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.

Pimping: useful exercise or outdated practice?

“Tell me the number one cause of malignant hypertension,” Dr. HPK asked me, on the first day of clinic. To be honest, I wasn’t sure. But I put forward my very best guess. I went home that night and, although I probably should have been reading about the causes of hypertensive emergencies, I found myself thinking about the art of pimping.

I came across an interesting article by Brancati, published in JAMA in 1989, on the purpose of pimping. He suggests that “the deeper motivation [for pimping], however, is political. Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem.”

I completely disagree. From my own experience, pimping is much more about identifying knowledge gaps and subject areas that need further work. I also find that the practice helps me remember cases and notable findings. Personally, I find it to be an important and useful pedagogical tool, not to mention an enjoyable exercise. I think that when learners hate pimping, it has more to do with the pimp than with the practice itself. Dr. HPK has a wonderful way of asking questions that seems supportive and helpful. I think that pimping can be a really good learning tool if it is respectful to students.

I also found myself wondering why the information gathered through pimping is so much better recalled by the student. I went back to an old lecture on memory delivered by Dr. Bonta in my first year of medical school. He taught us about the integral role of the amygdala as a modulator of memory. He explained that emotionally charged events lead to an increase in glucocorticoids which eventually lead to better recall of the events through the amygdala. It seems to me that pimping produces just the right emotionally charged event for the student (who is fearful of getting the answer wrong) to facilitate the best recall of the case or learning point.

As I reflect upon my role as a future learner and teacher, I can definitely see a role for pimping. As long as the pimp is supportive and respectful but can produce enough of an emotionally charged response from the student, it can be a useful teaching tool. The question at this point is how to teach teachers how to pimp.

-Carolyn