PUNs & DENs was originally invented by Dr. Richard Eve, GP Tutor in West Somerset.

IT CAN BE DIFFICULT knowing how to select topics for continuous medical education. GPs are flooded with articles and the offer of courses and lectures on every subject. It’s all too tempting to just learn more about the things we are interested in, and probably already know about. It appears that teaching from expert specialists does not often change what we do despite their having all the results of the latest trials at their finger tips. Because specialists’ ‘talks to slides’ at drug company sponsored events do not change our behaviour, we must try other methods of selecting which gaps in our knowledge we are going to fill. It might be logical to conclude that such selection should be patient driven if it is going to be relevant, have a chance of changing our behaviour and improving our service.

Small group work is trendy but variably good. Skilled facilitation may help us, but probably real learning is down to us, as individuals. But what a varied lot we are! Individuals are at different stages, sensitive to different stimuli that inspire the wish to learn. We have different styles of learning, different needs and vulnerabilities. Individual doctors need to explore their own needs in their own way and in their own time.

Learning with PUNs can provide the answer. It is driven by patients (but only indirectly). It self selects areas of weakness and in doing so provides a starting point from which to progress. It has has many advantages:

• it is simple, easy and good fun;
• it takes minimal time;
• is relevant to the daily work of General Practice;
• it costs you no money;
• identifies your education and training needs;
• will improve your consultation skills;
• identifies not just individual needs but Practice needs as well.

It does not explore what the Doctor wants (e.g. learn what I already know with minimal effort and maximum reward) nor what the Patient wants (eg patient Charters, demands and Sunday Times Readers). PUNS does not involve mentors spending hours helping you expose all your weaknesses and ignorance and setting out a plan to turn you into ‘superdoc’. All it guarantees is that, if you do find time for some learning, it will be relevant, owned by you and improve the care you give your patients. So what is it and how does it work?

PUNs are Patients’ Unmet Needs. They are discovered in consultations simply by asking ourselves at the end, when the patient has gone, ‘How could I have done better?’. During consultations we are commonly aware of gaps in our ability, gaps in the ‘in-house’ systems or attitudinal problems. You need to focus on the patient’s Needs to identify these. The doctor, not the patient, will decide whether the patient’s needs have been met. Recognition of deficiencies lead to the discovery of Doctors’ Educational Needs - DENs. When you discover Patients’ Unmet Needs you have found your first PUN ! It's simple really!

P.U.N.=Patient's Unmet Needs
D.E.N.=Doctor's Educational Needs

How To Discover PUNs
You can collect PUNs on your own but it is better if a group does it together - all the doctors in a practice or non-principal group. Be focused and collect for one week. After every consultation you ask yourself - “Was I equipped to meet the patient's needs? How could I have done better?” Consider this for all consultations - not just the easy ones. In this way areas can be identified that would benefit from further learning or development. PUNS can be divided into four classes as below.

After collecting for a week you are in a position to define Doctor's Educational Needs or DENs. Identify PUNs that can be easily solved by chatting to colleagues or by delegating to practice staff. GPs can't possibly be omni-competent and so PUNs may be met without fulfilling a DEN, for example, by delegation. PUNs that require some time spent on them form DENs that, by definition, need addressing, so called DEN fulfilment. Sometimes PUNs will be met not by individual doctors but by changes elsewhere in the practice administration or managerial development. In summary:

1. Spot the PUN
2. Define the DEN
3. Meet the PUN by Delegation or DEN fulfilment or changes in practice management.

DEN fulfilment may be done on an individual basis but may be better achieved if groups of doctors share their identified DENs. In this way shared educational sessions could be arranged - Self-Directed Learning Groups. You could apply for educational support for such meetings.

The Log Book
The Log Book consists of the Discovery Page and the Process Page. A sample of each is included at the end of this chapter. The log book is confidential to you. You don’t have to show it to anyone.

The Discovery Page
1. Record some patient identification so you can remember the consultation in which the PUN was identified eg computer identification, age, sex.
2. Describe the PUN you have identified
3. Define the area for improvement, development or change
4. Classify into relevant areas: KC: Knowledge clinical; KN: Knowledge non-clinical; S: Skill; A: Attitude.

The Process Page
5. Outline the Learning Plan - define personal DEN, practice development plan etc.
6. Apply for educational support
7. Go away and fulfil your DENs (do whatever is required - read it up, attend a course etc)
8. Bring your efforts back to the group and share them.

Giving it a Go
Discoveries are made right across the range of problems encountered in General Practice. The greatest benefit is often the opportunity to share PUNs with other GPs and, by doing so, discovering shared educational needs. Learning with PUNs generates an enthusiasm for organising in-practice learning as well as improving practice organisation. In pilot studies of the method strike rates (No.of PUNs found/No.of consultations) varied from 2% to 45%. Low strike rates were due to not bothering to collect small PUNs or because the identified PUN was actually solved during the consultation by getting out the books or getting on the telephone there and then. Doctors with high consultation rates had more PUNs. Some GPs admitted to being reluctant to record a PUN that would create an unwanted DEN. It is important not to feel inhibited when collecting PUNs - remember that the discovery page is personal and confidential to you. You do not have to address everything that you discover but be honest with yourself while collecting. You are then quite likely to find colleagues discover similar PUNs.

You should aim for a strike rate above 10%. If you score below you are not looking hard enough. If you score over 50% you are probably far too self-critical! Collect for a week - if you haven't collected 10 then keep going until you have. When you have collected your PUNs, hold a meeting and take it in turns to disclose some and write them on the flip chart. Start with knowledge PUNs. By the time you get to sharing some of your attitudinal PUNs, colleagues will be more relaxed and begin discussing what they find most irritating and how they handle various types of heart-sink patients. You may well end up arranging further meetings to meet shared DENs. Inviting the practice manager to attend enables him/her to put into action any organisational changes you decide to make.

PUNs and DENs Track Record
Learning with PUNS started in West Somerset in 1995. Now most local practices have tried it. Not only have individuals identified something relevant to learn but communication and interaction between doctors and staff have improved. Over forty GPs are members of self- directed learning groups after two years. The whole process is PGEA approved. "PUNs and DENs" are non-threatening and learner-centred. Learners go at their own pace and address issues that they own and which relate to improving patient care. It is no panacea but sharing it can be great fun. As General Practice CME is reviewed, and attempts are made to make it more relevant to needs of both patients and doctors, it is likely that methods such as this one will become increasingly important.

Already the RCGP has acknowledged the potential of PUNs and DENs as a possible method of recertification and educationalists across the country are developing PUNs and DENs in their areas. It is a process that non-principals could easily see now. Examples are given overleaf.

Further information from:
Dr Richard Eve,
Clifton Lodge Surgery,
17 Cheddon Road, Taunton,
Somerset TA2 7BL