Teaching in an ambulatory clinic - how to make routine follow up unboring

One of my colleagues doing a botulinum toxin injection

I have worked with students in my outpatient botulinum toxin injection clinic for about five years now.  The students who work with me in this clinic are generally first year students.  When I first signed up to have students work with me in this clinic, it was primarily because from a scheduling standpoint, it made the most sense as I often have a fourth year student from the neurology clerkship working with me on my other afternoon clinic, and the first year students are in class all morning.  It was only after I had the students working with me for a few weeks that I realized I was doing the same thing over and over again.  Injecting botulinum toxin is fun to watch a few times, but after that, it all looks the same.  I've tried to use some strategies which can be used in any clinic to help students in this experience to still get value out of the clinic even after being with me for 10 weeks.

1)  Discuss communication and encourage empathy:   I spend a lot of time talking about how
I try to shift my approach from a communication standpoint with each patient.  We talk a lot about how I approach patients who may have personality quirks or special circumstances.  As many of the patients in my clinic have been seeing me for years, I try to provide background for the students about how other aspects of their care have affected their lives in general, and how I've needed to make adjustments to their dystonia treatment over time.  I can talk about a wide-range of conditions including some very deep discussions I've had with patients about end-of-life issues in the past.  This allows each patient encounter to create a space to talk about more than just "This is another cervical dystonia," and turn it into a more rich discussion of this is how I I talked to this patient about cervical dystonia in the light of a new cardiac diagnosis and what changes we made.  Those changes don't have to be made that day for it to be a salient discussion point with the student.

2) Even small amounts of participation is appreciated:  This works better for first year students who often have little clinical experience, but I think it does  help even with more experienced learners.  In the botulinum toxin injection clinic, I will have the students only observe for the first day or so.  After that I have them clean the injection area with alcohol swabs, and hook up the EMG ground and reference leads.  Although that doesn't sound like much, for a student, it makes them understand that they are being helpful and are a valued part of your team.  In truth, it does make things go faster as it takes about the same amount of time to wash my hands as it does to prep the patient for the injections.  As possible, I also try to let the students do one injection in a relatively straight forward site by the end of the ten weeks.  It doesn't always work out that a good patient/ injection works out on the last day of the rotation.  But, even doing one injection for a student is potentially a big deal.  Not as big a deal if they were in healthcare prior to med school, but most of the students who have worked with me would probably put that .25 cc IM injection on their list of highlights for the year.  You just need to put yourself back in the shoes of a first year student to remember how excited you were to do just about anything back then.  Then let the student do a very low risk part of the procedure.  Let's be clear, I'm not advocating for the student to do an injection into the iliopsoas (an injection with an EMG needle into the anterior thigh very near the femoral nerve/ artery/ vein).  But doing something on a small scale is good.

3)  Ask them what they are currently learning and try to find a connection:  Doesn't always work, but if they are learning about microbiology, have them read between patients about clostridium.  If they are learning about basic physiology, have them read about neuromuscular junction synapse function.  If they are learning about cardiac function, have them look up the anticholinergic effects of botulinum toxin.  Or if a patient you see has A fib, have them look that up and listen to their heart in clinic.  The trick is to try to make it not feel too constrained, and not feel like you are making something up for them to do, but to make it something they see value in learning more about.   This also applies to the professionalism or clinical skills teaching sessions most students are learning as well in first and second year.

4)  Show them a bit of the business side of medicine:  This again sounds boring to you and me, but most students don't have much exposure to how the billing system works.  At least once or twice during the course of their experience with me, I'll have the students look over my shoulder as I input the billing codes for the patients.  I explain briefly the difference between a CPT code and an E&M code.  I talk about how I put in the prescription for the toxin.  I understand this system will probably change a bit before they are billing, but I again try to put myself in the position of where I was as a first year student, and I had no clue what that stuff was all about.

There are a few lessons I've learned in the ambulatory setting.  But using these thoughts, I recently had a student write on one of my faculty reviews how they were worried once they found out they were in a procedure clinic for 11 weeks, but were amazed how interesting it was each week.  I also have had students who have been requesting to work with me for the past several years.  I'm sure this is not a novel list, and others have thought about this before. 

How much data should you give in a medical education case presentation?

