Reflection on the teaching session

A good teaching session is organized and relevant. It is geared to the level of the audience, it makes them care, and imparts upon them a simple message upon which they can build, think, and expand. But if I learned anything from this selective experience it is to make no assumptions. In preparing to teach, especially for a formal session, one must guess at what the audience already knows. However, this cannot be taken for granted. It is important to probe and challenge the audience so that their general understanding becomes clear. It may mean that the teacher must veer somewhat from their original plans, but this flexibility is critical in the success of the session. The important thing is to fulfill the teaching objectives, not to stick to a prepared script. The same is true of clinical practice. We are constantly faced with diagnostic dilemmas where we must make an educated guess. This guides how we investigate, or even empirically treat. But we also look for clues about whether we are right in histories, labs, and clinical course. We cannot simply assume we were correct and go ahead with our present management plan. As issues arise, we adjust our plan and address specific points. With flexibility and constant feedback, focusing on the greater goal - whether a learning objective or a patient oucomse - we will be more successful in the long run.

-Sarah

“Scut work”: an important part of medical education?

When I started clerkship, I found myself doing a lot of “scut work”, or tasks that did not seem to have any educational benefit. Each rotation seemed to have its own. In surgery, this meant retracting or suctioning during a long procedure. In internal medicine, it meant completing discharge summaries, or dictating the notes of patients you had observed. Sometimes, it meant doing things like ordering dinner for everyone on the team and getting all the lab results and charts together before rounding. I often found myself wondering: Am I truly learning? 

In retrospect, I realized that I was (although I didn’t know it). Learning in medicine is so much more than just simply information about diseases and treatment plans. In fact, a lot of clerkship meant learning how the hospital runs and what goes into making sure discharges happen smoothly, patients get to their procedures, and proper documentation is written. It also meant learning how to function well as a team-member and doing menial tasks for others often made me feel more valued as a team player.

I also learned to embrace every experience. Yes, dictations or discharge summaries may have seemed trivial at first, but I began to realize how important they were for continuity of care for the patient once they left hospital. I was also able to derive important lessons from looking through the chart from beginning to end, and often I would realize the personal mistakes I had made throughout the visit. 

In a February issue of the NEJM, two physicians make the statement that medicine is a service profession. They argue that service to patients should not be regarded in opposition to medical education. They write: “As we train future physicians, we should convey the message that service to patients is fundamental to our professional role and an invaluable mechanism for learning.” I happen to agree completely.

-Carolyn

PBL (and why all hope is not lost)

My PBL experience in medical school was less than ideal. The factors contributing to this were both internal and external. I found myself often travelling a long way for a very short session, where the expectations place on students were low and the level of excitement - on the part of both teachers and students - was minimal. I found that my own detachment with the process and my own sense of being stretched for time led me to prepare and consolidate less than I should have, and as a result I did not benefit as much as I could have from the sessions.

There is a discussion elaborated in the literature regarding what makes a good PBL session. One element is social and cognitive congruence - that is, the ablility on the part of the tutor to relate to the student and think and communicate at the student level. I can certainly identify times where this was done - at least in part - and where I felt it motivated me to participate more in the discussion. It is suggested in the literature that this state of congruence is a strong predictor of student engagement. There is also a discussion of the role of expertise and how much the tutor should offer. Apparently, offering expertise leads the student to study less and potentially acheive more. It is possible that offering some degree of information may in fact be helpful, at least for very early learners, as establishing a scaffold can direct students to use their reading time in a more efficient manner. This should not, however, undermine the most important aspect of PBL: working through the case.

The biggest issue that worked against me in PBL was the detachment of all parties from the discussion. After all, PBL is about social interaction in the learning environment. It demands that all individuals contribute to the discussion (and it is invariably improved by the presence of snacks). This leads me to consider that rather than emphasizing only the main learning objectives of each case and the task of information finding, PBL could serve as an important opportunity to teach medical students how to get interested: how to engage with a case. I found the moment I began to function in a clinical environment in clerkship I was immediately engaged in information finding, critical thinking, and collaboration. If we push students in PBL to really wrestle with the case, to come up with investigation and management plans, to consider what still needs to be known, and to preempt issues that might arise, we will not only foster more engaging sessions for student and tutor alike, but we increase the level of preparedness of medical students to think around real cases when they enter the clinical environment.

