Adventures in Ultrasound

Ultrasound has always been a bit of a black box for me. Aside from a handful of radiology lectures in preclerkship, our exposure has been limited to periodic opportunities during clerkship rotations. Given the increasing use of ultrasound for various applications at the bedside, these skills will be important to have in the future. 

This past Thursday we had the opportunity to spend and hour with Dr. Cavalcanti in the simulation lab at Toronto Western learning how to use the ultrasound maching, utilize ultrasound guidance for paracentesis, and identify anatomical structures in the abdomen.

We started with how to use the machine itself, a simple place to start, but something that I had not been taught explicitly yet. We learned how to change probes, change the type of exam, and modify the depth and gain. We then moved on to using the machine to detect pockets of fluid in a model of an ascitic abdomen. I have seen ultrasound used to do this on a real patient, and the model offered a better than expected simulation of the abdomen.  We then used a fairly advanced ultrasound simulation model to identify fluid in Morrison’s pouch and in the splenorenal recess.  The simulation was able to render both the ultrasound image and a 3-D animated image of the anatomy in real time, which is a fantastic way to teach trainees about how to visualize the structures they’re seeing on the ultrasound machine.  Clinical teaching about ascites was interspersed throughout the session.

I did a PubMed search about ultrasound teaching and simulation after the session and came across an interesting tidbit in a recent article. Coincidentally, a study was recently published in Medical Education that examined whether training in pairs was non-inferior to training an individual.  In “The effect of dyad versus individual simulation-based ultrasound training on skills transfer” thirty learners were randomized to receive training on transvaginal ultrasound simulators either individually or taking turns in pairs.  Participants were final year medical students completed a pre-test, training, and post-test. They were then evaluated performing an ultrasound examination of the uterus, lateral pelvic wall, and pouch of Douglas.  In the end the results showed that training in pairs was non-inferior to training as an individual, which could make training in the future more time-efficient and cheaper. On an individual level, I didn't feel that taking turns with my colleague during the training session we had on Thursday had any tangible drawback- it was a great session using fantastic technology. 

-SR

Tea Steeping vs. iDocs- A Learner’s Perspective

After a discussion about competency-based programs, I took the opportunity to read “A tea-steeping or i-Doc model for medical education” by Dr. Brian Hodges (http://www.ncbi.nlm.nih.gov/pubmed/20736582). The article explores two different paradigms in medical education, and how they could be reconciled and applied to current needs to medical education.

 The first example that Dr. Hodges discusses is the traditional “tea steeping” model that is fairly familiar to those of us currently in medical school. The “tea steeping” model is the predominant one currently, and refers to the fixed duration of medical training (three or four years), after which it is assumed that a learner will become a competent practitioner.  In other words the tea is the student, and the hot water is the school. This model is firmly entrenched, and a complete departure from it would be quite difficult. Changes have been made to it over time, such as modifying the curriculum, admissions requirements, or lengthening the time of training. 

Issues with the “tea steeping” model include issues with evaluation of trainee performance (often at the end of rotations or courses rather than continuous assessments) and a disconnect between the basic sciences and clinical training. However, at the same time Dr. Hodges states that model may be better for developing habits of mind such as cognitive flexibility and tolerance of ambiguity.

The second model of competence development that Dr. Hodges describes is an outcomes-based one. He describes it as the “iDoc” model, drawing parallels between manufacturing iPods and manufacturing trainees that have a certain set of competencies (in fact he describes how some of the language surrounding outcomes based training reflects that used in manufacturing).  In this model, students progress when they demonstrate competency in certain areas. For example, the orthopedic surgery residency program at the University of Toronto ensures that residents gain mastery of skills in modules such as basic fractures, complex trauma, and pediatric orthopedics. While this model could make training programs more efficient, the logistical issues (organizing rotations, preceptors, and dealing with variable length of training) would likely preclude full implementation.

As a medical student (for a few more months) I generally agree with the benefits and drawbacks of each model. There are times when I reflect on how much time is left until July 1^st and begin to feel somewhat worried about skills I have not mastered or presentations I have not yet seen. As a future resident, I would feel reassured to be in a program where I have to demonstrate clear competency in certain important domains before being considered “fully trained”. However at the same time, I wonder if my mastery of skills would suffer with time after completing the “module” in which it was taught. I can appreciate that the logistics would be difficult to manage, and the variable length of training would make it difficult to plan my career around.  In terms of the “tea-steeping” model, I have appreciated the fact that I was immersed in a four-year journey of learning. I was able to take this time to develop new ways of thinking and approaching problems, and didn’t feel pressured to take on the next module so I could move forward. 