Many people like to use cases to teach principles in medical education.  This makes a lot of sense as it highlights how whatever information being presented will be relevant even to a busy practitioner.  Clinical cases are also commonly used in assessments to assure that students and other learners understand a concept as it applies in a clinical setting.  Most of these cases whether taken from a real case the presenter has seen or whether it is made up by the presenter has a lot of information in it.  This is to help lead the learner usually towards a specific diagnosis.  I think there is value to this approach, and I think it can be used appropriately.  However, I have noticed a paradox being set up with the amount of information presented in a case in a presentation or assessment.  The paradox is the more information presented, the less broad clinical thinking is, and the more the case focuses on a single disease state, and the less it focuses on clinical reasoning.

To begin my explanation of this, let me explain what I have commonly seen, and thus what people expect from a case presentation.  Usually a fairly complete history and physical examination is presented with the level of detail normally encountered in a chart note.  Sometimes the information is irrelevant, but typically there are key pieces hidden in the data to allow the person to find the correct answer.  The goal of the learner is to find the key piece of information which will move them to the correct disease.  One example would be a kid with developmental delay who is presented with a really long history.  Somewhere hidden in the history is the physical finding of a 'cherry red spot'.  For those who are not neurologists, even years after taking boards, there is likely a monosynaptic arc in your temporal lobe which automatically just screamed, "Tay Sachs disease."  If it didn't scream this before, it has now been re-cemented in your memory banks to reside there from many more years.  The trouble with this is that it can lead to premature closure - most neurologists, especially pediatric neurologists, would argue that there are actually a number of other conditions with a 'cherry red spot,' and if all you think it Tay Sachs, you may miss the actual diagnosis.  In this case, the overy complex medical case presentations (or books like 'First Aid') may be doing a bit of a disservice as they are designed to help you pass MCQ tests, and not to help necessarily in the clinic.  I'm not arguing the all medical knowledge is bad to know, nor am I arguing that a well-developed schema of important differentiating features of diseases is irrelevant.  In some cases, learning about a single disease entity is the goal of the learning session, and this may be entirely appropriate.

What I am arguing is that we should consider using cases which don't have the hidden key word which points to a specific diagnosis if you are trying to teach about a broad diagnostic topic like developmental delay in a kid.  I would argue that a very skeleton case with even just a chief complaint, duration of illness, and cursory demographics can be effectively used as a case presentation.  This works well for either introducing a topic or as an assessment to be sure your instructional experience has been successful.  The first thing I hear from audience members when I put up a slide with not very much information is, 'I need more history, and a physical.'  Why?  I think part of it is that it is true that you do need more information, but part of it is they are not used to a format of learning where the answer is not supplied on a silver platter.  Think back to how many case presentations you have been given that didn't have that hidden factoid in it somewhere.  But, I'm not trying to teach about the factoids with these cases, I'm trying to help people learn about the depth of their illness scripts.

In other words, everyone knows that an expert clinician in a particular area has an ordered differential diagnosis in their head way before the hidden factoid is presented.  However, we don't spend much time in education with ambiguity.  We like to spend a little time on the differential, and a lot of time talking about the really rare diagnosis or rare variant of a disease.  I'd like people to spend more time on thinking about how they formulate a differential.  I'm more interested in what my medical students (or other learners) can give me as a differential diagnosis for a person with a chief complaint of parkinsonism, than whether they can ferret out the early apraxia and language dysfunction and correctly diagnosis CBD (corticbasal degeneration).  What I'm more interested in is can they come up with an ordered reasonable differential with a little bit of information, and decide which questions and physical exam findings will be needed to work through that differential.  In doing so, we build a much more robust illness script for those diseases.  Now I have a script for developmental delay for Tay Sachs which is deeper than just 'cherry red spot.'  I think we just need to use these techniques more as medical educators so our audience comes to expect working with ambiguity and not certainty.  The main reason for this, is that real life is ambiguous.  Real patients are ambiguous.  And in real life, I'm honestly not sure my fundoscopic exam skills would be good enough in an toddler to actually see the 'cherry red spot.'  So, if all I have is that in my illness script when presented with a kid with developmental delay, I'm hosed.

Medical students want syllabus 3.0

I've been getting feedback from students over the last two years on what materials they would like to have included in the course materials distributed with our second-year neuroscience course.  I have heard a very clear message from the students over the two years I've been teaching the course.  The expectations for what is included in the course materials and which readings are required has changed over the last few years.

Let me take you back to the mid-nineties when I took my medical school course work (and my college experience in the early 90's).  Let's call this syllabus 2.0.  I received copies of all the slides presented (as long as they were in PP, we still had some lecturers who used slide carousels and they had minimal notes printed - call that syllabus 1.0).  In class we took notes.  If you missed or ditched class, you could look back over what the lecturer talked about by subscribing to a note taking service which was run by the students.  Readings were from the required textbooks.  Test questions covered anything in the printed syllabus as well as anything said verbally in lecture (even seemingly off-hand remarks) and anything covered in the textbook.

