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Medical undergraduate teaching in chronic wound care (a survey)
RESEARCH ARTICLE
Medical undergraduate teaching in chronic wound care {a survey) Gerry Bennett Consultant Physician, Department of Health Care of the Elderly, The Royal London Trust
Earlier this year Professor Bennett sadly died following a short illness. His obituary was published in the last issue of the Journal of Tissue Viability. The following article from Gerry Bennett was first published in the Journal of Tissue Viability back in 1992 (Bennett G. Medical undergraduate teachinig in chronic wound care (a survey). Journal of Tissue Viability 1992; 2 (2): 50-Sl.). It is reprinted here to remind readers of one of Gerry's contributions to this Society and to the wider field of wound care. Perhaps members would be interested in repeating this survey to see what changes have occurred since 1992? If you would be interested please contact the Editor through the Tissue Viability Society Office. We hope to publish one of Professor Bennett's final publications on pressure ulcers in a forthcoming issue of this journal. The sole amendment to Gerry's paper has been to change pressure sore to the more commonly used term (in 2003) pressure ulcer. A survey via postal questionnaire was sent to all medical schools and colleges in England, Scotland, Wales and Northern Ireland enquiring about the teaching on chronic open wounds (e.g. pressure ulcers and leg ulcers) to medical undergraduates. A 70% response rate revealed 6 medical establishments with 'probably' no teaching and a range of tuition from 0-35.5 hours. The teaching faculties were varied but examination on the material taught was not universal and the course content varied markedly. With an ageing population and large numbers of chronic wounds costing enormous sums to treat, there is a great need to include the topic of chronic open wounds (prevention and management) in the curriculum of all medical graduates.
T
he current cost of providing care within the NHS is a major and controversial theme. Budget holders and indeed all health care professionals are under constant pressure to assess treatments, rationalise resources and reduce costs. There is a vast knowledge base concerning the prevention and management of chronic open wounds and in addition rapidly rising costs mean that critical assessments of procedures are needed. This process will
© Tissue Viability Society 150
need an input from doctors who will have to be educated in a comprehensive way in this truly multidisciplinary area. The field of chronic open wounds (mainly leg ulcers and pressure ulcers) has historically been seen and is currently accepted by most doctors as a nursing preserve I. This narrow minded approach is due to change for many reasons including the large numbers involved2 the direct need for a multidisciplinary approach, the enormous cost of treatment3 and the new spectre of litigation4. Doctors especially will need to develop an expertise and knowledge base concerning these chronic open wounds to participate fully in this multidisciplinary approach so essential for prevention and treatment. To see how newly qualified doctors might fare in this brave new NHS world it is reasonable to examine what they are currently being taught on the topic.
Methodology A brief postal questionnaire was sent to the Deans of all the 27 medical schools and colleges in England, Scotland, Wales and Northern Ireland. The Deans were requested to circulate copies of the questionnaire to all departments involved in the teaching on chronic wounds (excluding the teaching of basic pathology and histology of wounds). The questionnaire was computer coded and on completion and return rendered anonymous.
Results There were 19 replies (a 70% response rate). Two medical schools/colleges indicated that there was definitely no formal teaching and four thought that there was 'probably' no teaching. The average amount of teaching was 6 hours (range 0-3 5. 5 hours). There were marked regional variations with England and Wales (excluding London) averaging less than 2 hours teaching, London 6 hours and Scotland l 7 hours. Two thirds of respondents indicated that all the students received the teaching whereas one third showed that only specific 'firms' or groups of students received the tuition . The teaching took place predominantly in the first clinical year. The list of 'teachers' is shown in Table I. The total numbers indicate that some students get teaching from more than one speciality though Dermatology, Health Care of the Elderly and, perhaps surprisingly, General Surgery feature most.
JOURNAL OF TISSUE VIABILITY VOL 13 NO.4 OCTOBER 2003
wound bed
preparation
what are the barriers to healing? Dead or Necrotic Tissue
e
Eliminate devitalised wound tissue with INTRASITE* Gel or INTRASITE* Conformable
Bacterial Imbalance
e
Reduce bacterial levels with: • IODOFLEX*/IODOSORB* (in wounds with moderate to • FLAMAZINE* (in dry wounds with low or no exudate) • AGICOAT* (a bacterial barrier for the prevention of infection)
Exudate or Slough
e
e
ALLEVYN* and CUTINOVA • Hydro will manage exudate and optimise moisture levels Reduce likelihood of infection by removing slough with IODOFLEX* /IODOSORB*
0
RESEARCH ARTICLE
Seventy per cent of students have some form of examination on the material taught but only 59% have this work examined in the Final MB or continuous assessment examinations. Concerning the content of the material taught 81% of teachers included preventative aspects, 62% the use of pressure relieving equipment and aids, 81% the use of various wound dressings but only SO% any elementary bioengineering or its application i.e. physiological measurement.