Like Dr. Hodges, I feel that integrating outcome-based training into the four-year curriculum would be a good approach. In some ways I can see this happening already, with our observed histories and physicals in our family medicine rotation (FM-CEX) and the mandatory patient encounters that we have to log for each rotation (though these are not evaluated). I believe that a formalized system for continuous evaluation and feedback during clinical work for each rotation (not just halfway through and at the end) would be a possible next step that I would like to see done.

-SR

Teaching Efficiently

In medical school, most of our didactic learning came during the first two preclerkship years. During clerkship, while we occasionally still have classroom sessions spread out through the year, the expectation is that we will learn primarily through a self-directed manner at home or during our clinical rotations. This learning may come in a variety of forms, including structured morning or lunch rounds, formal bedside teaching, and case-based discussions. Certain clinical rotations such as internal medicine, tend to have more formal teaching sessions, while in other rotations, it is really up to the student to be proactive in asking the preceptor for teaching moments.

Unfortunately, integrating numerous teaching moments into a clinical day may lead to decreased efficiency in delivering care, especially noticeable in community outpatient clinics, where a physician may see up to 60 patients a day. Having a medical student in this setting can result in significant delays, even more so when the preceptor tries to inject important teaching points after each case.
As such, many academic physicians may find it challenging to balance their teaching responsibilities with their primary role as a physician in deliverying efficient, quality patient care. Some, who are extremely motivated to teach, compromise by scheduling fewer patients on the days that students are present, while others who are less enthusiastic about teaching may act more distant toward students. This dilemma speaks to the need for teaching strategies designed for quick case-based learning in fast-paced and time-constrained environments.

Of the many existing teaching strategies, the One-Minute Preceptor (OMP) model has been studied the most and demonstrated to be effective in improving student clinical reasoning skills, knowledge base and case presentation. The model, which recommends five steps for an effective teaching encounter, has been shown to not affect overall clinic efficiency, although studies specifically looking at physician productivity while utilizing this teaching strategy have yet been done. The role of teaching and the art of teaching aren't part of the standard curriculum that all medical students and residents go through, thus resulting in physicians with varying levels of teaching experience. This has certainly been evident as I rotated through the large number of preceptors during clerkship. I can therefore see how incorporating teaching strategies such as the OMP into the post-graduate medical education curriculum (and faculty development) can be beneficial in establishing standards for teaching as well as standardizing learning expectations for students.

One of the reasons why I was interested in this particular selective was that I wanted to learn how to teach and how to teach effectively. However, learning how to teach isn't as easy as it sounds when you consider the different levels of competency of each student, the content-appropriateness based on level of training, the deliverance of the content, and incorporating the teaching moments into a busy day without compromising efficiency and work flow. By being introduced to effective teaching strategies, such as the OMP, early on in our medical career, we can begin to apply them earlier and use them as a springboard in synthesizing our own personal approach to teaching students.

- JJ

Taking Risks

I've never considered myself a risk-taker; in fact I would very adamantly assert that I'm terrified of taking risks, of pursuing actions and routes that aren't thoroughly calculated to produce a predictable and ideally positive result. Perhaps I feel this way out of fear of critique and judgment for how the result may act as a direct reflection of my intellect, a feeling that I imagine I share with many of my fellow classmates. Entering medical school, we have always been academic achievers that strive for perfection. Very few of us have a history of failure - we avoid failure by understanding what it takes to succeed and acting in a predictable manner along that line of knowledge.

So imagine my surprise when I was officially dubbed the "risk-taker" during my first clinic experience with Dr. Ho Ping Kong, a widely-acclaimed physician here at Toronto Western Hospital known for his cryptic questioning style and complex patient cases, which ultimately add up to a very different clinical learning experience. The "risk-taker" title came after he presented a case of exophthalmos through a  patient photograph and asked us what the diagnosis was. Having been taught to approach patient cases with a thorough history first, I was rather unfamiliar with generating a diagnoses based on appearance only. He continued to press us for a diagnosis, however, and with Graves Disease on the top of my mental list I quickly blurted it out. To my surprise, it was the correct diagnosis. The rest of the clinic day proceeded with similar questions: more diagnoses based on images; questions about patients' social histories that we clearly don't know yet, among many others. Surprisingly I found myself more comfortable with taking risks. Giving the wrong answer wasn't a deterring anxiety anymore, as it had been in other settings.

