Pretibial Myxedema: Photos in Ambulatory Care Teaching

 In ambulatory care clinic, we saw a patient with Grave’s disease. The patient also had pretibial myxedema, a dermatological finding typically associated with Grave's disease and constitutes a prong in the classical Triad of the Grave’s disease that includes hyperthyroidism, ophthalmopathy, and dermopathy (even though realistically this dermopathy is only seen in 5% of patients) (1). Pretibial myxedema is characterized by scaly thickening of the skin that is typically slightly pigmented and may assume an orange-peel appearance.

We have learned about pretibial myxedema on several occasions in class. We are often shown the classic image of it – a photo with slight hyperpigmentation over the shins – so this is always how I have also envisioned it. The patient we saw in clinic had this classic presentation of pretibial myxedema so it was not difficult to identify.

After seeing this patient and discussing the case, our preceptor continued to show us a few photos. He didn’t tell us what they were of. One was an image of hyperpigmentation and slight induration in the area of the medial tuberosity. Another showed erythema and slight ulceration over the shins. We didn’t realize it at first, but both were images of pretibial myxedema.

To help develop expertise, it is important that students are exposed to a variety of case and also the spectrum of presentations of the same disorder or clinical feature (2). This is of the greatest challenges of ambulatory care teaching, and perhaps medical education in general, as students often only get the opportunity to see one representation of a disorder during their brief time in any particular site or specialty. Our preceptor’s use of photos (with patient permission), to help capture and convey to his students some of that variety in clinical presentations and clinical cases, which we may otherwise not have the opportunity to see, is a practice that I greatly appreciate. It probably is not easy to develop a treasury of photos of good teaching cases, but certainly it is a technique that would be worth emulating.

(1)  Davies TF. Pretibial myxedema in autoimmune thyroid disease [Internet]. In: Ross DS, editor. UpToDate. 2012[cited 2012 Jan 22] Available from: http://www.uptodate.com.myaccess.library.utoronto.ca/contents/pretibial-myxedema-in-autoimmune-thyroid-disease?source=search_result&search=pretibial+myxedema&selectedTitle=1%7E14

(2) Schmidt HG, Rikers RMJP. How expertise develops in medicine: knowledge encapsulation and illness script formation. [Internet]. Medical education 2007 Dec;41(12):1133-9.[cited 2011 Aug 11] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18004989

-Jenny (Signing off. It was a great selective! Hope you enjoyed reading our musings. :) )

Medical Expertise: The Power of Knowing

“How expertisedevelops in medicine: knowledge encapsulation and illness script formation” is a 2007 publication by Schmidt and Rickers in Medical Education. The development of expertise is described as going through phases: 1) understanding disease in term of pathophysiology, 2) encapsulation into diagnostic labels/models, 3) transition into illness scripts (narrative with pertinent contextual details or enabling conditions), and 4) possessing interpreted scripts for each disease. This process of attaining expertise is facilitated by integrating the teaching of basic science and clinical cases, increasing students’ exposure to variety of patients and diseases, and supporting reflection in the context of mentors and peers. 

Although these phases make intuitive sense, there are certainly elements that I did not fully appreciate before, such as the critical importance of acquiring contextual information to create patient and disease narratives. I wish I have sought out sooner this concept of how medical expertise is acquired. Without this concept of what our goal ultimately is, how the progression from medical novice to expert occurs, it may be akin to trying to put together a puzzle without having seen the final picture. I wonder if I had known this earlier, whether I would have changed the way in which I learned?

 It would perhaps be useful to give students an earlier introduction to the basic concepts of medical education. We can teach students about what expertise means, what the journey towards it entails, and the rationale behind the different teaching methods. This could help students become more active and focused learners. Otherwise, we may be trapped into thinking that PowerPoint lectures are the best way to learn, when they are but a component of the process. It may help students appreciated the value of different teaching methods and ameliorate antagonism with what may otherwise be perceived to be unconventional techniques. Perhaps this is also a way for us to encourage conversation about medical education and inspire a new generation of medical educators.

- Jenny

1. Schmidt HG, Rikers RMJP. How expertise develops in medicine: knowledge encapsulation and illness script formation. [Internet]. Medical education 2007 Dec;41(12):1133-9.[cited 2011 Aug 11] Available from: http://www.ncbi.nlm.nih.gov/pubmed/18004989

PowerPoint: Reflections on a Conventional Teaching Technique

Dr. Southwick’s “Spare me the PowerPoint and bring back the medical textbook” is provocative publication that broaches the important debate of how to most effectively teach medicine. PowerPoint has clearly become the most popular and predominant mode of post-secondary education. There are many potential reasons for this. For one, the PowerPoint is probably the easiest method for mass transmission of pure information: it replaced chalkboards or overhead slides because, without having to recopy text or switch slides, this vastly increases the tempo of information dissemination. PowerPoint also has an impressive host of functionalities for incorporating images, transitions, and movies, which eclipses all its predecessors. And now, more importantly it has become the convention, the expected method of teaching, such that to do anything but would probably raise a few eyebrows.  

