Friday, July 31, 2015

Is there an upside to the noise of seemingly irrelevant content in medical education?

As I have worked in planning curriculum in medical school either as a course/ clerkship director or in various school-level committees, a common question keeps coming up. How much is too much information?  Or conversely how little do you need to know about basic science to be able to competently practice medicine?

The age of the 'Google' search and other tools like Epocrates and PubMed being capable of getting a seemingly endless stream of factoids answered instantly makes this question more difficult. How much do I need to know versus how much do I need to be able to know how to look it up?

I don't think there is a perfect answer to this question, but let's use as an example GI histology. As a neurologist, if you asked me how much I have used my knowledge from medical school of GI histology in the past six months, I would probably laugh. Most neurologists would probably laugh as when you ask that, what comes to mind immediately is the day in med school microscopy lab where we looked at the slides of intestines and identified the villi cells. I don't do that anymore - like ever.

However, in the last six months I have taken care of Parkinson's patients with gut motility problems and constipation and I've also taken care of people on whom we were considering gluten-sensitivity as differential diagnostic points. We also know the carbidopa/levodopa competes with protein in small intestine absorption. How much of my ability to understand these basic problems with occur daily in my clinic is founded in part on my original knowledge of GI histology? What I think it critical to consider when considering what level of detail of GI histology is important to physician training is to consider what is implicit knowledge that allows me to solve problems. This means looking beyond the typical response to any given topic where a practicing physician says, "I never use that." (Biochemistry anyone?) This means spending time unpacking the implicit framework knowledge on which you have built much more complex concepts. On the flip side, there are some things which I learned in med school which I really don't ever seem to use much now even as much as I try to rack my brain to figure out if I do use them.

I'm not sure of the best way to puzzle this question out. I'm a little worried about running the grand experiment of just stopping teaching the med students all the tiny details we have taught in the past without first pausing to understand the repercussions. There is not likely going to be a firm line in the sand somewhere where a given topic is relevant or irrelevant, it'll look likely more like a large sandy smudge. However, every teacher of med students has to draw their line somewhere, and it would be good to have some alignment within a med school system.

Friday, June 26, 2015

How might a pure competency-based curriculum change residency interview season?

OHSU is one of several schools that recently received an AMA-funded grant to push medical educational innovation.  Our new curriculum, YourMD (yeah it has a cool marketable name), is in many ways a test lab for this grant (to be clear, most of what I'm going to discuss here is beyond the scope of the current version being developed for the YourMD curriculum, and I'm outlining my personal view of what the model may look like in the future).  One of the primary themes in OHSU's work for this grant is to create a workable competency-based (not time-based) model of medical education.

Multnomah County Hospital residents and interns, circa 1925  
As you can imagine, there have been many questions about the logistical problems with such a system.  One of the issues raised at our institution as this concept has been discussed at various faculty meetings is the perceived trouble students in such a system will have in finding a residency program.  After all, the student will have this transcript which looks remarkably different from most of the current school transcripts.  It will have a bunch of competencies and EPA's.  It may not have any mention of honors.  How is a residency director to be able to choose who is the best candidate for their program?

I've thought about this a bit, and have a few ideas.  First, if the school is truly competency-based, just the fact that the student has been able to graduate should indicate that:

a) The student understands and applies the knowledge necessary to start as an intern,
b) The student clearly demonstrates the skills necessary to start as an intern
c)  The student clearly demonstrates the professionalism necessary to start as an intern
 
To my mind (assuming the system will work as advertised), this is revolutionary.   This means you don't have to guess as a residency director what you are getting.  You don't have to read between the lines for the secret codes hidden in the letters of recommendation.  This person is ready for residency
.  End of line.

So, then what do you look for now?  Now, as a program director, you can begin to look more at what other experiences and skills does this particular individual have that would help them thrive at any particular institution. Instead of trying to assure that the person had 'honors' in internal medicine, the medicine program director can sort applicants in all manner of ways. They could determine their program wants people who have above-average skill in quality-improvement, or they could decide they want residents who are particularly interested in medical education. They can rank based on how well they operate in a team-environment. They can look for students who have had particular experiences that would benefit them in their environment - say a lot of rural practice experience or many rotations in an under-served inner-city.  Each program director can choose what they'd like to highlight, and I don't see a problem with letting students know what they are looking for in applicants. This makes the interview sessions even less about figuring out if this person can operate on the ward successfully, and more about does this person fit well with our system and our culture.

If competency-based education works, this may be something residency program directors will need to think about. We're all well on the way to competency-based education. So, program directors, prepare yourselves. I think it'll make interview season more fun actually.

Friday, March 13, 2015

Robert's rules and the digital age (or my one day as chair of the curriuculum committee)



http://digitalcollections/files/h/214.jpg
Oregon Medical School Admission and Advanced Standing Committee1950's
Sometimes things happen to you without much thought or planning.  In February, I was sitting in what I thought was an inconspicuous corner of the room during the monthly curriculum committee.  Paul Gorman, the committee chair was paged, and somehow found me even though I was behind him, and motioned for me to take over the meeting.  I've been chair of the clerkship directors subcommittee for over a year now, so chairing is not completely foreign to me.  However, the curriculum committee is bigger and sometimes contentious, so my pulse quickened just a tad.  My reign ended approximately 3 minutes / 2 comments later.  I thought I was done, and slunk back into my usual spot against the wall, only to be re-jolted as Paul said he would be gone for the next meeting, and Robert's rules required that he could not appoint an alternate chair, but the committee must appoint an alternate chair.  A voice said, "Well, he did a good job."  Moments later, I was voted curriculum committee chair for a day.
 I was impressed that Paul knew there was a Robert's rule pertaining to the absence of the chair, and as the newly-appointed curriculum committee chair of-the-day, I thought I should review Robert's rules myself.  The OHSU school of medicine website on committees led me to this document.  It's on the one hand a very tedious set of rules.  On the other hand, it represents a time-tested means for a group to come to a decision on matters important to an organization.  However, there are a few areas that I noticed where this document may need some updating.