Discussion The survey highlights the lamentable lack of education concerning the prevention and management of chronic
TABLE 1. Undergraduate medical education Who teaches the subject?
Dermatology Health care of the elderly General medicine
open wounds that most of our medical undergraduates are receiving. Some questionnaires were returned with detailed letters of explanation outlining the reasons behind the paucity of appropriate teaching. These ranged from the honest, 'in simple truth there is no structured teaching whatsoever on the management of wounds', through the informative, 'the General Medical Council will be issuing new guidelines about the medical curriculum late this year', to the frankly pompous 'the business of the medical school into the 1990's is learning rather than teaching .. we do not think this task is about stuffing them with even more provision (data) for the journey: their canoe will sink'. Metaphorically speaking medical students should be taught to swim and life-save, there is less danger of their canoe sinking than the patient drowning. Chronic open wounds may be an unglamorous aspect of medical life, they affect particularly the elderly and especially the elderly sick yet the resultant morbidity and mortality is considerable. Economics apart, doctors must join, intellectually and morally, the other specialities dealing daily with these patients. This will not happen unless the management of chronic open wounds becomes a compulsory addition to the medical undergraduate curriculum and as such is examined in the final MB (there is currently no shortage of patients).
General surgery Vascular surgery Plastic surgery
The survey was organised via the Tissue Viability Society. My special thanks to the secretary John Gisby and his assistant, Dawn Roberts.
Orthopaedic surgery !-Accident and emergency Chiropody Nursing
152
1. Callam MJ, Dale JJ, Harper DR, Ruckley CV. Lothian & Forth Valley Leg Ulcer Study, Scotland; Buccleuch Press, 1987. 2. Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provision of care. British Medical lournal1985; 290: 1855-1856. 3. Wilson E. Prevention and treatment ofleg ulcers. Health Trends 1989; 21: 97. 4. Silver J. Letter. CARE, Science and Practice 1987; 5: 30.
JOURNAL OF TISSUE VIABILITY VOL 13 NO.4 OCTOBER 2003
Medical undergraduate teaching in chronic wound care {a survey) Gerry Bennett Consultant Physician, Department of Health Care of the Elderly, The Royal London Trust
Earlier this year Professor Bennett sadly died following a short illness. His obituary was published in the last issue of the Journal of Tissue Viability. The following article from Gerry Bennett was first published in the Journal of Tissue Viability back in 1992 (Bennett G. Medical undergraduate teachinig in chronic wound care (a survey). Journal of Tissue Viability 1992; 2 (2): 50-Sl.). It is reprinted here to remind readers of one of Gerry's contributions to this Society and to the wider field of wound care. Perhaps members would be interested in repeating this survey to see what changes have occurred since 1992? If you would be interested please contact the Editor through the Tissue Viability Society Office. We hope to publish one of Professor Bennett's final publications on pressure ulcers in a forthcoming issue of this journal. The sole amendment to Gerry's paper has been to change pressure sore to the more commonly used term (in 2003) pressure ulcer. A survey via postal questionnaire was sent to all medical schools and colleges in England, Scotland, Wales and Northern Ireland enquiring about the teaching on chronic open wounds (e.g. pressure ulcers and leg ulcers) to medical undergraduates. A 70% response rate revealed 6 medical establishments with 'probably' no teaching and a range of tuition from 0-35.5 hours. The teaching faculties were varied but examination on the material taught was not universal and the course content varied markedly. With an ageing population and large numbers of chronic wounds costing enormous sums to treat, there is a great need to include the topic of chronic open wounds (prevention and management) in the curriculum of all medical graduates.
T
he current cost of providing care within the NHS is a major and controversial theme. Budget holders and indeed all health care professionals are under constant pressure to assess treatments, rationalise resources and reduce costs. There is a vast knowledge base concerning the prevention and management of chronic open wounds and in addition rapidly rising costs mean that critical assessments of procedures are needed. This process will
© Tissue Viability Society 150
need an input from doctors who will have to be educated in a comprehensive way in this truly multidisciplinary area. The field of chronic open wounds (mainly leg ulcers and pressure ulcers) has historically been seen and is currently accepted by most doctors as a nursing preserve I. This narrow minded approach is due to change for many reasons including the large numbers involved2 the direct need for a multidisciplinary approach, the enormous cost of treatment3 and the new spectre of litigation4. Doctors especially will need to develop an expertise and knowledge base concerning these chronic open wounds to participate fully in this multidisciplinary approach so essential for prevention and treatment. To see how newly qualified doctors might fare in this brave new NHS world it is reasonable to examine what they are currently being taught on the topic.