 While knowledge is an important aspect of education, operationalizing information is the crux of medical education. For example, not only do we need to know what diabetes is, how it can present, and ideas about management, we also need to actually be able to identify the patient with a new presentation of diabetes, think about what a diagnosis of diabetes means with for a patient in the context of separate issues like hypertension, and develop an individualized management plan. To do all this requires practice and knowledge integration, aspects that we perhaps don’t emphasize enough in pre-clerkship.

 Dr. Southwick’s recommendation of bringing back the textbook is interesting because it is a point that I have talked to others students about and we were nostalgic about the times when learning emphasized textbooks. Textbooks provided a much more satisfying form of learning. Most of us have probably experienced the frustration of not understanding what a point in a slide meant because the point-form structure had taken the idea completely out of context and robbed it of the clarity of linguistic structure. PowerPoint is truly powered for HIGHLIGHTING ideas – points – and not to convey complexity holistically.

This publication also brings up the concepts of Just-in-Time Teaching and Peer Instruction, as useful teaching tools. It also outlined 7 basic principles of teaching that I personally thought would be quite useful to keep in mind:

1.        “encourage contact between students and faculty

2.        develop reciprocity and cooperation between students

3.        use active learning techniques

4.        provide prompt feedback

5.        emphasize time on task

6.        communicate high expectations

7.        respect diverse talents and ways of thinking”

Food for thought: how do we strike the balance between knowing a lot and knowing things well?

-Jenny

 1. Southwick FS. Spare me the PowerPoint and bring back the medical textbook. Transactions of the American Clinical and Climatological Association 2007;118:115-122. http://www.ncbi.nlm.nih.gov.myaccess.library.utoronto.ca/pubmed?term=spare%20me%20the%20powerpoint

Ágoston Kecskés

992868991

January 20, 2012

Blog Entry #14: Tips on clinical reasoning

A new ‘Twelve tips’ article appeared in a recent issue of Medical Teacher on clinical reasoning.[1] Unfortunately, I was not terribly inspired by what I read. The tips were very broad and were applicable mainly in retrospect. That is, I did not feel that had I an opportunity to redo my core rotations I would have acted much differently.

My performance in the clinic is far from perfect – that’s part and parcel of being a learner. I could think of many ways that I could have improved my core rotations. However, there is a difference between advice that works in the present and advice that’s works in retrospect.

The first tip is to maximize learning from each patient encounter. Residents and attending physicians often tell their clerks to read around their cases. Throughout my core rotations I heeded this advice. I carried around a small pad to jot down concepts I wanted to follow up on in my studying. But I never had trouble thinking of how to connect my learning to the cases I had seen in the course of the day. The problem was always that I had TOO many cases to read up on. Furthermore, I inevitably had to choose between reading up on something esoteric and weird and wonderful, and something relatively common but relatively mundane. And then I also had to keep up with the required studying and readings for the final examinations.

The second tip is to capitalize on pathophysiologic knowledge to make diagnoses. The trouble with this approach is that bread and butter presentations often have a tried and true list of possible diagnoses. One often cannot derive these diagnoses from pathophysiologic first principles – or at least no easily. In addition, often the pathophysiology is only understood piece-meal and connecting the dots is either unintuitive or simple incorrect. A lot of the pathophysiology taught in medical school are “just so” stories. More to the point, one’s time with each patient is limited. There often simply isn’t enough time to think through the pathophysiology of the diagnosis for each patient. Moreover, the diagnosis is often unclear so one would have to think through the pathophysiology of several diagnoses and compare each.

The other tips suffer similar limitations. Most motivated medical students already either know these tips or can quickly derive them. More often than not, the problem is motivation and time.

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[1] R. A. Kusurkar, G. Croiset, and Olle Th. J. Ten Cate, “Twelve tips to stimulate intrinsic motivation in students through autonomy-supportive classroom teaching derived from Self-Determination Theory,” Medical Teacher, http://informahealthcare.com/doi/pdf/10.3109/0142159X.2011.599896; accessed 19 January 2012.

Ágoston Kecskés

992868991

January 19, 2012

Blog Entry #13: The humanist clinician-teacher

A convincing argument can be made to support the claim that good teachers must be – at the risk of sounding unsophisticated – ‘nice.’[1] There are many reasons for this. First, patients expect their physicians to involve them in their healthcare decisions so physicians must model this interaction for their trainees. The days of the patronizing, patriarchal physician are dead and gone. Second – and more germane to the topic of medical education – medical students expect – or at least hope – that their preceptors will treat them with dignity. It’s considered increasingly taboo for attending physicians to ‘overwork’ their medical students and residents. The support for this trend, for example, is medico-legal, ethical, and even economic.

But learners also function more effectively when they enjoy the company of their teachers. Most learners’ favourite teachers were also individuals with whom they got along personally. Most learners’ favourite lectures were entertaining. And why shouldn’t they be? Presumably, medical students are studying because they love medicine. So why should exploring that which you purport to love be mundane? And if it is mundane, then why should you expect it to ever improve? Students also perceive their teachers’ specialties and patients as extensions of the teachers themselves. Teachers that humiliate their students, for example, risk turning their students not just against themselves but against their specialties and patients as well. Certainly a bit of stress can help motivate students to ‘work harder’ but students shouldn’t have to fear or deliberately avoid their preceptors.

