Friday, April 19, 2013

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. 

Saturday, April 13, 2013

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.