In this model, the material is presented, but there is a intentional (or unintentional) fire hose level of information delivered.  It was up to the student to wrestle with this large volume of information, distill it down to essential concepts, and organize it in their brain to allow them to pass the test.  It was expected that there would be some test questions which were not covered explicitly in class, and the purpose of those questions was to differentiate the top of a group of very highly motivated students.  The upside of this model is that if forces the student to be able to analyze large volumes of information some of which is not a core concept, and independently synthesize the important concepts.  This skill is not outside of the required skill set to be a doctor in a clinic.  The downside is that there is room for the individual student to miss the boat and miss out on important concepts which aren't explicitly identified as core.  Also, this model can increase student anxiety during test preparation as you are not clear until you take an exam if you are missing the boat.

Let's move to 2013.  Our course syllabus was inherited from the above paradigm,  and we have been modifying multiple lectures.  Hence our lectures don't have well developed outlines or notes by the faculty to accompany PP presentations.  Students have on several occasions pointed me towards courses at our institution and others where the course materials include extensive annotation by the faculty in addition to the slides.  Students over the last two years have said things like (paraphrased):

"What I want is to have everything I need to know about this lecture written down so I can go learn it."
"I don't want to have links to a whole bunch of useful information about a topic, I want a single link to a very succinct, applicable resource."
"Even if the syllabus for a class is 450 pages, if it is all I need to look at, that's what I'd prefer."

Another way to state this is the students would like a curated information repository which is finite, organized, and focused on the learning objectives.  This sounds to me like it is mirroring discussions about moving from web 2.0 to web 3.0.  In other words, there is a desire to block out noise and focus on what is important to the individual.  Thus, all information in the course materials is honed to efficiently deliver information necessary to perform well in the course.

The upsides of this is that is very clear what the student is expected to learn.  From a pedagogy standpoint, this is an ideal situation for an educational model based on measuring competence.  Hence it is clear what measure to obtain, and all learners can potentially reach this bar.  The downside is that this perhaps does not help in the long run as this is not how real life medical decision making occurs.  There is no finite set of combinations of signs and symptoms, so often there is a need to be able to process a cacophony of noise and distill out the important ideas.  There is always more to read or more detail, and part of being a doctor is gaining skills in deciding how to be your own curator.

Which is better?  My view is we should aim in the grey of the middle.  I think it should be clear what is necessary to pass the exam, and if all material covered in class, small groups, and presentations is mastered.  I agree that if there is a picture slide, that it is reasonable for a lecturer to include some text to create context for the slide.  I do think it is also reasonable to have some way of assessing whether a student can surpass these minimal competency levels.  On an exam, that means asking questions which may not have come specifically from the readings.  It may introduce a novel topic and apply the concepts learned in class in a new way.  What are your thoughts on how much detail should course materials contain?

How we teach medical students to view other healthcare providers

I've been thinking about an aspect of the 'hidden curriculum' lately.  It came up in reviews of the neurology clerkship over the last several years.  There have been a few comments over the last few years about staff and residents making statements behind the closed doors of the conference room about the competence of colleagues from other departments and other institutions.  I don't think this is unique to our department or to our school of medicine.  The question I have is why does this happen?

I know this is not unique to us as I encountered these same scenarios as a student myself on all the services I rotated through. This is a typical scenario, a resident takes a call with a request for a consultation by another service.  They hang up the phone, and break into a tirade (sometimes with expletives included) about how stupid the person/team was for not being able to address this problem by themselves.  Too often this exchange happens before the phone is put down, and it can grow into a literal shouting match. I've seen this same pattern after discussions with support staff for a lab value or to call an on-call tech in to the hospital ob the weekend.  There's also the easy target of the referring physician from a smaller hospital who called to transfer a patient.  Often these comments include jokes about the intelligence of the people on the other end of the phone.