What was it about this particular clinic experience that made me step out of my comfort zone? A number of factors come to mind, however I want to focus specifically on Dr. HPK's mentorship style -a style that differs remarkably from the traditional "approach to ______" usually employed by preceptors. He challenged us to think both within and outside the box, and welcomed our responses regardless of how wrong we were. He injects humour, history, experience and personality into his teaching points, helping us connect patients with stories. As different as it was, his teaching style really worked to keep us engaged. The fact that most of his patients have complex histories and/or diagnoses is also an added bonus, allowing us to explore aspects of health away from the bread-and-butter cases we normally encounter. Together, these facets created an environment that encouraged risk-taking. To be honest, I didn't expect myself to enjoy this style of teaching as much as I did. I'm usually quite disengaged when stepping out of my comfort zone, but in an environment where you're not expected to always have the correct response and you're encouraged to think big and broadly, risk-taking doesn't seem much like a risk anymore.

-JJ

Practice Makes Perfect

My colleague on this rotation and I were lucky enough to have the chance to use the Harvey machine last week under the tutelage of Dr. Matthew Sibbald. The Harvey machine simulates a variety of cardiac and respiratory physical exam findings, and so we got to listen to a variety of murmurs and feel simulated pulses. It was a valuable hour of learning that combined great traditional teaching from Dr. Sibbald with the technology of the Harvey simulator.

Aside from the day-to-day clinical work of clerkship, the learning activities that I have found among the most valuable are simulation activities.  During our surgery, anesthesia, medicine, and emergency medicine rotations we were able to take part in simulation activities that used models and electronics to mimic a variety of medical presentations and emergencies. These ranged from heart attacks to anaphylaxis to traumas. These activities allowed us to apply our knowledge in a practical way and to (sort of) experience what these situations might be like in real life.

The latter point is the first part of why I find these activities so valuable. It’s one thing to regurgitate a written answer on a test, but it is something entirely different to put yourself in the shoes of a resident running a code, immersing yourself in a simulation that responds dynamically to your decisions.  While in the end you know no patient is going to be harmed, it is easy to treat these simulations as real situations.

The second part of why I find these simulations so valuable is because they offered us a way to work on skills that we do not often get the chance to develop during regular clinical work. For example, during our session with Dr. Sibbald and Harvey, we had the opportunity to hear and feel a variety of physical findings for aortic insufficiency that we hadn’t encountered in clinical practice before (and likely won’t for some time). 

Practice makes perfect, and it’s hard to practice skills when the chance doesn’t often come up. Although there is nothing that can truly simulate real life, we’re lucky that these great tools have been developed for us so that we can practice crucial skills, solidify knowledge we’ve learned from our lectures and textbooks, and gain some experience so that we are more prepared outside of the simulation setting.

How Do We Get "There"

I remember observing fourth year medical students during my first rotation of clerkship as a newly minted member of the internal medicine team. They worked efficiently, exuded confidence, and seemed so comfortable in their roles.  I felt a little overwhelmed, a bit lost, and quite unsure of what I was supposed to be doing.  I wondered how I would ever hope to be close to their level in a year’s time.

Fast-forward a year later, and I found myself on the opposite side of the equation. I had the opportunity to work with third year clerks on a couple of electives, and I would sometimes hear them articulate those same thoughts that I used to have.  I would tell them the same thing that those fourth years would tell me as a CC3: that they would get “there” before they knew it.

I wish I could have told them exactly what to do to get “there”, but it was hard given I am not so sure what “there” is. Sure, I felt a little more confident as a fourth year student than I did as a third year on my first or second rotation, but there was no clear difference in my mind (as opposed to say, observing a staff physician and a clinical clerk). There were no clear steps that I could say led to this minor boost in confidence, there were no “aha” moments, and no one area that I could recommend focusing on.  In fact, I found myself in the same boat again, observing the PGY-1s and wondering how I was supposed to be like them come July 1^st.