-Sarah

Do students need more feedback?

Feedback is one of the most vital aspects of medical education. It allows learners to develop expertise, identify strengths and weaknesses, and helps define expectations. It also helps to foster a relationship between the student and the teacher and makes them both active partners towards the student’s progress.

Nonetheless, I found myself in many rotations feeling as if I had no idea how I was performing. I remember meeting with my CTU preceptor on the last day of my rotation and being surprised that I had done well (I guess I should be thankful it wasn’t the other way around). Why is feedback so often forgotten? 

The first is undoubtedly an issue of time restraints – supervisors may be just too busy to have a formal debrief. It is also possible that supervisors have limited information about the student’s actual performance or do not know what the correct standard the student should be held to. It is also possible that there is a worry about the consequences of negative feedback, both in terms of the learner’s self esteem or the future relationship of the teacher-student. Or, perhaps the student is getting feedback and just doesn’t realize it.

Supervisors need to be trained on giving feedback. The feedback also needs to be constructive and should identify areas of improvement.  I have seen a few “models” on giving feedback in the literature and they all seem to outline a similar framework:  set up an appropriate environment, ask the student about their own perceptions, give them the feedback, give specific examples, and review. Seems fairly intuitive.

But, we cannot simply just blame the teacher. We students need to take responsibility for our own education. We need to learn to ask for feedback. We also need to take active roles in self-appraisal and self-reflection. I think as we go forward, we should be relying far less on feedback from supervisors and far more on our own personal assessments of ourselves.   

-Carolyn

Rare diseases

"When you hear hoofbeats behind you, don't expect to see a zebra" 

Over the last two weeks in Dr. HPK’s clinic, I have seen many rare diseases, ranging from dermatomyositis, tendinous xanthomas, to bacterial endocarditis. This is my first time seeing many of these diseases and I am in awe of Dr. HPK’s ability to so confidently make the diagnosis. I have found myself wondering: how much time should be devoted to teaching rare diseases in the medical curriculum? How does one gain the skills necessary to make the diagnosis of a rare disease? And how many cases of a rare disease must we see to confidently diagnose? 

As I did some reading in the area, I was surprised to see that novices are much more likely to make the diagnosis of a rare disease. They are also much more likely to be wrong. This is based on fundamental principles of cognitive biases known as the “availability heuristic,” that the most easily remembered diseases are also the most probable.  This, combined with the fact that rare diseases tend to be the most easily recalled by novices (why else would they be called fascinomas?) suggests that novices are predisposed to making the diagnosis of a rare disease. Having seen a case of dermatomyositis in the clinic, I hope that I will not attribute every case of proximal muscle weakness to this diagnosis. 

Rare diseases should really only be taught fleetingly in medical schools. Medical schools should allot an amount of time to teaching a specific disease that is directly proportional to the prevalence of that disease.

  

Experts can accurately diagnose rare diseases because they are better able to weigh probabilities and are much more likely to have seen all of the uncommon presentations of common diseases. They use pattern recognition much more than the novice clinician, and are therefore usually able to accurately assign a diagnosis. In this way, experience is the best teacher of rare disease. Dr. HPK explained to us that you only need to see one single case of a disease to diagnose it correctly. I think what he meant was that you only need to see a single case to think of the disease – diagnosing is much more difficult.

-Carolyn

Cost Consciousness in Medical Education

 Teaching cost-consciousness to the medical student has often been framed as a paradox. How can we teach the student to always think in the best interest of the patient while at the same time asking him or her to consider the cost to the medical system? I would argue that teaching medical students to become aware of costs will not necessarily drive them to choose less effective investigations or interventions, but rather to be able to identify the more cost-conscious of two equally appropriate options. This discussion, then, focuses not on ethical dilemmas but rather on informed decision-making.

