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Page 30 | Bulletin 93 | September 2015 first two questions, data from the First NELA Patient Report shows that preoperative assessment of risk is associated with improved delivery of subsequent standards of care, such as the presence of consultants for high risk cases, and admission to critical care. The EPOCH trial, based on the NELA dataset, will also provide valuable insight into how improvements in care can be facilitated in hospitals. Quality Improvement, not Audit Whilst the aim of ‘audit’ is to improve patient care by comparing care against standards, anyone who has read national audit reports or other guidelines will often see the same recommendations crop up year after year. The audit process generally involves: ■■ Collecting data for a period of time. ■■ Analysing it against standards of care. ■■ Discovering that ‘we could be doing. better’. ■■ Presenting the results at a departmental audit meeting. ■■ NELA Report Asking everyone to ‘please do better’. ■■ Re-audit again in several months’ time (and discover that not much has changed!). The problem is that the traditional model of ‘clinical audit’ operates on timeframes that are too long, and does not address the underlying reasons why things don’t happen as they should. Quality improvement science aims to address this by emphasising the use of local data to drive small-scale changes, carried out on short timescales. As an audit, NELA compares actual provision of care against standards of care. However, the real improvements in care will only arise if we view NELA as a quality improvement project that allows clinicians to see the results of making small-scale changes. These changes will need to be made in the whole range of pre-, intra- and postoperative areas of care, i.e. perioperative care. Within NELA, we have a role in leading these changes in perioperative care. Taking ownership of this issue will allow us to be formally involved in designing a service that’s fit for purpose, namely one that allows patients to receive the best possible care.
Page 31 | Bulletin 93 | September 2015 Medical students and perioperative medicine: balancing vision and content How do you design a curriculum for perioperative medicine for medical students? Come to that, how do you design any curriculum? It’s not a question most anaesthetists have to grapple with every day, if at all. Ben Shippey Director of the Clinical Skills Centre, University of Dundee School of Medicine Honorary Consultant Anaesthetist, NHS Tayside Andy Norris Consultant Anaesthetist, Nottingham, Head of School, Anaesthetics, Health Education East Midlands Andrew Smith Consultant Anaesthetist, Royal Lancaster Infirmary, Year 4 Undergraduate Lead, Lancaster Medical School At a most basic level, what is taught is determined by where it can be scheduled. So we could start by making sure that every medical student is attached to a department of anaesthesia for at least a week at some stage in their clinical training. So far, so good. But what are we going to do with them when they’re with us? What can we legitimately lay claim to? What can we do that others can do, but don’t do as well? Our contact with undergraduates has to be good for future patient care, but is also about recruitment to the specialty, public image, and promoting an understanding of what we do for those students who will not join our ranks in the future. All undergraduate medical curricula are built around the requirements of the GMC's 'Tomorrow’s Doctors' document, last published in 2009 (http://bit.ly/1C9IIHa). This document, which is structured around three overarching domains (doctor as a scholar, doctor as a practitioner, doctor as a professional), does not explicitly define the skills that are required of newly-qualified doctors in terms of clinical area, specialty, disease or treatment process. This is in contrast to the closely-specified perioperative medicine competencies drawn up by the Royal College of Anaesthetists for our postgraduate curriculum. However, many Royal Colleges and other specialist organisations (amongst them the RCOG and RCR, with the RCPCH on the way) have produced documents outlining what their specialty can contribute, and these are best seen as professionally-generated advisory appendices to 'Tomorrow’s Doctors'. To link perioperative medicine effectively to 'Tomorrow’s Doctors', we need to embed the relevant generically-expressed learning outcomes into the different stages in the care of a patient undergoing surgical intervention. For example, it is relatively straightforward to see how the statement in 'Tomorrow’s Doctors' paragraph 14(g): ‘Respond to patients’ concerns and preferences, obtain informed consent, and respect the rights of patients to reach decisions with their doctor about their treatment and care and to refuse or limit treatment’ is an aspect of medical practice that is relevant to the care of the patient in the preoperative period, and how that at 22(c) ‘Work with colleagues in ways that best serve the interests of patients, passing on information and handing over care, demonstrating flexibility, adaptability and a problem-solving approach’ might be appropriately addressed around the discharge of a patient who has undergone a surgical procedure. Perioperative medicine does not feature, as an entity, in most undergraduate curricula. Elements of perioperative medicine are, no doubt, taught as components of other themes or modules within the curriculum, but are hidden within modules defined by scientific discipline, medical specialty or physiological system. Students compartmentalise knowledge largely according to the labels that are attached to it as a result of where it appears in the curriculum. In order, therefore, for ‘perioperative medicine’ to be recognised as an entity, there would need to be some adjustment to the labelling of modules within undergraduate curricula to reflect that shift in emphasis. More broadly, such an approach both encourages students to think, as we do, outside and across specialty boundaries and to recognise that the labels attached to learning modules have more to do with administrative structures than what patients actually need in terms of healthcare, and how this care is delivered. For instance, an innovative way to teach perioperative medicine would be to link surgery, anaesthesia and primary care through the stages of referral, preoperative assessment and preparation, hospital admission, and postoperative recovery and follow up. At one
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