Methodology A brief postal questionnaire was sent to the Deans of all the 27 medical schools and colleges in England, Scotland, Wales and Northern Ireland. The Deans were requested to circulate copies of the questionnaire to all departments involved in the teaching on chronic wounds (excluding the teaching of basic pathology and histology of wounds). The questionnaire was computer coded and on completion and return rendered anonymous.
Results There were 19 replies (a 70% response rate). Two medical schools/colleges indicated that there was definitely no formal teaching and four thought that there was 'probably' no teaching. The average amount of teaching was 6 hours (range 0-3 5. 5 hours). There were marked regional variations with England and Wales (excluding London) averaging less than 2 hours teaching, London 6 hours and Scotland l 7 hours. Two thirds of respondents indicated that all the students received the teaching whereas one third showed that only specific 'firms' or groups of students received the tuition . The teaching took place predominantly in the first clinical year. The list of 'teachers' is shown in Table I. The total numbers indicate that some students get teaching from more than one speciality though Dermatology, Health Care of the Elderly and, perhaps surprisingly, General Surgery feature most.
JOURNAL OF TISSUE VIABILITY VOL 13 NO.4 OCTOBER 2003
wound bed
preparation
what are the barriers to healing? Dead or Necrotic Tissue
e
Eliminate devitalised wound tissue with INTRASITE* Gel or INTRASITE* Conformable
Bacterial Imbalance
e
Reduce bacterial levels with: • IODOFLEX*/IODOSORB* (in wounds with moderate to • FLAMAZINE* (in dry wounds with low or no exudate) • AGICOAT* (a bacterial barrier for the prevention of infection)
Exudate or Slough
e
e
ALLEVYN* and CUTINOVA • Hydro will manage exudate and optimise moisture levels Reduce likelihood of infection by removing slough with IODOFLEX* /IODOSORB*
0
RESEARCH ARTICLE
Seventy per cent of students have some form of examination on the material taught but only 59% have this work examined in the Final MB or continuous assessment examinations. Concerning the content of the material taught 81% of teachers included preventative aspects, 62% the use of pressure relieving equipment and aids, 81% the use of various wound dressings but only SO% any elementary bioengineering or its application i.e. physiological measurement.
Discussion The survey highlights the lamentable lack of education concerning the prevention and management of chronic
TABLE 1. Undergraduate medical education Who teaches the subject?
Dermatology Health care of the elderly General medicine
open wounds that most of our medical undergraduates are receiving. Some questionnaires were returned with detailed letters of explanation outlining the reasons behind the paucity of appropriate teaching. These ranged from the honest, 'in simple truth there is no structured teaching whatsoever on the management of wounds', through the informative, 'the General Medical Council will be issuing new guidelines about the medical curriculum late this year', to the frankly pompous 'the business of the medical school into the 1990's is learning rather than teaching .. we do not think this task is about stuffing them with even more provision (data) for the journey: their canoe will sink'. Metaphorically speaking medical students should be taught to swim and life-save, there is less danger of their canoe sinking than the patient drowning. Chronic open wounds may be an unglamorous aspect of medical life, they affect particularly the elderly and especially the elderly sick yet the resultant morbidity and mortality is considerable. Economics apart, doctors must join, intellectually and morally, the other specialities dealing daily with these patients. This will not happen unless the management of chronic open wounds becomes a compulsory addition to the medical undergraduate curriculum and as such is examined in the final MB (there is currently no shortage of patients).
General surgery Vascular surgery Plastic surgery
The survey was organised via the Tissue Viability Society. My special thanks to the secretary John Gisby and his assistant, Dawn Roberts.
Orthopaedic surgery !-Accident and emergency Chiropody Nursing
152
1. Callam MJ, Dale JJ, Harper DR, Ruckley CV. Lothian & Forth Valley Leg Ulcer Study, Scotland; Buccleuch Press, 1987. 2. Callam MJ, Ruckley CV, Harper DR, Dale JJ. Chronic ulceration of the leg: extent of the problem and provision of care. British Medical lournal1985; 290: 1855-1856. 3. Wilson E. Prevention and treatment ofleg ulcers. Health Trends 1989; 21: 97. 4. Silver J. Letter. CARE, Science and Practice 1987; 5: 30.
JOURNAL OF TISSUE VIABILITY VOL 13 NO.4 OCTOBER 2003