Central to the issue is a consideration of barriers that may prevent an individual from making cost-conscious healthcare decisions. Perhaps the most obvious element of informed decision making is lack of knowledge of all available options. This is very relevant for the medical student who is only becoming acquainted with management and who, for lack of exposure, may be familiar only with the most common course of action at a given institution. Beyond knowledge of available options, many physicians lack knowledge regarding costs of those options. After all, never on ordering or an intervention or on its completion do we see the bill. Some have argued that, for example, labelling antibiotics with their cost in the ordering system may drive physicians to make more fastidious choices (sorry for the pun).

But let’s take the discussion one step further. Even if we did ask medical students to familiarize themselves with the cost of every available intervention, it would remain extremely difficult to comprehend the effect of any given choice on the medical system. After all, the effect is a summation of many separate decisions made by different individuals, which can lead the individual to think, well, ‘what’s the big deal’. Especially when there is a sick patient sitting in front of you, and the bigger, more expensive, ‘shotgun approach’ is often the most comforting to both patient and provider. The implication here is that cost-consciousness in practice will require not only information about costs but also a culture change in that we should feel responsible to consider costs in our decision-making. Our focus in medical education, then, should not necessarily be to teach students all the available interventions and their cost (which will change over time anyway), but to highlight situations in which a cost-conscious decision is being made so that this becomes a central element of the decision-making process.

-Sarah

Does software have a purpose in clinical diagnostics?

I recently read an article in the New York Times about the use of software to develop differential diagnoses. It talks about Dr. Gurpreet Dhaliwal, a professor of clinical medicine at the University of California, who is considered to be one of the great diagnosticians of our time. He is able to come to a correct diagnosis through intricate thinking processes and experience, but he also gives credit to a diagnostic program that he uses as a “second check” called Isabel. Isabel is certainly not the only diagnostic software program on the market. In fact, the history of computer assisted diagnostics dates back to the 1970s, with multiple programs currently on the market.

And it’s not just internists who can use this type of software. Radiologists have also been developing computerized schemes that can automatically detect and quantitate abnormalities in radiological imaging. The purpose of it is to improve diagnostic accuracy and the consistency of a radiologist’s interpretation by using what the computer outputs as a guide or a second opinion.

My first instinct was to think about how useful this type of adjunct could be to our regular diagnostic processes. If we could successfully merge the consistency and preciseness of computer software into our own routine thinking processes, I would think that we might be less likely to miss diagnoses and more likely to consider diagnoses we might have otherwise disregarded.

On the other hand, computer assistance is unlikely to be adopted by all medical practitioners. Many Physicians use experience and pattern recognition to determine a diagnosis, and often do not need the aid of a computer to output a list of differential diagnoses. Furthermore, isn’t medicine more than just sifting through a list of possible illnesses? I think that Medicine is much more of an art than it is a science. It’s about understanding patients’ motivations, showing empathy and effectively communicating and collaborating.

I think at this point in time the use of computer assists is perhaps a little too simplistic. If Medicine could be boiled down to simply plugging in patient factors and outputting the likeliest diagnosis, we would all have been replaced by computers by now. Nonetheless, how and where these types of tools are incorporated into practice in the future remains to be seen.

Original article:

http://www.nytimes.com/2012/12/04/health/quest-to-eliminate-diagnostic-lapses.html?pagewanted=all&_r=1&

-Carolyn

Continuity in Medical Education

Medical school has been a very fragmented experience. The first two years consist of a series of lectures with speakers often changing every hour. Even in moving to clinical learning in clerkship, rotations last a couple of months if not weeks, and supervisors often change even within that period. I have often felt confused about expectations, approaches, and even methods of practice. Which has led me to often wonder: why is medical school so fragmented, and is this fragmentation really necessary?

I've often thought about whether or not medicine can be viewed as an apprenticeship - where a student picks their teacher from which they will learn the trade. However I find the analogy falls short. Physicans do not act as individual experts but practice within complex system of professionals. It behooves us, then, to travel within the system as students so that we may have a diverse experience. The question of how many teachers do we need to have for a diverse experience is difficult to answer. Although a single teacher may give a better appreciation for lifestyle, career development, and also feedback over time, it would be just a small exposure to a piece of a greater system. 