In some ways, an effective bond between a teacher and learner can overcome the individual deficiencies of both. For example, a good clinician-teacher may not have all the answers, but his/her enthusiasm may motivate the learner to seek out the answers for him/herself. Students are also far more likely to make a genuine effort to please a teacher they like than one they fear. This can easily translate into less adverse events, better follow-up, and greater patient satisfaction.

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[1] Claude Beaudoin, Brigitte Maheux, Luc Côté, Jacques E. Des Marchais, Pierre Jean, and Laeora Berkson, “Clinical teachers as humanistic caregivers and educators: perceptions of senior clerks and second-year residents,” Canadian Medical Association Journal, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1232732/; accessed 19 January 2012

Ágoston Kecskés

992868991

January 18, 2012

Blog Entry #12: The student becomes the teacher

The tradition of teaching is alive and well in internal medicine. Each year, new third-year clinical clerks join the ranks of the clinical teaching units while keen fourth-year clinical clerks rotate through during electives. Both groups are taught by the first- and second-year residents situated above them in the hierarchy of the clinical teaching unit. From higher still, the attending physicians dispense pearls of wisdom to all. That’s how we become physicians. But how do we become teachers? How do we learn and perfect our teaching scripts? How do we teach others to teach? Certainly, leading by example is a popular method of teaching in internal medicine. The dictum of “see one, do one, teach one” often holds true to some extent. And leading by example is very powerful indeed. All too often we learn this lesson the hard way when we develop poor habits by mirroring those of others.

But it doesn’t seem that a good example is sufficient. Despite how finely honed the internist’s skills of observation are, observation is rarely a sufficient condition for good teaching. We need something more. We need a structured approach to passing on teaching skills to clerks in internal medicine.[1] Some might argue that this already exists: attending physicians, for example, routinely assign to clerks relevant topics to be researched and presented to the team. The problem is that clerks are so concerned about presenting accurately and comprehensively that the art of teaching is lost. The problem is compounded by the time crunch on medicine teams, which often leads to members of the team filing in and out throughout the presentation. The presentation falls apart completely if the senior resident or attending physician interrupts the clerk for clarifications or corrections, thereby undermining the clerk’s confidence and flow. One way around this would be to have the clerk present to the senior resident prior to the large-group session, thereby vetting any errors. Subsequently, the focus could fall on the art of teaching instead of the art of saving face in front of your preceptor.

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[1] S. Hartley, D. Gill, F. Carter, K. Walters, and P. Bryant, “Being an effective clinical teacher,” Teaching in the Clinical Setting, http://fds.oup.com/www.oup.co.uk/pdf/0-19-851072-1.pdf; accessed 17 January 2012.

Virtual Patients: The Sequel

Then the real work of the project began. The student team met in order to outline the goals of the case series and identify the topics that we want to cover. Since case writing takes a formidable amount of time, we need to be judicious in the cases that we choose. We wanted to create online, interactive, evidence-based internal medicine virtual patient case series for clerkship students. We wanted to emphasize management and knowledge integration through explicit discussion of management rationale and making connections to clerkship skills such as how to present cases, write admission orders, sign-over patient information, etc. I also had the opportunity through this current Selective to conduct a literature review on Virtual Patient cases and pilot our first case, in order to help improve the quality of our cases.

A huge flurry of activity also occurs behind the scenes including obtaining funding for the project, getting in touch with Faculty Mentors to see how to best integrate our project with the UofT Medicine curriculum, and trying out different interfaces to find an efficient way to make our cases flow and include assessement from the start.

 Currently, we are focusing on case writing and prototyping our cases, and we are also waiting to hear back from funding sources. The next phase, hopefully, will involve finalizing our cases and presenting them to appropriate committees for assessment for educational use.

I have certainly learned a great deal through being involved in this project about communication and teamwork, leading and managing a student initiative, as well as the challenges of developing effective educational tools. Hopefully, everything will come to fruition and we will eventually have a neat series of Internal Medicine cases that will be helpful for students to come. 

Here are a few good resources that my team and I were looking at to whet your appetite for Virtual Patients:

Family Medicine Cases: https://sites.google.com/site/sharcfm/

NEJM Interactive Cases: http://www.nejm.org.myaccess.library.utoronto.ca/multimedia/interactive-medical-case


-Jenny

Virtual Patients: Story from the Frontlines

Virtual patients are interactive computer simulations of clinical scenarios used for educating healthcare professionals (Posel, Fleiszer, & Shore, 2009). Virtual patients are meant to help address complexities in medicine, promote active learning, and encourage critical decision-making (Posel, Fleiszer, & Shore, 2009).

Now, here is how I got involved with building virtual patient cases. Back in October of 2011, I started a project called Internal Medicine Clinical Encounters. The idea for it first began during my Pediatrics rotation, where we were introduced to a Virtual Patient case series called CLIPP (Computer-assisted Learning in Pediatrics Program) developed by medical students in the United States. I greatly appreciated the step-by-step approach to common pediatric cases and found it to be an excellent resource. While going through my Medicine rotation, I wanted to find a similar resource for Internal Medicine but most resources were either not freely accessible or were targeted towards an American audience.

 During my electives in my final year of medical school, I was inspired by my preceptors and their strong interests in medical education to reflect on my own experience in medical school and what I can do to improve this for future generations. It was then that the idea of creating a series of core Internal Medicine cases took form and took hold.

