I think it is important that we get off-line now and again. Read a book. See your family. Go for a walk/run.
At one point today I was on one Skype call, receiving Skype messages, on a separate Microsoft Team meeting, receiving emails, taking phone calls and participating in WhatsApp conversations. And we are still to add comms methods.
Nobody has headspace for that much multi-tasking, multi-comms.
So take a break. Listen to some music. Do something else that downsn’t involve screen time.
I keep hearing the works never waste a crisis. The COVID-19 pandemic certainly fits the bill for the RACP Physicians Exam. In Australia the barrier for junior doctors to progress from basic physician trainees to advanced vocation trainees consists of a multiple choice examination and then for those that pass, a clinical examination consisting of short cases that assess examination skill and long cases designed to assess capacity to manage patients from a problem-based perspective. This year the clinical examination may not be able to be run. Normally held across July/August it could be postponed until October. The problem with this is that the practising for the exam takes months and is not possible to do with the infection control required during the pandemic. This is not to mention that the registrars themselves will be on the frontline and also will be emotionally and physically fatigued even if they don’t catch the virus. October is after the usual recruitment period for the subsequent year so there will be flow on effects. 2020 will be remembered as a lost year or 20/21.
The questions we should ask as a profession include: (1) does the exam ritual actually ascertain competence as a future physician, (2) is it really a good discriminator between those who can do the job and those that can work to the test, (3) does it really assess the knowledge-base, (4) does it assess ‘soft’ skills such as communication and team work, and (5) does it really assess readiness for vocational training.
It should be said that there are other assessments in play such as log-books, structured activities such as mini-CEX and case-based discussion, as well as supervisor reports. However, these assessments, in particular the supervisor reports, may not be very objective, and trainees not performing up-to-scratch can slip through the system. Ultimately the exam is the arbiter of progression.
The college should think of different approaches to assessment that spread out across training. These should address core competencies but with sufficient breadth to cover the key specialties including cardiology, respiratory, neurology, gastroenterology, geriatrics and endocrinology. Haematology, oncology and immunology are important but have boutique aspects that are not always necessary for the general physician to know. Viva exams that focus just on knowledge without necessarily having patient examination could be considered. (Video) observed practice and clinical audit could also be considered. Reduced emphasis on assessments that can be biased due to candidate performance anxiety is desirable. Additional focus on other contributions outside routine ward care should also be considered – for example leading innovation through RMO Associations or quality improvement activities. Alignment with the approaches to CPD that the college has implemented is desirable.
After the plague year we shouldn’t return to business as usual.
Yesterday the Royal Australasian College of Physicians @TheRACP held its’ annual written exam, a 5 hour long barrier exam for progression to the viva voice examination that progresses the candidates to advanced training in medical sub-specialities. For the first time the college chose to use computer-based assessment rather than written assessment and engaged @PearsonVUE to undertake the process. It went spectacularly wrong with the software essentially seizing up towards the end of the first half of the examination. The problem has been attributed to an as yet unknown glitch. The exam was called off and is now re-scheduled as a paper based test on the 2nd of March. This was also not the only problem with a process that included inconsistent supervision, inconsistent mobile phone policy, misinformation, failure to take into account the needs of the candidates (like expressing breast milk) and lack of a back-up plan. The consequences are manifold. Trainees planned holidays immediately after the exam and these are now put on hold, no doubt with financial loss. Extra time off the wards will be required. There may be interruptions to other training events scheduled a year in advance and recruitment that commences in August/September for the subsequent academic year could in theory be disrupted. This is all not to mention the psychological distress caused by the most important test of their lives (apart from the viva).
Can any good come of all of this?
All of these future physicians are entering an age of completely digitised medicine. In fact they are the first generation where all hospital based records and prescribing will be undertaken electronically and private practice is fast moving in the same direction. Some of these future physicians will hold titles in their healthcare organisation like Chief Information Officer and hold higher degrees in health data management and analytics. I think for those candidates who suffered the events of yesterday there is a teachable moment. Just as the RACP simply cannot afford for the digital assessment system to fail as health care providers we cannot afford for our digital systems to fail. Downtimes in the electronic health record (EHR) are a bit like the computer aided flight systems on a plane failing. Cyberattacks or power-outages might results in critical system failure. How can we look after a patient if even for short periods of time all their health-related data is not accessible? People will have infusions running when computers crash. Operations will be underway. Critical life-saving information could be unavailable. Patients lives might hang in the balance just as trainees sitting the exam might see their futures hanging in the balance.