The question then becomes whether our fragmented education is really just a reflection of  a fragmented system of a multitude of 'superspecialties'. Although this certainly allows for a diverse experience, it can be confusing for an early learner to function in a highly specialized environment, where too much expertise can lead to too narrowed an approach to certain presentation with limited patient exposures. Although expertise is often about pattern recognition, it is important to be able to pick out a given pattern from a variety of presentations. 

But does continuity really exclude diversity of experience? I would argue that it does not. Although our current clerkship structure approaches separate specialties as silos, many have argued that adding longitudinal elements to the curriculum can serve to unify the experience. Which elements should be longitudinal? Perhaps those elements that underlie all specialties - commmunication, clinical decision making, and critical appraisal. Or, perhaps a longitudinal patient interaction that will allow the medical student to better understand a patient's journey with illness. In order to reap the benefits of both approaches, it will be necessary to interleave both elements into the curriculum. 

-Sarah

The Art of Observation

My acronym vocabulary has increased exponentially in medical school. It's a very useful way to condense information. Whether it's a differential for cough, ACS management, or indications for dialysis, acronyms function as the skeleton for a given body of information. The issue with acronyms, however is that we can become so focused on remembering what each individual letter stands for that we sometimes forget to look beyond the memory tool. After all, the mind guides the eyes, and it becomes difficult to properly observe a patient when there's a page from T-notes - real or imagined - between me and them. 

 About fifteen years ago, a course was started at Yale University aimed at teaching medical students to discover the art of observation by, well, observing art, or more specifically, the people depicted in classical works at the Center for British Art. The goal was to teach medical students to just look, and that in looking, picking up on cues in the patient's appearance and their environment, a diagnostic answer can often be seen. This selective has been a reminder to look, and to look closely. Although I can always rely on T-Notes for my acronyms, I will only be able to put the whole picture together by carefully observing the patient.

 -Sarah

Can we teach students how to communicate?

This week at CEEP rounds, a project was presented on teaching medical students and residents how to have code status discussions with patients and their families. The lead on the project developed three different videos that focused on the “right” way to have a discussion, reinforcing areas such as encouraging patients to tell you about their perceptions of their health, addressing their own preconceived notions, and allowing time to have further discussions on the topic.

In my opinion, the project has immense potential and definitely addresses a need. I vividly recall the first time I was asked by my senior resident to “get the code status” from an elderly patient admitted for shortness and breath and hypercalcemia related to progression of mesothelioma. I stumbled through the discussion and came out of the room having reached a consensus that he would be “full code”. I could see the look of disappointment on my senior’s face when I told her the news.

Reflecting on the situation, I know I could have had a more meaningful conversation with him. I also know now that perhaps 3 am in the emergency room was not the ideal time to have the code status discussion. Obtaining code status is not taught to medical students in our current curriculum despite having to do it routinely on the internal medicine CTU service. We are taught how to break bad news (which we almost never do as clerks) with small group learning, mock situations and standardized patients. I think that there is a definite need for more teaching at the undergraduate level on how to effectively and empathetically have these difficult conversations, not just isolated to code status but in other areas as well (such as obtaining consent which I have also found to be personally challenging).

At the end of the presentation, Dr. Panisko asked a very thought provoking question: Can we truly teach communication? Or is it a process learned best through personal experiences and learning in the clinical setting? The question is hard to answer. Certainly, in the curriculum, students have found value in being taught how to break bad news, whether through small group discussions or practicing with standardized patients. It’s hard to know though if this value is translated into tangible skills in the clinical setting. Nonetheless, I still think it’s worthwhile to continue to develop novel ways to teach these sorts of communication skills to medical students and residents, whether through one-on-one mentoring with an experienced physician, practicing with classmates or standardized patients, or perhaps even one day learning through videos or online modules.

-Carolyn

When did learning become a science experiment?

