Monday, June 27, 2011

Should medical students be taught Parkinson's by Movement Disorders Specialists?

I've been thinking about this topic for a bit after it was discussed as a side point by Dr. Doug Gelb, neurology clerkship director and card-carrying general neurologist from the Universtiy of Michigan. He argued that when choosing a teacher for his courses, he prefers someone who is less specialized in the subject matter than a world's expert in that particular disorder. The background of this is that there is an increasing trend for neurologists to sub-specialize. Especially those people who choose to work in academic centers, it is often seen as your way to distinguish yourself and create a niche from which you can work towards a cleaner path to promotion. I am not immune to this, as I sub-specialized in Parkinson's Disease, and of my residency classmates who went into academics, we all are sub-specialty fellowship trained (albeit an n of 3).

Dr. Gelb purposefully invited lecturers for the clinical aspects of the neuroscience course to speak on areas where they are not fellowship trained (indeed he gave many of the lectures himself). This is a very interesting approach, as the typical medical school model is to get the most senior, and most well-known person in your institution who is willing to talk to do the lecture. The theory is that a person who spends all their time seeing patients in one area, and reading literature in primarily one area will become so engrossed in the small points that it becomes very difficult to see to the broader picture. Hence, even though medical students should focus on differential diagnosis of Parkinson's and early treatment, the lecturer may spend a few cursory slides on this (as it is relatively boring material for them), and then skip to detailed slides of rasagiline as a potential for neuromodulation and the neurophysiology of deep brain stimulation. If you're not a Movement Disorders specialist, you may not really understand why these two topics are very interesting and worthy of multiple slides. That's the point. In this line of reasoning, we are training medical students to be generalists, and they can then specialize and differentiate in residency. Thus, they need to know what a generalist will need to know to be able to care for these patients in their typical practice. The other point he made is that students would rather have a consistent face and style to the lectures by limiting them to a few key faculty, than have a parade of world-renowned gurus each doing a one hour stint of a four to sixteen week course.

I'm not sure I'm ready for all sub-specialists to be banned from the lecture halls. I've seen many lectures by sub-specialists which have really be quite nicely done, and targeted at the appropriate level. In some respects, it's like giving a talk at any level, there is some skill involved, and the skill-set necessary to become well-known in your field and well-published in your field is not the same skill-set necessary to be an effective lecturer. I also think that the specialist is going to be more adept at answering questions that come up from the audience as these can be varying away from the knowledge one learns by seeing a few patients with this condition and ventures more into experience gained only by having been exposed to rare phenomenon. Here a generalist may not have the depth of knowledge, and may be working on older literature or their patient experiences may be skewed due to not seeing the volume.

Hence, I would make two suggestions. One, if a generalist or a specialist gives a talk, it may be a good idea to have your slides reviewed by that person's counterpart to see if there are gaping holes or large volumes of unnecessary minutia. I think if I'm choosing between two skilled teachers, specialists are probably better suited to teach the material. However, if you are faced with a well-trained, excellent speaker who is a generalist, and a specialist who is a great clinician, but not a great teacher, I would choose the generalist. With the caveat, that if the specialist is available, maybe an alternative would be to have the two people team teach the module. This team-teaching model might be ideal in that you could have one or two people be the core faculty who introduce topics and then lend the microphone to various specialists to provide more depth to the discussion.

What do you all think? If you had an equally-good specialist or generalist, whom would you choose.

Disclosures: As a sub-specialist, I understand I may be biased here. Also, I used choosing of lecturer as a model to posit the discussion, but really this could be applied to any formal teaching session or clinical teaching scenario.

Wednesday, June 1, 2011

What does Mark Zuckerberg have to do with Twitter patient privacy issues?

If any of you have any interest in health care, and have been on Twitter, you all know about the debate which has been swirling about privacy issues and professionalism. Let me start out by stating that I highly doubt this post (or any post) will likely change some people's behaviors. At the end of the day, Twitter is a free space where you are able to to post whatever comes to your mind, so the individual will still have the ultimate choice what goes on their stream. If you missed it, the original post by Dr_V, Bryan Vartebedian, that brewed the 'storm in a tweetcup' (name via @scanman) is found here.

However, choosing what one puts on the stream got me thinking about one of major issues in the divide between those who are for healthcare professionals posting whatever comes to mind, and those who are against it. It brought me back to an article I read a while ago about Mark Zuckerberg. The link takes you to a similar article (I couldn't find the exact one I read), but the essence is that with the progression of the use of social media, and in particular Facebook, Zuckerberg felt there was no more need nor use for privacy. What I read his remarks to mean is that in the world before Facebook, we went to work as doctors, nurses, PA's, etc, and we shared a social space with those workers which was different from how we were when we were in a space with patients present. We then went home, and had a social space with friends. There were social norms associated with how I was to act as a doctor with my patients (or in earshot of patients), and these were different that if I was in the resident room with the door closed. The language was different, the tone of the conversations was different, and the subject matter was different.

Enter Facebook. Now, I have this social feed that goes not just to targeted groups, but to everybody at once. The old physical barriers of social spaces were broken, and now I share everything with everyone. Everyone has made social gaffes by temporarily forgetting who all is in the 'room' and a Facebook status that would otherwise have been innocuous becomes a social nuclear bomb. There are two ways to go once you have had this experience. One, which Zuckerberg advocates, is to say that the old paradigm of having a compartmentalized existence is essentially a false way of living, and everyone should understand that there really is only one you, thus you should be free to express any thoughts you have to all of your friends. This creates a more real and genuine world over all. Thus, if my patient can look at my social media presence and see that I struggle with daily frustrations just like everyone else, I'll be better to relate with them, and build a better bond in the long term.

The other view, is that these social spaces were created over time for a very good reason, and there really should be boundaries between professional life and private life (and what is said in front of patients and what is said in the resident room). This view argues that the blurring of these lines leads to confusion in the doctor-patient relationship. How can a patient trust me to talk to me about a potentially embarrassing social history point or pain in an unflattering area of the body if they are concerned that I will likely step out of the room and make a disparaging remark about them on their Twitter feed. That remark may then be retweeted to viral levels before I've found my car in the parking lot.

Obviously, this debate is more complex than just this point, but I think a large part of it comes down to whether you agree with Zuckerberg's position or not. Do you feel that your online social media presence on the open web (and Twitter is much more open than Facebook) should be compartmentalized or not? I thought about this as @DrGhaheri had a conversation with @SeattleMamaDoc about how to define the lines of the debate. He had wondered if if was based on political viewpoint, but quickly corrected himself. He tweeted, "not cons/liberal from political standpoint but as a lifestyle. Maybe "proper" and "conservatism" had to do with judgment." I think that the line is not entirely conservative vs. liberal (although each of those views probably lend to having you lean one way or another). I think the answer is more, are you pro-Zuckerberg or anti-Zuckerberg. Feel free to leave your thoughts below.