So, why does this happen?  Let me discuss one possible reason.  First, from a medical training perspective, I was taught very early to be a critical thinker.  Much of clinical reasoning - especially diagnosis and treatment decisions - occur in a vast grey area between the seemingly sharp lines of common diseases and syndromes seen in medical school textbooks and lectures.  This means you should approach every patient's problems from the beginning and rework the steps to diagnosis to assure yourself of the correct diagnosis and treatment path.  Taken in a positive way, if you come to a different opinion than previous providers, you can potentially change the treatment course and make the person better - which is good.  Taken in a negative way, every time you do this exercise, you find that there are many people who don't think like you do, and you can start to get the idea that you are the only provider in the region who has competence.  This bias towards thinking that presumed errors are based on incompetence are sometimes actually true - perhaps the provider is indeed not safe to practice medicine.  However, I think this is not really true as often as may be grumbled about int the confines of a conference room. First, clinical presentations are often subtle initially, and just the fact that you are evaluating the patient later makes things clearer.  Also, you already know what didn't work which usually helps narrow the differential diagnosis or treatment options.  Also, you have no idea what the context of the day/ night was for the provider as they were making those decisions.  Again, I'm not saying that every misadventure is justified, but I'm saying as professionals our job is to take care of the patient.  Out job is not to jump to conclusions about what happened before we were there.

This behavior then gets passed along to our students who see it modeled all the way from residents to staff.  It's accepted as normal behavior, and like other parts of the hidden curriculum it is passed down from one generation to the next.  Please remember this the next time you are tempted to make a disparaging remark.  Now, I'm not saying good natured joking and  friendly competition should be outlawed.  There are very good jokes out there about neurologists, and I know some good neurosurgeon jokes.  Humor can help us all deal with stressful situations.  I'm not for banning it completely.  I'm just asking for some thought before making a sarcastic comment about a colleague.  Would it be OK for that person to be in the room with you when you say the comment?  If yes, then it is likely just some banter.  If no, it may be time to rethink.  Especially with students in the room.

One final thought.  The other side of the coin is that we usually hear back from colleagues who tell us about things we did well.  Rarely do our colleagues report back to us on things we could have done better.  Thus, you likely have a reporting bias on your own performance on  these types of issues.  So, be careful who you are criticizing as it may well be yourself.

Medical eduacators - no degree required?

Higher education has a this little secret.  Although it is getting better, most of the people responsible for delivering content and designing curriculum don't have a degree in education.  I'm not saying I'm the most learned educator, but I do have a undergrad degree in education.  I frankly fall back on the learning theory and curriculum design background daily as a medical educator.  However, my colleagues around the country don't have that.  I'm not talking about going to a one- or two- day seminar on teaching skills.  I'm talking about a degree from a university or college that states you have completed coursework in education.  I don't see that around these parts much.  And I honestly think medical education (and higher education) suffers for it.

I'm not saying that there are not good teachers in medical schools.  There are wonderful and devoted teachers in every aspect of medical education.  Also, years of teaching does help refine one's skill, and many medical educators have 'learned on the job' and have a decent knowledge base of educational theory.  I'm also not saying that everyone who has an education degree of some ilk is automatically a great teacher.  I'm also not saying that this is at any medical school in particular, but really it's everywhere.

What I am trying to say is that just like I'd rather see a cardiologist for my chest pain than a pediatrician, I'd rather have someone with some training and background in how learning happens and best ways to do education be the person teaching our future physicians.  There, my rant is done, and I feel better.

Clinical assessment variability - what is really causing it?

There was a recent article in Academic Medicine by Dr. Alexander and colleagues from Brigham and Women's Hospital describing the amount of variability in clerkship grading among US medical schools.  They found that, unsurprisingly, the grading systems for the clinical years had really no consistency at all.  There was inconsistency among the grading systems used (traditional ABCDF or honor/pass/fail or pass/fail) - (table 1), and even within the schools which used a similar scale the percentage of students receiving the highest grade was all over the place (table 2).  So, the question is what do we do with this information?  I think no one really expected findings that were different, but now the answer is out there, in print (or on digital reader screens).

I think part of the answer to where we go from here is to decide if this article was really asking the right question.  The authors do start to talk about this in the discussion section, but I'll try to lay out my thoughts with a little different spin than they gave their discussion.  I think the real question is what are we using the assessment of the clerkship performance for?  What is the essence of what we are trying to measure?  Only when there is broad consensus not only between schools, but within the individual courses of each school will there get to be any semblance of uniformity of grading of students.  I see at least two competing interest which influence how a clerkship director decides to come up with a grading system.  The first is the idea that the students should be measured on how competent they are in the area the clerkship is grading.  In other words, when they are on call as a first-year resident or as a 50 year-old physician, do they have the knowledge and skills to assess a patient with a given problem.  Second, the clerkship director also wants to be sure that the students at their school have a fair chance to compete for selective residency programs.  Thus, there also needs to be a system to distinguish high-achieving from low-achieving students.  The first system is more about the individual student, and with this system, by definition, everyone should be able to achieve the highest score with enough effort and work.  In the second system, it is more about evaluation of the program, and the group.  In this system, it cannot be possible for everyone to achieve the highest score.  However, the system can be manipulated on both sides to aid students or to make it more hazardous.  There are benefits and risks of each system - as with anything in medicine.