Philosophiae Naturalis Principia Mathematica

In 1687, Isaac Newton published his Principia, or Mathematical Principles of Natural Philosophy. It became one of the most influential works in the history of science, guiding for the next three centuries the way we would describe the motion of the universe and everything in it. And he did it with a few formulas: three laws of motion and one law of universal gravitation. Simple. Beautiful. Perfectly applicable in a vaccuum. If only everything in our daily experiences could be described with such expository efficiency. Unfotunately, the conditions of a vaccuum are not conducive to maintaining life. Alas! We must, as living creatures, contend with living in the outside world: a much more comlicated environment where moving objects, though still submitting to the laws of motion, are also pushed and pulled by a massive number of other forces - friction, wind, magnetism - that quickly confuse muddle our predictions of where things will end up and the path they will take in arriving. How confusing.

Caveat Lector

I am not a physicist or a mathematician; not a teacher or a doctor (yet). I am, however, a student. And I have been for quite a while now. The job of a student is really quite simple: to learn, learn, and learn some more. And just like motion, learning is not random. The world of cognitive psychology has taught us a number of principles that underlie the learning process, and that can lead to predicable, reproducible results, at least within the highly controlled environment of scientific research. And although students often find their capacity to learn, like everything else in the natural world, to be affected by a number of forces - time, interest, relationships, carpal tunnel syndrome - I will now attempt to boldly argue that there is at least one universal truth at play in medical learning even when the whole picture gets muddled by outside forces. Now hear this: acquisition does not imply integration.

Chaos in the Classroom: Regehr vs. Norman

What is chaos theory? I'll be honest, I have no idea. It has something to do with the complexity engendered by innumerable interacting relationships that shape one another in systems. It makes the outcome really difficult - maybe even impossible - to predict. It's a physics thing that most people aren't anywhere near capable of understanding. But let's play along for the sake of conversation and join in the dialogue with a couple of experts in the field of medical education research who have engaged in a mental experiment comparing chaos theory to the learning process - and who have disagreed about its applicability. Here's the (highly simplified) capsule:

Regehr: We should shift our focus in medical education research from the search for proof of a single generalizable principle toward a better understanding of the sorts of problems that can emerge in learning environments, and to how we may better describe the complexity of those environments.

Norman: If we wanted to describe the complexities of the learning environment, we would have to use all the computational power in the world, which would be a waste of time anyway because it's more important to focus on what we can learn about how individuals learn and how we can make this learning more efficient.

The focus here, whether at a system or at an individual level, is on description of the phenomena at play, with the presumed end result being to increase our capacity to design more effective educational interventions. Medical students - inexperienced as we are - are not subatomic particles, and the application of theoretical physics to the sphere of medical education is a quantum leap. In the reality of a profession where test score does not imply performance, learning can be described only in a qualitative manner. To apply physical theories intended for quantitative description is to ignore the elemental structure of medical practice in which medical education is embedded.

The Search for Truth in a Complicated World

Learning is complex at an individual level. Place that individual within the context of a classroom, a ward, a hospital, and a greater system of professionnal practice, and the forces, both internal and external, generated by a multitude of interacting relationships and responsibilites becomes so variable and difficult to describe that the likelihood that any one individual will efficiently learn any single piece of knowlege becomes computationally impossible to predict. Research into efficient teaching and learning strategies can help individuals to acquire details, even approaches, but cannot serve to force an individual to integrate this information into a system of practice. The essence of medical learning is integration of knowlege through experience. And although it may be impossible to simply and accurately describe the effect of this system on the individual, this does not imply that we cannot improve educational processes. Which brings me back to the search for truth.

There's a distinction to be made between a functional truth and an absolute truth. Newton's laws of motion are functionally true. General relativity may more accurately describe the truth of how subatomic particles interact, but we still rely largely on Newton's laws because, for all intents and purposes, they work quite well on a practical level for most computational questions. Now, please forgive the irony here: although there may exist absolute truths about the efficiency of educational systems, we would be better served my relying on what we can learn about the learning process at an individual level so that we can apply practical interventions that are likely to prime the individual to learn within an already established system of practice. After all, physicians function as individuals within teams, institutions, and health systems. We must maximize our individual learning to establish our own system of practice. In a era where best practices have become a moving target, the medical student who learns to learn more efficiently with become the better physician.



Sarah.