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.

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.

Senioritis in medical school - How to motivate the abulic state

It's that time of year where med students throughout the US shake hands with the Dean, and pull their tassels in unison from the right to the left.  In the months leading up to the tears and endless photo ops that mark any graduation, the students are finishing up the last few rotations of their medical school career.  Although some students retain focus on their swan-song rotations, in every heart there is always the lure of looking beyond the present rotation to the allure of residency in all its glory.  Some have more trouble than others with maintaining drive at the end of the final year.  Most students post-match are taking electives or required courses which are not directly aligned with their chosen field of study.  This makes some sense for getting a Dean's letter together and positioning one's self to be a desirable residency applicant.  Post-match all of this does not seem to matter as much.  Indeed, there has been discussion among academic educators that there is a missed opportunity in the fourth year of medical school largely based on articles like this one from Dr. Lyss-Lerman and colleagues which outlined residency directors view of how well the fourth year is working to prepare for residency.

So, I have a bunch of fourth year students in my neurology clerkship, in fact I have only fourth-year students with the exception of a few third-years that can take neurology as an elective in one block in November.  These students are largely not going into neurology.  How do I try to keep them engaged in our neurology rotation.  (Full disclosure - I'm fully aware I can learn more about how to do this.  I definitely still get some students for whom my little tricks don't work.  This is partly why I'm starting this discussion so that we can all learn from each other).  Here are some of my ideas:

- Have them create their own goals - In orientation, I encourage the students to come up with their own course goals and objectives.  I have prepared goals and objectives, and they are held accountable to those, but there may be specific areas they want to focus on as an area of weakness or as an area which is important for their specialty.  I tell them that in residency, you will not always have clear objectives which are overtly given to you for every rotation.  Thus, I made a habit in residency of picking 2-3 key things I wanted to learn.  When I was on cardiology as an intern, I wanted to sharpen my EKG reading skills and my cardiac exam skills.  Thus, I had something to focus on while taking care of those patients.  Intrinsically created goals are more motivating.  I encourage the students to follow that model as they move on in their career.

-  Encourage exploration of topics related to their field - This is partly a student-led issue, and partly faculty development.  Often students will stay engaged if the faculty recognizes what they are going into, and discusses aspects of a neurological case which is of interest to the student.  For example, we had an OMFS fellow rotating through the neurology clerkship, and I took him aside to discuss a case of a siallorhea I was seeing in the setting of neurodegenerative disease.  Sure it's important for him to know how to treat those diseases from a neurologic standpoint, but he's going to be more interested in the salivary issues.  This can then be used as a doorway to get them to be interested in the rest of the disease.

- Try using games - I haven't used this in my clerkship yet, but as a medical student and a resident, we had an attending (Dr. Harold Adams) who would play Neurojeapordy several times during the rotation.  Students were put into teams, and asked neuro-trivia questions about neuroanatomy, neurological differential diagnosis/treatment, and neurological history.  As a student (and a resident) I really enjoyed this.  It's a way to get students to want to read up on disease states, etc.

- Scare the bejeezers out of them - I will often also play the card that in only two to three short months, they will be responsible for caring for patients on their own (in a supervised fashion initially).  Their signature will mean something, and when someone in their care has a neurological problem, they will likely be the first person to evaluate the situation.  Starting on July 1.  Most students understand this logic.

These are just a few ideas I've used.  Any other thoughts on how to motivate the post-match senior on a required rotation?  Leave them in the comments below!

Virtual hospitals - The future of medical simulation?

I was flipping through Facebook the other day, and saw a video posted by a friend.  It was over 17 minutes long which is eternal in the world of Facebook videos, but I thought I'd give it a try as it looked interesting.  It ended showing people from 'The Gadget Show' making a simulator which not too long ago would have been pure fantasy.  They built a tent with 360 video output capability that also has a 360 degree treadmill to allow you to move in the virtual world by walking as you would in real life.  They also hooked up an X-Box Kinnect sensor to pick up other body movements.  They through in a few other cool add-ons, and they ended up with a truly immersive environment for a first person shooter game.  You can watch the video here.

I got to thinking that this technology is now available, and could be used in medical school to train physicians.  It's not yet at the level of being a holodeck, but it is closer than we've ever been before.  I could envision a program where there is an ambulatory office building, and the student has their own clinic to run where simulated patients come in be interviewed.  The physical examination is done through use of gestures mimicking what the real PE would be, or it could be coupled with a simulation manikin to elicit the physical findings.  Then the student has to go back to a virtual staffing room, and dictate the encounter, and order testing.  They then move on to the next patient.  If you had enough of these built (assuming in the future this type of technology gets cheaper), you could envision having a 'continuity clinic' set up completely in a simulator.  This might include seeing some of your regular patients back as they come through the emergency room for acute conditions or even going to the OR.  It could be as complex as there is time and money to create the scenarios.