I don't think these interests are necessarily incompatible, but they create a tension which I've seen in national meetings and in local curricular meetings.  I also think most clerkship directors are not aware of how this tension affects the grading system they have developed.  I think their not aware as the debates I've heard are usually about tools for assessment or the numbers of honors.  Rarely does the debate get to the level of what is our ultimate purpose for the assessment.  The answer to that question must shape how grades are assessed.  Only when we all become very clear about what we our goals are for the assessment will we truly be able to come to a place where we can have a national dialogue about how to unify the system.

Simulation training vs natural history in LP battle royale

I read an article on the use of simulation in teaching lumbar puncture (LP) technique to residents by Dr. Simuni and her medicine colleagues at Northwestern University.  I thought it was a really interesting article and helps to add data to the idea that a curricular plan in medical education which includes deliberate practice and simulation does a really nice job of teaching learners a new skill.  It hints that this deliberate practice in a logical fashion is better than the traditional model.

I'm not so sure this paper really definitively answers the question that this practice is superior to the traditional training model.  In brief, the article pits final scores on a mastery checklist of first-year medicine residents who underwent a three-hour educational session including simulation to teach proper LP technique against neurology residents who were asked to simply do the LP simulation while being graded on their performance on the checklist.  I think this result may stand over time and additional studies, but I have a few problems with it.  First, the neurology residents were not shown the checklist.  I think this is a big deal.  I don't know the proper place to do that to get adequate controls, but essentially the medicine intern group was taught to the test.  It was deliberately pounded into their heads over the three hour session that these are the things they are going to be graded on.  That's what deliberate practice is all about.  It's about repeating something to get it right.  To my mind, that is teaching to the test.  The neurology residents weren't given time to familiarize themselves with the simulator (at least it didn't say they were).  They also weren't oriented to what they would be evaluated on, so of course they didn't perform as well on the checklist.  As they have likely done multiple LP's it might have also been easier to skip to inserting the needle in a simulated environment as it feels artificial, and it feels like this is the ultimate goal.  It might have been more useful to go to the bedside of the next LP these residents did and see if the 'real world' performance was different between the PGY-1 group and the neurology residents.  I doubt any neurology resident would forget to get informed consent in the 'real world' (but I may be wrong).  Maybe the simulation training in part, trains you how to take the final simulation exam.  I'm not saying that it was not a good idea to do the simulation training, I do.  I'm also not saying the checklist is invalid or has no practical applications, it does.  I'm saying that the PGY-1 group had the deck stacked in it's favor. 

I would also argue that the way I learned to do LP's was essentially with deliberate practice over time with multiple patient experiences.  When I was first starting, I had a senior resident or faculty over my shoulder giving me feedback on my technique.  Could this have been improved upon by adding a simulation session at the beginning of my training, absolutely!  But I don't know that this study really proves what they say it proves which is that traditional training is inferior to simulation, and neurology residents can easily be schooled by interns fresh from the simulation lab.  This is shown by comparing the neurology residents with the interns at baseline.  The neurology residents were all better just eyeballing the data.  I think if you had put the neurology residents through the training, they also would have achieved a higher level of mastery.  *That's a neurologist talking of course :)

I do want to say that I am a bit concerned at some of the mastery items the neurology residents missed (as were the authors).  The anatomy questions would have likely been taken care of by brushing up on the anatomy before the test, but you could argue especially a senior neurology resident should know that.  The authors were concerned about anesthesia, but that could have been a function of being in a simulator vs 'real world'.  It could also show how one of the schools has a local practice which is different from national norms.  The setting up of the tubes and manometer in a proper fashion is a bit vague to me, and I'm not sure I'd know what the proper position should be for that.  I wouldn't make that a make or break point on this procedure.  Not saying how I know this, but one can recover surprisingly well with the one handed method of unscrewing the caps in a pinch.

So this is a long response to the article as the editorial that accompanied it was trying to make the point that the traditional model was inferior and should potentially be reconsidered.  I don't think that is what this study showed.  I think it did prove that mastery level is attainable with a 3 hour simulation lab for PGY-1.  I'm not sure it really proves they are better than neurology residents.  They may be, but I don't think this was a fair assessment of that.