 I spoke with other students in my class and found that my idea resonated. We formed a small dedicated group of student Case Writers, supported with a few team members with more technical expertise. I got in touch with one of my mentors, who was very interested in our idea and who became our Faculty Advisor. Together we contacted and recruit a team of staff physicians to be our Faculty Case Editors.


To Be Continued…

-Jenny

Ágoston Kecskés

992868991

January 17, 2012

Blog Entry #11: Grand rounds

            Since the beginning of this selective in medical education, I have frequently reflected on my learning experiences in medical school. It has helped me realize what has worked for me and perhaps why. More than anything, however, this selective has given me a framework within which to think about my medical education experiences. I've given some thought to one particular application of medical education: grand rounds.[1] Ensconced in the pomp of tradition, grand rounds represent an opportunity for physicians in a broadly defined group to assemble and learn something together. But what is the value of grand rounds? Earning credits towards continuing education seems to be a key part of this exercise, but is there more? In particular, what is the value of grand rounds for lower levels of trainees? I have been attending grand rounds for three years now, and I still lose my bearings approximately 15 minutes into the presentation. Sadly, grand rounds presentations typically violate many of the "rules" of good presentations. For licensed physicians and certainly for more senior attending physicians, the value of grand rounds seems to be high. Grand rounds are often the only time that members of some specialties have an opportunity to interact with and learn from each other. There is a disturbing tendency of presenting very esoteric cases at grand rounds, the value of which is highly suspect. The most important parts of these presentations to the audience (e.g. when to suspect a particular disease or condition, when to refer a patient, how to order a test) are often lost in the myriad details or glossed over superficially. The value of conciseness in these cases also cannot be overemphasized. Senior physicians regularly instruct (and in some cases berate) their clerks to try to consolidate information, only to turn around and provide excruciatingly detailed accounts of esoteric diseases. It is as if the audience members are so proficient at managing every disease they see in clinic that they are bored and can only learn from esoteric cases.

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[1] R. M. Lewkonia and F. R. Murray, “Grand rounds: a paradox in medical education,” Canadian Medical Association Journal, http://www.cmaj.ca/content/152/3/371; accessed 16 January 2012.

Ágoston Kecskés

992868991

January 16, 2012

Blog Entry #10: Illness scripts

            I first heard about illness scripts[1] two weeks ago. I'm glad I did because although I knew about them before, I now have a name for them. Over the course of the daily morning reports during my first exposure to the clinical teaching units at Mount Sinai Hospital I was convinced that my junior and senior residents were geniuses. They seemed to have the answers before the question was even posed! They also seemed to have an "approach" to everything and they hammered that home time and again. I didn't realize it at the time but that was my first exposure to the illness script.

Of course, scripts are not specific to medicine. I have used scripts for all sorts of learning tasks at school, work, and even at home. These scripts speak directly to the notion that George E. P. Box's phrase that "all models are wrong, but some are useful." It's awfully tempting, however, to be lured in to think that models are reality. On serially busy days on the clinical teaching unit as a clerk, I have often been tempted to put off seeing some of my less acutely ill patients until the end of the day. I would think back on their illness script and try to convince myself that as long as the patient stuck with the script we would be fine. But patients don't stick to their illness scripts. In fact, they seem to waver from them exactly when you least expect it - or at least when you need them most to remain steadfast.

Despite that illness scripts serve as the basis for much of our learning in clerkship, they are not explicitly taught. It would also be nice to know how to optimize my illness scripts. Should I take an expert nap? Should I whip out my smartphone during bedside rounds to visually connect my textbook learning to my patients? I suspect the answers to most of these questions are not fully understood, but at the very least I would have liked an introduction into how physicians think before they asked me to try to be a physician.

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[1] Henk G. Schmidt and Remy M. J. P. Rikers, “How expertise develops in medicine: knowledge encapsulation and illness script formation,” Medical Education, http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2923.2007.02915.x/full; accessed 16 January 2012.

Publication on Ambulatory Clinic: More from Dr. Irby

In the publication titled “Teaching and Learning in Ambulatory Care Setting: ThematicReview of the Literature”, Dr. Irby painted a bleak picture of education in ambulatory care clinics in late 1980s to early 1990s. Findings suggest that the ambulatory clinic setting is often poorly conductive to learning because of a variety of factors including tight time constraints, lack of continuity, and insufficient use of observation of trainees for the purpose of feedback. Most concerning of all, is the conclusion that students make dubious gains through their ambulatory care experience and many significant deficiencies remain (although one can argue that improved diagnostic pattern-recognition is important and one ambulatory rotation is not meant to cure all of a learner’s problems).

Some of the points raised in this publication was very refreshingly provokative. For example, it deliberated the issue of how preceptors correct trainee’s clinical errors. A referenced study found that preceptors often apply “face-saving” strategies such as create opportunities for revision, treat wrong answer as plausible but requiring modification, and hinting to invoke the right answer. These methods, though compassionate towards students, bear the heavy limitation of possibly impeding trainees’ “accurate self-assessment”. This is not a trivial point, as I recall instances where I have wondered if an answer given was actually outright wrong or simply in need of tweaking. One of the strategies that I have observed to be both clear and not confrontational was to acknowledge an answer given e.g. with “I can see why you may think that” and then continue with “but the actual answer is this and here is why”.