I often thought in residency that it would be interesting to have an immersive simulated hospital where you could spend at least some of your time as a medical student or as a junior resident.  There you could have freedom to make some truly independent decisions and see what happens.  I think the advantages to something like this are obvious and are akin to the flight simulators that pilots use to train.  It will never replace time spent on the wards with skilled clinicians giving supervision and feedback.  I don't think the technology is there for a completely realistic medical simulation.  But it is getting closer. 

Are laptops/ tablets connected to WiFi forces for good or evil in lecutre hall?

This post is in response to several things I've read and heard lately about the use of devices to connect to the internet in medical school large group teaching sessions.  Essentially these posts or comments have been either strongly in favor of the introduction of these technologies, or strongly against.  I haven't found much of a middle ground.

Those against argue from the idea of distraction.  The argument is laid out in several recent research studies looking at the effects of multitasking on cognitive performance.  The basic idea is summarized pretty well here, in an article from the San Fransisco Chronicle.  This is the view held by many basic science course directors who make comments to the effect of, 'if they have their laptops out, they are likely playing solitaire.'  I've also seen some people speaking about generational differences in learning styles who state that the Millenial generation has grown up with multiple electronic devices going.  This falls back on the data that they feel like they have done this for a long time, and should be good at it, but they are not really.  As they don't have any insight into this potential hazard, we as course directors should act to squash this tendency by telling everyone to turn off their electronic devices.  Hence, the common wisdom among these presentations is that it is important to have the learners switch off their devices on entering the classroom for their own good.

On the other hand, there are many potential up sides to having a wired classroom.  First, audience response systems using web-based or local networks are becoming more sophisticated and more robust.  This is much more than the audience clicker system where the audience can push a button to answer usually a multiple choice question (A,B, C, or D).  But there are systems like Twitter that can allow 'back-hallway' discussions or ability to ask questions which can be answered by the presenter in real time.  Newer platforms can collate rich text entries and also collect images.  Many of these allow ability to catch if the audience is out of step more efficiently by than the traditional method of waiting for someone to raise their hand.  Secondly, there is also the ability for the individual learner to go down a 'rabbit hole' right away to pursue a question they may have had.  For example, I interjected a clinical example of hemiballism after a lecturer was talking about subthalamic nucleus anatomy.  I had not shown a video, as I just stood up and extemporaneously gave the discussion.  As soon as I was done talking, a student in front of me had called up a video of hemiballism with a video demonstrating it.  And these are just a few brief examples of the good that can come from online activity during a lecture.

The last point I'd like to bring up, is that this will likely not be a point of discussion soon.  Our med school is considering going to a paperless system where all notes are distributed electronically. Our med school is likely a bit behind the curve on this.  My point is the same devices that allow you to read PP slides, and take notes on them also play Angry Birds.  There's not currently a good way to facilitate one task while blocking the other.  My point is that the ability for a lecturer to demand that everyone turn off their devices.  Thus, this may be analagous to a record company trying in the late Nineties to divert attention from digital devices playing their music and focusing only on
CD's.  Who's bought a CD recently?

So, where do we go from here?  As I look over the neuroscience course this morning, most electronic devices (except mine) are showing slides on epilepsy treatment (which is the lecture we're having today).  So most people are using the technology wisely.  However, with email only a click away, the temptation is strong for attention to wander?  What are your thoughts?

What I learned from the cerebellum yesterday about timeliness

*Note - photo is archived, and not from the lecture mentioned

My fellow course director yesterday gave what was actually a very nice lecture on the cerebellum to our second-year medical school neuroscience class.  It was clear, and it was logical.  But it caused a bit of trouble.  The trouble was that it included a lot of detail.  He had an hour and a half, and he covered 65 slides which for one of my lectures is usually more than I attempt, but I didn't think he was rushed as he went through, so I don't have a problem with that.  he was logical in his presentation and it was all pretty clear, so that wasn't a problem.  It was also organized relatively well.  No, the trouble came from the age-old medical student complaint that the test is today.  And he changed his slides the night before.  And did I mention that the test is today?  And they already had to review brainstem anatomy with cranial nerves and the motor system as well for this test earlier in the week.  And did I mention that the test is today.