First, it mentions specifically a lot of papers, here are three examples:









This language should probably be cleaned up to say "document" at the least.  Also, what's the deal with not being able to write on the papers?  Should we extend this rule to pdf marking apps like Notability?  It seems a titch silly to me to have this laid out, but perhaps this is for maintaining the integrity of the first draft.

Next, there is this bit about everybody needing to sign the document physically:


Can we amend this to say we can 'sign' by a form of electronic signature - in many cases now a reply from a personal email account with a signature block is what is required.

The last bit I found that needs updating pertains to remotely logging into a meeting (I found this on FAQ about parlimentary procedure):



I'm thinking that as time goes along, remote log in to meetings via web or phone will become more the norm than the exception.  I haven't been to a curriculum committee meeting in over a year where someone wasn't logging in remotely.  I think this one should be changed so the default is that remote login of any sort in real-time should be considered present and able to vote.  Being absent and voting only by email, is probably along the lines of mail-in votes, and probably should be prohibited.  As the rules don't mention video login or VOIP logins at all, I think this rule needs updating as well.

As I'm not a parlimentary expert, I'm not sure if these issues have already been addressed, I'm just going by what my school of medicine references as the rules we abide by.  It's overall a good system, it just needs a bit of a nudge into the twenty first century.   Please leave your thoughts or any updated parliamentary rules links you are aware of below.

Thursday, February 20, 2014

6 things to make your medical school lectures better

So, I realize that many schools are trying to minimize lecture hours, but the truth is that this modality will not likely ever go away completely.  As such, I've made a draft of some guidelines for lecturers in the course I co-direct based on common mistakes I've seen.  Implicit in these guidelines is the idea that I have a lot of rotating lecturers, and some of these issues can be avoided by decreasing volume of presenters.  However, we're stuck in a cycle where I can't really easily change that in the next year.  Please share in the comments if you have other things I haven't addressed.

*Note - NSB stands for neuroscience and behavior -a 9 week introductory course on neuroanatomy, neurophysiology with and some clinical neurology, psychiatry, and neurosurgery.

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NSB lecturer guide:
Please adhere to the following guidelines when giving lectures for NSB.  These are general trends which I have noticed over the last few years in terms of best practices and things to avoid if possible.  In general, please remember that these are students who have spent the last year and a half going to lots of lectures.  Things which seem trivial to you as you only do one or two lectures, for them are agonizing as they see these issues over and over again for two years.

1)            Do look over the slides of lecturers who are talking about related topics to your lecturer.
- Helps a lot with keeping continuity through the course.  It would be nice to not have you say, “I’m not sure if you have been over this before or not.”  If you are not sure, please look it up or ask.

2)            Don’t ever say, “This will not be on the test.” 
- Sometimes it is a minor point in your lecture, but it is a major point in a prior lecture (again why it helps to talk to others) or a later lecture (maybe even in the next block).  OK to say, “This is a minor point for the purposes of this lecture,” or “For this lecture, this is primarily FYI.”  We tell the students that everything mentioned in class is potentially testable.  If you don’t want us to potentially test it, don’t mention it at all.  If you must say this, talk to the course director to be sure it REALLY will not be on the test.

3)            Try to stay away from disclosure slide jokes.
- The first person who puts up the “I am actively looking for people to give me money so I can disclose it” slide is funny.  The next five are not so much.

4)            Please know how much time your lecture is scheduled for, and try to stick to that.
- Our general lecture block time is 50 minutes.  In general, we plan our lectures to end 10 minutes prior to the next lecture.  So if your lecture is at 10, you should plan to be done by 10:50.  If you bleed over, this makes everyone behind you have to modify their talks.  If you have a lot of slides left, and are running short on time, consider stopping where you are at, and recording the end of the lecture to be posted online.
- If you are the last lecturer of the day, it is OK to keep going (within reason).  However, please announce that it is OK for students who need to leave to be able to get up and go.  Some students have tight commute times to get to community preceptor sites by 1 PM or have to walk across campus to do OSCE testing over the noon hour.  Also keep in mind that there are noon talks which occur periodically in the lecture hall.

5)            If you are not skilled at PP or basic functions of the audio/visual equipment, please learn minimum functions.
- For PP, you should be able to start and stop your presentation, restart  from the middle of a presentation, go backwards and forwards using only keyboard, understand what the purpose of a right click is, start and stop video presentations, be able to disengage auto-advancing of slides.
- For A/V, you should be able to turn on and off overhead projector, mute/ unmute the screen, turn on/off the mic,  Turn mic up/ down using front panel controls.
- If you are uncomfortable with this, talk to TSO, and they can help you learn how to do these things.

6)            Do feel free to experiment with audience participation techniques.
- Using clickers for in-lecture quizzing, use of pause for students to work through a problem together, and other techniques are great ways to get students involved in the lecture.