This publication was overall critical of the state of education in the ambulatory setting at the time of its study. It emphasizes that without thoughtful organization, an ambulatory setting can naturally decay to a state of educational chaos. Dr. Irby recommends a few strategies to improve ambulatory care education including: 

1. improve continuity e.g. with more longitudinal ambulatory experiences
2. improve collaborative and self-directed learning e.g. by offering ambulatory morning reports
3. provide faculty development: e.g. teach teachers to set expectations with students, teach to students’ needs, observe and give feedback, encourage reflection, provide mentorship and positive learning environment, and reflect on one’s own teaching strategies

-Jenny

Ágoston Kecskés

992868991

January 13, 2012

Blog Entry #9: MUPS

            Virtually all medical students encounter medically unexplained physical symptoms (MUPS)[1] at some point during their training, although they often don’t know it. MUPS is different things to different physicians. In preclerkship, I recall a lecture on some of the rheumatologist’s favourite MUPS. As I progressed through my core rotations during clerkship, my learning became necessarily more self-directed. Thus, I found myself adding more diseases to the MUPS list. In urology, MUPS was interstitial cystitis. In gynecology, MUPS was idiopathic chronic pelvic pain. In internal medicine, MUPS was irritable bowel syndrome. If the diagnostic criteria explicitly require the lack of any physical evidence of “disease,” chances are you dealing with MUPS. I never called it MUPS until recently and I suppose it doesn’t really make a difference. Still, sometimes it’s nice to be able to put a name to a disease (spectrum).

            MUPS is a good example of a topic that is taught very differently in the official versus hidden curriculum. Even mentioning MUPS to most physicians is sure to produce eye-rolling and sighing. The sight of a MUPS patient in these physicians’ waiting rooms is sure to prompt tales of past trials and tribulations in the management of said patient. In my experience, while most physicians (especially most academically affiliated physicians) will tow the party line on empathy and psychosocial awareness MUPS patients tended to test the patience of even the most invested physicians. Furthermore, MUPS patients also invariably tested the management skills of said physicians. It’s not difficult to be empathic towards a cookie-cutter, cooperative patient receiving a terminal illness diagnosis. MUPS patients, on the other hand, leave you wondering why you decided to pursue a career in medicine.

It’s precisely for these reasons that I have learned so much from MUPS patients. They had an uncanny ability to send me scrambling to dust off the cobwebs of preclerkship (e.g. effectively conveying empathy from ASCM, as well as the ninth and tenth items on the differential diagnosis of diffuse fatigue in isolation from problem-based learning cases and lectures). They routinely induced counter-transference, which routinely led to deeper introspection and reflection. They also underlined the importance of developing disease-specific scripts when educating and counselling patients. Most patients remember how their diagnoses are delivered. MUPS patients in particular have a iron-clad memories in this respect, making it all the more important to deliver information thoughtfully and effectively.

Sadly, the management of MUPS is still not well-developed. We’re not even sure if we know what MUPS is and some even question if it even really exists. Only a few RCTs have been performed on MUPS patients, but they are beginning to practice. For example, Smith et al. (2006)[2] demonstrated an improvement from baseline to 12 months of 4 or more points on the Mental Component Summary of the SF-36 in 200 subjects under the care of nurse practitioners.

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[1] Ralph D. Richardson et al., “Evaluation and management of medically unexplained physical symptoms,” The Neurologist, http://journals.lww.com/theneurologist/Abstract/2004/01000/Evaluation_and_Management_of_Medically_Unexplained.3.aspx; accessed 13 January 2012.

[2] Robert C. Smith et al., “Primary care clinicians treat patients with medically unexplained symptoms: A randomized controlled trial,” Journal of General Internal Medicine, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1924714/; accessed 13 January 2012.

Publication on Ambulatory Clinics: Unsatisfying Lack of Limitations

I have been reading the publications by Dr. Irby on the topic of teaching in Ambulatory Medicine. In “What Clinical Teachers in Medicine Need to Know”, he interviewed 6 teachers with “excellent ratings” from the Department of Medicine at the University of Washington School of Medicine in Seattle. He concluded that there are several “domains” of knowledge important to being an effective teacher, including knowledge of medical content, the learners, the clinic patients, the context of the practice, general teaching principles, and teaching script. While Dr. Irby’s publication is well-referenced, I found the lack of a “Limitation” section or an explicit discussion of the study’s limitations unsatisfying. Even though small sample size is common in qualitative studies, I would still have appreciated acknowledgement be given to this, followed perhaps by an explanation of why this study remains valid despite this. All the teachers in the study belonged to the same school, which could impact the generalizability of conclusions. For example, are these domains consistent between these teachers because these concepts are truths or simply because the same teachers have had the opportunity to exchange teaching methods with each other over coffee?

I also found the term “teaching script” interesting. This concept is recurrent across Dr. Irby’s two publications and draws parallel with the language used to describe medical learning (illness script). This linguistic homology almost suggest a similarity in how we structure our own knowledge and how we reformat it in teaching. Or, at the very least, a similarity in the way we think about the way we think.  