Trainees who experienced the digital failures of 19/2/18 who go on to take responsibility for digital healthcare will reflect on their experience with terror. They will manage the risk and work hard to ensure that their digital health care environment is as safe as possible. Catastrophic failure is never 100% preventable but due diligence, user testing, good risk management and risk mitigation could have prevented these calamitous events.
Clearly marriage equality will lead to the end of civilisation through devastating disruption of the social fabric of society. This will be the final straw. After all think of all of the other things that have led to society’s demise (in no special order):
- The Pill
- Martin Luther’s list nailed to the doors of the Catholic Church
- The Steam Engine
- The Internal Combustion Engine
- Women voting
- Non-landowners voting
- Native title
- Rock and roll
- The miniskirt
- The swim suit
- Abolition of slavery and apartheid
- Women in the workplace
- The forty hour work week
- Abolition of child labour
- Paid parental leave
- The old age pension
- Genetically modified food
- Solar power
- In vitro fertilisation
- Free love
- No more white Australia policy
- Nationalism (well that actually came pretty close -still might)
- Abolition of rule by hereditary monarchy
- Women on the battle field
- Dissolution of Empire
As you can see from the following graph – marriage equality is new to the game but we’ve been overcoming the end of civilisation for centuries.
Sonata for Violin and Piano No.1 in A minor op.105
Sonata for Violin and Piano No.2 in D minor op.121
Disc 25 – Beethoven Violin Sonatas with Gidon Kremer (1987)
Ludwig van Beethoven
Sonata for Piano and Violin No.4 in A minor op.23
Sonata for Piano and Violin No.5 in F major op.24 “Spring”
Disc 26 – Bartok, Janacek & Messiaen pieces for violin and piano with Gidon Kremer (1990)
Sonata for Violin and Piano No.1 Sz 75
Sonata for Violin and Piano
Theme and Variations for Violn and Piano
Disc 27 – Beethoven Cello Sonatas with Mischa Maisky (1991)
Ludwig van Beethoven
Twelve Variations On “Ein Madchen Oder Weibchen”from Mozart’s opera The Magic Flute op.66 in F major
Sonata for Piano and Cello No.1 in F major op.5 no.1
Sonata for Piano and Cello No.2 in G minor op.5 no.2
Seven Variations On “Bei Mannern, well he Liebe fuhlen” from Mozart’s opera The Magic Flute WoO 46 in E flat major
Disc 28 – Prokofiev Violin Sonatas with Gidon Kremer (1992)
Sonata for Violin and Piano No.1 in F minor op.80
Five Melodies for Violin and Piano op.bis
Sonata for Violin and Piano No.2 in D major op.94a
Disc 29 – Beethoven Cello Sonatas with Mischa Maisky (1993)
Ludwig van Beethoven
Sonata for Piano and Cello No.3 in A major op.69
Sonata for Piano and Cello No.4 in C major op.102 no.1
Sonata for Piano and Cello No.5 in D major op.102 no.2
Twelve Variations on a Theme from Handel’s oratario Judas Maccabaeus WoO 45 in G major
Disc 30 – Shostakovich and Haydn Piano Concertos (1994)
Concerto for Piano, Trumpet and String Orchestra op. With Guy Touvron on trumpet
Piano Concerto in D major Hob.XVIII:11
The Wurttembergisches Kammerorchester Heilbronn under the baton of Jorg Faerber
Bonus Track: Pytor Ilyich Tchaikovsky
Piano Concerto No.1 in B flat minor op.23
Berliner Philharmoniker conducted by Claudio Abbado (1995)
Disc 31 – Bartok and Ravel with Nelson Freire on piano (1994)
Sonata for Two Pianos and Percussion Sz 110
Ma Mere l’Oye (Mother Goose) for Two Pianos and Percussion
Rapsodie espagnole for Two Pianos and Percussion
With Peter Sadlo and Edgar Guggeis on percussion
Disc 32 – BeethovenViolin Sonatas with Gidon Kremer (1994)
Ludwig van Beethoven
Sonata No.6 for Piano and Violin in A major op.30 no.1
Sonata No.7 for Piano and Violin in C minor op.30 no.2
Sonata No.8 for Piano and Violin in G major op.30 no.3
Disc 33 – Beethoven Violin Sonatas with Gidon Kremer (1995)
Ludwig van Beethoven
Sonata for Piano and Violin No.9 in A major op.47 “Kreutzer”
Sonata for Piano and Violin No.10 in G major op.96