eating disorder. b c d e f g h i j k l You and your friend have just returned to UK after a long elective period in Japan. You have just driven from Strasbourg and caught the 5.30am Shuttle through the Channel Tunnel. You were unable to buy food in France due to lack of francs, your friend is phoning about the rugby tour he is about to organise. b c d e f g h i j k l Your friend has diabetes mellitus and you were both anxious about reaching this service area because you were delayed by having to change a tyre and your friend unwisely had no emergency food rations available but had taken the regular insulin dose. b c d e f g h i j k l You are travelling through France and to save money on overnight accommodation you are alternating driving with your friend as well as crossing the Channel on the night ferry. Two hours driving and two hours sleeping seems to have suited you well but your friend looks tired and its your turn to have a sleep although it is morning. b c d e f g h i j k l Your friend has been very impressed with all the tourist attractions in London and you are driving to Windsor Castle. Your friend has been homesick recently and that is the reason for this telephone call to Japan. You have stopped at one of the best services catering areas around 16 London which has an excellent selection of international food. a b c d e f g h i j k l EMQs are also useful ways of testing clinical photograph recognition skills. Again this could be used to check your knowledge of road signs but it is very easy to substitute clinical photographs or charts either in the menu of options or in the items. Word Substitution Questions This is a version of a series of Single-Best-Answer questions imbedded in a description or technical explanation. They are potentially good tests of understanding and may be introduced increasingly in your examinations. Here is an example Instruction: Select the most appropriate word in the list by entering the letter of that word on the mark sheet. The most ecological transport in cities is by 1(a) pedal-power, (b) lead free petrol, (c) diesel, (d) steam. 1 [a] b c d This is because the main danger to public health from transport is 2(a) accidents, (b) air pollution, (c) teratogens in water, (d) noise. 2 a [b] c d 3 a [b] c d For there to be a major change in city environments there would need to be 3(a) civil war, (b) money to be made on alternative transport, (c) invasion from outer space, (d) global conversion to virtual reality. 17