-Jenny

Ágoston Kecskés

992868991

January 12, 2012

Blog Entry #8: The bells toll for traditional classroom lectures

            During this morning’s discussion, we briefly discussed the end of traditional classroom lectures in medical education. For a nice summary of the salient points, see American RadioWorks®’s three reports on the subject (http://americanradioworks.publicradio.org/features/tomorrows-college/lectures/). The lecture style for which the University of Toronto has become (in)famous is soon to be rendered obsolete. So what is the heir apparent?

            Assuming the aim is simply to improve the efficiency and effectiveness of the delivery of medical education, online video-taped lectures would seem like an easy and popular way choice. The traditionalists would be unlikely to put up too much of a fight as the essential format would not change dramatically. Furthermore, access would be guaranteed as desktop computers are ubiquitous and smartphones are not far behind.

There could be more subtle benefits too. Because the recording and posting of online video lectures is in many ways a fixed cost, one could invest a bit more upfront to ensure that the best lecturers’ presentations are posted. Furthermore, faculty time spent teaching would be dramatically reduced. Alongside each presentation, one could post transcripts and PowerPoint slides. In addition, a more comprehensive set of study notes could also be posted for the purposes of defining “testable” material for the purposes of examination. Thus, lecture content would be standardized which would allow smartphone users to upload the content they had studied throughout preclerkship to be recalled and reapplied as point-of-care during clerkship and even into licensing examinations and residency. For those worried that standardizing the lecture material would pigeonhole students’ learning and understanding of key concepts, a(n) (annotated) bibliography could also posted with each lecture with hyperlinks to applicable, readable resources. This would be more than enough for the vast majority of students. Besides, medical students are supposed to be highly selected (e.g. in personal essays, interview questions, academic records, and extracurricular activities) for self-directed learning. Why not put their skills to good use? Frequently asked question sections could accompany each lecture as a resource for students seeking clarification of unclear concepts. Furthermore, it would be much easier to apply restrictions on lecturers’ presentation (e.g. time, number of slides, content) thereby aligning presentations with the given learning objectives. The videos could also be adapted for viewing on smartphones so students could learn on the go.

            Admittedly, an online video-taped lecture format is not a dramatic departure from the traditional classroom lecture format. Still, it’s a step in the right direction. Next up: transitioning the University of Toronto to (real) PBL.

CN IX/X Palsy: A Fact Hard to Swallow

We discussed in clinic a case of possible CNIX/X (gossopharyngeal/vagus nerve) palsy presenting with dysphagia and weight loss. Here’s a quick review of the functionalities of these cranial nerves, how to examine for abnormalities, and differential diagnosis.

CNIX is responsible for swallowing, taste and sensation over the posterior 1/3 of the tongue and palate, promoting salivation from parotid, and it forms the afferent limb of the gag reflex (Walker,1990). CNX is important for  swallowing, phonation, and articulation (as it contributes to the movement of the palate, pharynx, larynx, and esophagus), and forms the efferent limb of the gag reflex. CNX also has autonomic functions such as gastric acid secretion, gallbladder emptying and heart rate regulation.

Physical exam in the context of possible CNIX/X palsy should include a full neurological and head&neck examination (Erman, 2009). Assess the patient’s voice including pattern, loudness, and articulation (e.g. the “ee” sound is hard to hold for more than a few  seconds with vocal cord paralysis). The gag reflex, palate elevation, and swallowing should be evaluated.

Differential for CNIX/X dysfuntion involving systematically thinking about different pathology from the cortex to the neuromuscular junction (Erman, 2009).

§      cortex (contribute to CN IX and X): acute stroke, tumor
§      extrapyramidal tracts (contribute to CN IX and X): extrapyramidal movement disorders
§      brainstem (nuclei): amyotrophic lateral sclerosis, syringomyelia, Arnold-Chiari malformation, tumor
§      peripheral nerve (CN IX and X): cerebellopontine angle tumor, skull base osteomyelitis, skull base fracture, glossopharyngeal neuralgia, diptheria
§      neurmuscular junction: myasthenia gravis

-Jenny

Ágoston Kecskés

992868991

January 11, 2012

Blog Entry #7: Changing habits of practice

            In my previous post, I started headlong into a tirade against Bowen et al.’s article[1] on the transformation of internal medicine residency education in the ambulatory setting. In this post, I continue my tirade.

The aforementioned two claims – that internal medicine residents spend less time training in ambulatory medicine than internists do in practice, and that ambulatory medicine differs significantly from inpatient medicine - seem to be the only driving forces motivating this literature review. Yet the authors find that “substantial changes in ambulatory education are needed” and that, as per the authors’ discussion, these changes should not be limited to simply increasing the amount of time residents spend in the ambulatory setting. Many, if not most, of the authors’ recommendations go well beyond (and tangential to) remedying a perceived discrepancy between training and practice in internal medicine. It feels almost as if the authors’ hypothesis was formulated after the data was collected.