Our third year clerkship is an immersive yet somewhat disjointed experience. We are thrown into different hospitals, different teams, and different disciplines. We are exposed to a variety of teaching styles depending on our rotations, residents and staff.  However, all of these experiences invariably seem to add up and spit us out on the opposite end of the core clerkship as students who can function reasonably well in a hospital or clinic setting.  What happened in that year that changed us? That got us “there”?

I have talked about this with my peers, and it usually comes to the consensus that the only things we know are that it requires time and experience in the mysterious contraption that is clerkship to develop more confidence in the clinical setting and that there are always greater levels to strive and work towards (i.e. developing into a PGY-1). 

“There” is a moving target, and what “there” is will always change.

What I am looking forward to doing during this selective is looking inside that contraption and seeing how it works. What components of it work to help us along our path, and which parts could be improved. I am excited to learn a little about how we learn (though I am certain I’ll only scratch the surface in three weeks), and to see what I can do to be an effective part of the clerkship experience for medical students as a resident in the (very near) future.

Transitioning from Transitions

Exactly one week ago I was sitting in a classroom, listening to a series of lectures and seminars meant to prepare us cohort of fourth year medical students for residency. The information presented was, for the most part, non-clinical, and addressed instead the social issues of medicine that we may face in the years ahead. For me, the week of classroom discussions, groupwork and clinical reflection was rather different from the weeks prior, which consisted of a rigorous CTU rotation followed by interviews, and would be just as different as the upcoming selective, which I have now since commenced. Over the four years of medical school, there are numerous transition periods, both formal (eg. Transition to Clerkship and Transition to Residency) and informal ones (eg. pre-rotation "crash course" weeks). I found that there were two main domains of difference that existed during these transition periods: the pace of daily activities, and the type of thought processes required to succeed in each working environment.

What I experienced during my most recent transition from classroom activity to clinical activity was difficulty in adapting to both of these domains. The change in pace of daily activities would be considered more of a physical change, though there certainly exists a mental adaptation as well. When you're not faced with rigid timelines for responsibilities on a daily basis for a significant number of days, the physical body may adapt to this new standard and become "sluggish". Simultaneously the thought processes involved in classroom learning is also different from the clinical setting, as one must switch from passive to active participation, which involves the addition of situational communication, idea synthesis, and problem interpretation and solving to the basic foundational components of listening and observing. When the first set of these skills become inactive for an extended period of time, you often require a period of time for them to get "turned on" again and regain your competency in them. For us learners, this period of time where we are "transitioning from a formal transition week" may last anywhere from a few hours to a few days (or perhaps even weeks) depending on what you're transitioning from/into, how long the formal transition period was, and your established level of competency in the required skills prior to the transition. Unfortunately, there is ongoing fluctuation of skill competency in junior medical learners since we are constantly learning to adapt to new rotations with each rotation often requiring different skills.  Having interspersed week-long classroom periods seem to fragment the continuous flow of competency training even more, at least perceived based on my clerkship experience.

So how can a clerkship curriculum address the fragmentation of working pace and thought process perceived by students? Or rather, is there even a way? Or is it more up to the student to learn to adapt his/her learning and working styles efficiently during these transitional periods to accommodate the curriculum requirements. I think a healthy balance is necessary in this case, achieved through feedback-guided curriculum changes as well as student motivation to take ownership of their learning. Take for the example a pre-rotation “crash week”, when students are bombarded with a wealth of information, often presented in extraordinary clinical detail. The basis of scheduling the teaching this way, in a way, still makes sense since we need at least some knowledge before seeing patients. However, not having seen any patients with the presented conditions yet, it’s rather challenging to apply the classroom knowledge to actual clinical cases in a meaningful manner. What some rotations do, is have the teaching spread out over the entire rotation allowing students to revisit and synthesize the information after having the opportunity to see patients with those concerns, thus eliminating the concept of the “crash week”. I understand that this may be more feasible in certain services over others; nevertheless after speaking to several colleagues most still feel the same way –that their learning tends to progress more continuously when education is delivered simultaneously rather than clustered together. The fragmentation seen here is but a morsel compared to the overarching challenge of continuity in medical education which has been the subject of debate for a long time. While certain changes have already been implemented, it’s highly necessary for us medical students to continue offering feedback on our current experiences and frustrations and how they’re contributing to our learning success.

-JJ