The authors at least mention the argument that “residents might benefit from training tracks tailored to their career plans, so that residents bound for careers as hospitalists would focus on hospital-based training.” This argument raises the question of why the authors did not bother looking into the mismatch between total times spent in residency training versus practice settings per individual instead of on a national level. It would seem incumbent on the authors to ensure at the very least that it is not by design that some residents are not receiving ‘adequate’ amounts of exposure to the ambulatory setting. Instead, the authors conclude that “the core of internal medicine training at the residency level should include a more robust exposure to continuity practice regardless of the resident’s future career choice.” This statement neither is intuitive nor flows from the authors’ findings. More saliently still, it stands in isolation of any cost-benefit analysis. As a result, it could be merely an expensive cop-out. As long as the authors do not have to foot the bill, how could more training possibly be a bad idea? Later in the article, the authors curtly mention that “financial pressures may limit available resources, including faculty time or clinical space.”

In contrast to the rest of this study, the authors’ limitations section is a breath of fresh air. The limitations of this study are so substantial, in fact, that it would seem more appropriate to list them before the results than after the discussion. Of note, the authors admit that most of their recommendations are drawn not from their findings but from “discussions with experts and knowledge of learning theories.” It would seem this paper could have been written without findings of any kind.

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[1] Judith L. Bowen et al., “Changing habits of practice,” Journal of General Internal Medicine, http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.2005.0248.x/abstract; accessed 9 January 2012.

Ágoston Kecskés

992868991

January 10, 2012

Blog Entry #6: Changing habits of practice

            I found Bowen et al.’s article[1] on the transformation of internal medicine residency education in the ambulatory setting frustrating. Right at the outset, I felt that the authors had bitten off more than they – or anyone, really - could chew.

The authors open with the anecdotal observation that there’s a discrepancy between the total amounts of time that internists spend in the ambulatory setting and that internal medicine residents spend training in said setting. The authors cited data neither about the distribution of internists’ time by setting nor about that of residents’ time. I am not sure I doubt their claim per se but presumably the data is not difficult to acquire. In fact, the data could easily generate enough material to fuel a second publication. It’s conceivable that the data is not easy to acquire owing of the enormous variation in the way different residency training programs are structured across time and space. In fact, this is very likely true. Consequently, the authors’ claim seems more of a sweeping generalization than appropriate motivation for a publication.

The authors also claim that there are significant differences between inpatient and outpatient practices. The authors even go as far as to give examples of such differences despite that, again, the data to support their claims is lacking. At the very least, one would expect the authors to cite a few case examples. As before, one would expect the data to demonstrate quite a bit of variation across time and space, rendering the claim a sweeping generalization.

…to be continued…

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[1] Judith L. Bowen et al., “Changing habits of practice,” Journal of General Internal Medicine, http://onlinelibrary.wiley.com/doi/10.1111/j.1525-1497.2005.0248.x/abstract; accessed 9 January 2012.

Ágoston Kecskés

992868991

January 9, 2012

Blog Entry #5: Teaching exercise

I spent part of the past weekend piecing together an effective teaching exercise for my CEEP selective. Many of my friends and family members are teachers in some capacity or another. I myself have taught high school, undergraduate, and even medical students in various formats. Thus, I generally think of myself as relatively knowledgeable of the challenges involved in assembling a lesson plan. I must say: I continue to underestimate the challenges that teachers face.

            Part of the challenge is uncertainty. There is uncertainty about what the audience knows, what they would want to know, and what they are capable of absorbing in the given 30-minute teaching format – more in terms of interest than intellectual capacity. Furthermore, these are all uncertainties that will be quickly exposed during the 30 minutes of teaching time. There is also uncertainty inherent in the teaching materials, particularly since my topic – smartphones in medical education – is both very recent and ideally should be evidence-based. There just isn’t very much written about smartphones, let alone anything substantial. For the purpose of formulating a research question worth asking, this is fantastic. From the purpose of conveying a valuable message to my audience, it is less than ideal. Then again, the value of the message is in the eye of the beholder. It’s also true that that if I were teaching dusty, well-established material then keeping the seminar interesting would be the challenge.

            To manage the uncertainty I am facing, I will draw on the experience of my friends and family as well as the perspective of my peers. As I skimmed through the medical education literature on theoretical frameworks for clinical teaching, I came across two useful articles from a series entitled “ABC of learning and teaching in medicine.” [1] [2]

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[1] David M. Kaufman, “Applying educational theory in practice,” British Medical Journal, http://www.bmj.com/content/326/7382/213.full; accessed 8 January 2012

[2] John Spencer, “Learning and teaching in the clinical environment,” British Medical Journal, http://www.bmj.com/content/326/7389/591.1; accessed 8 January 2012

Ambulatory Clinics: Learning Through Reflection

Today, our discussion focused on learning in the ambulatory clinics setting and the publications on this topic. Ambulatory clinics constitute a significant component of many Internists’ practice and yet our exposure to the ambulatory settings is often limited. For example, our own clerkship only includes 4 half-days of ambulatory clinics. Although students often enjoy their ambulatory experience, it sometimes feels as if we have just oriented ourselves before we leave again. My interest in learning more through the ambulatory care setting was one of the reasons that drew me to this selective.

What is the benefit of ambulatory care education and how can we optimize it? The importance of this type of experience lies in the fact ambulatory care is quite different in nature from the inpatient experience. Ambulatory practices often involving managing more complex and chronic conditions, through short but longitudinal visits (Bowen et al., 2005). This means that management plans need to be developed quickly but there is expanded opportunity to see the long-term response to treatments.

Publications on teaching in the ambulatory clinic setting emphasize a few strategies for optimizing learning (Bowen et al., 2005; S. Lipsky, 1999).

1. Matching learning and expectations to learner’s level e.g. through sharing learning goals, consistent relationship between learner and teacher.

2. Encourage students to formulate hypothesis and explain rationale to promote active engagement in clinical decision making.

3. Encourage reflection, journaling of ideas, and identifying personal learning issues.

The last point point is perhaps the most fascinating, as with blogging and our daily discussions, reflection has certainly been an active component of this selective. Reflection is considered a valuable part of clinical learning as it targets readings and helps create meaning from experience. For myself, I find that reflection helps put ideas into context, flush out my questions and learning goals, and encourage exploration of interesting topics. I hope to continue daily reflection as a part of my future routine. :)

-Jenny

Lyme Disease: Diagnose Responsibly

Lyme disease was one of the topic of discussion from ambulatory clinic today. Lyme disease is a disease cause by spirochete bacteria of the genus Borrelia (Sabatine, 2011). These pathogens are transmitted by Ixodes ticks, which in turn is usually carried by animal host such as deer and mice. The effects of Lyme disease can be localized (stage 1), disseminated (stage 2), or persistent (stage 3). Its clinical features include a characteristic bullseye lesion called erythema migrans, as well as fatigue, arthralgia, heart block, myopericarditis, cranial neuropathy, and aseptic meningitis.

Lyme disease diagnosis usually involve serology assessment via ELISA, with Western blot confirmation of postive results. ELISA alone can give false positives in the context of other spirocheta infections and conditions such as SLE, RA, and HIV. Treatment typically involves a course of doxycycline (e.g. 100mg PO BID x 10-21d for early disease and 100-200mg PO BID x 2-4 weeks for disease with significant systemic effects).

A large part of our discussion focused on the impact of overdiagnosis and overtreatment of Lyme disease. Questionable diagnosis of lyme disease in some patients can lead to lengthy, costly, and aggressive treatments. Lyme disease lends itself to this phenomenon because of the possibility of false positive in serological testing and the fact its clinical findings are often complex and non-specific. It is important to be cautious in diagnosing Lyme disease since inappropriate treatment, as expected, leads to negative patient outcomes and misuse of healthcare resources (Reid, Schoen, Evans, Rosenberg, & Horwitz, 1998).

Physical Exam Tip from Dr. Ho Ping Kong: if you want to accentuate muscle fasciculations e.g in the context of neuropathy, it helps to tap gently on the muscle belly. 

1. Sabatine MS. Lyme Disease. In: Pocket medicine. 2011 p. 6-21 - 22.

2. Reid MC, Schoen RT, Evans J, Rosenberg JC, Horwitz RI. The consequences of overdiagnosis and overtreatment of Lyme disease: an observational study. [Internet]. Annals of internal medicine 1998 Mar;128(5):354-62.Available from: http://www.ncbi.nlm.nih.gov/pubmed/9490595   

- Jenny

Ágoston Kecskés

992868991

January 6, 2012

Blog Entry #4: MKSAP

Today we discussed the advantages and disadvantages of the Medical Knowledge Self-Assessment Program (MKSAP).[1] Specifically, we reviewed the 1998 version of the MKSAP.

Most of the advantages of the MKSAP are relatively obvious: it is quite comprehensive, it covers all of the major subspecialty areas of internal medicine, and it facilitates independent learning. I was pleasantly surprised to see the inclusion of an annotated bibliography of the key journal articles referenced in the MKSAP text. Such a resource can be invaluable in familiarizing oneself quickly with some of the landmark studies that guide practice in the various internal medicine subspecialties.

The disadvantages of the MKSAP are more subtle. The MKSAP suffers from all of the drawbacks of a multiple choice question format. For example, self-assessors are asked to select the “best” answer from four choices. While simple, this format belies the underlying complexity of the questions. For instance, one cannot choose an answer that is not presented as one of the four choices. In the same way, many of the questions are leading and do not provide self-assessors an opportunity to answer more realistic, open-ended questions. One also cannot choose more than one answer. This is a particularly frustrating limitation in a scenario given that self-assessors may be accustomed to ordering a battery of tests instead of one test at a time and given that self-assessors have also been taught for years to make decisions based on the whole clinical picture versus a single piece of evidence. It is also worth mentioning that the MKSAP can be prohibitively expensive for many trainees. The MKSAP also makes for a cumbersome point-of-care resource.

Happily, some of the disadvantages of the MKSAP could be readily remedied. For example, the drawback of having equal weighting assigned to unequally important questions could be remedied with a simple weighting system. Alternately, the most basic and important questions could be considered separately in the marking scheme to represent a “core” body of knowledge that self-assessors would have to be familiar with to achieve minimum competency. In addition, the MKSAP could “force” learning by not allowing self-assessors to move on after answering questions without confirming the principles underlying both the correct and incorrect answers. This is particularly true of the newer electronic versions of the MKSAP.

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[1] American College of Physicians, “MKSAP 14 Online - American College of Physicians,” Medical Knowledge Self-Assessment Program, http://mksap15.acponline.org/; accessed January 7, 2012