I accept part of this is on me as a first-time course director.  There were somethings in the schedule which we purposefully changed in terms of timing to try to improve the flow of the course.  Of course, we have had the typical issues of lecturer availability changing up the timing of a session here or there.  But, some weeks we just kept as it was, as they worked last year.  This is one of those weeks.  I didn't even really revert my mind back to med student mode to realize that putting something as complex as the cerebellar anatomy the day before the test was a bad idea.  It was a bad idea, as basic educational literature supports the idea that concepts are retained more if they are repeated and if they are applied.  We really didn't have time to do either with the cerebellum.  So, next year we will rectify that problem.  This year, the schedule has been set for several months, and there's not much room now to swap things around.

My reason for this post isn't about whether this was an ill-fated lecture or not, it is more about the student reaction to the lecture.  I was in the back of the room as the lecture ended, and the reaction generally from those that sat in the entire auditorium was best described as anger and frustration.  Frustration I can understand.  I can understand that there was a lot of information presented and that this may have been perceived as not being 'fair'.  However, there was also an underpinning of anger that, although I understand where it comes from, I find a little troubling.  I've seen on Twitter some posts by med students after a bad lecture where the venting becomes more of a personal attack on the lecturer themselves.  That is where I think there is a bit of a problem.  This also comes out in the narrative evaluations we receive from students for courses.  There are plenty of comments which are truly helpful, and point out errors which can be corrected.  Then, there are those that don't give much rationale for why the lecture was not good and how to improve it for the future, but they are just downright mean.  I totally realize the the first and second year of medical school is a time of high pressure and stress.  I also understand that processing all that information in the time required is a monumental task.  I understand how a poorly organized talk can make things worse.  I understand that medical students are paying a lot of money for this.  But I also understand that as good as any educational program is, there are going to be times where you try something and it doesn't come off as planned.  I also know for sure that my co-course director's intent was to provide more details to clarify the major points he was making.  His intent was not to harm, but to help.  I think the majority of lectures I went to in medical school, the lecturer honestly wanted to help the students learn about things they are passionate about.  True it is not always presented with great oratory skills or organization, but I think the number of lecturers who truly despise students and purposefully are trying to mess them up is very small.  So, all I'm saying is that part of professionalism we are trying to teach in the medical school curriculum should include how to give reasonable feedback to educators without being judgmental.  Yes, the lecture was ill-timed, and changing slides on dense lecture the day before the test was ill-timed, and that feedback should be given.  It's not OK in frustration to launch an all-out personal assault.  Because, at the end of the day, most medical students still find a way to wade through those messes and learn what needs to be learned.  It's not fun, but as I move forward in the 'life-long learning' cohort, most of the stuff I'm presented with is a huge disorganized pile of information some of which is contradictory, and I need to work it out myself as I have a regular test I take regularly in the exam room of my clinic.  And also, the theory is that the course director's job is partly to take that reasoned feedback and create changes for next year to improve.

Paper vs Pixel - Use of On-line or traditonal books in medical education

I was at at team meeting yesterday to orient faculty to the neuroscience course I'm co-directing next year.  We were going through the section where I was relaying to them our required texts for the course.  One of the faculty (who happens to be a physiologist) asked which physiology text we were using for the course.  On the list we have a nice neuroanatomy text, a brain atlas, a psychiatry text, a pathology text, and Harrison's.  He felt the neurophysiology discussions in our clinically minded neuroantomy text were lacking, and the other faculty in the room agreed with him.

So this left me with a dilemma.  Do I have switch from our current neuroanatomy text with a definite clinical foundation a more comprehensive text with neurophysiology covered more completely?  Such a text was used in the past, and was felt to be too dense for the needs of medical students.  Do we have them buy a text that focuses only on neurophysiology in addition to the neuroanatomy text?  I think this would likely just lead to them not buying this text as we'd only need a few chapters, and I'm not sure it would be very useful for them in the future honestly.  It would likely be more dense than the book we already rejected.  Do we just give them the lecture notes to study from?  Or do we search for/develop online references for them to use.

This last point led me to the rebuttal I had to requiring the students to buy another textbook.  My impression from talking to fourth year students is that the majority of them do not buy textbooks any more.  I can actually see good reason for that.  First, textbooks are and always have been expensive.  Textbooks are also notoriously slow to adapt to new information (new editions come out every few years, and take a year or so to develop, so are at best a year out of date, and at worst 2-3 years out of date when they are read).  Compare that to most online resources which are free (or available for free through institutional subscriptions).  Online resources aren't guaranteed to be updated frequently, but at least the possibility is there for them to be updated frequently.  Also, with the advent of more interactive pages, there is a chance for things to be updated as new information is developed through crowd-sourcing.  Hence, my idea that asking students to buy another text is foolish, as I'm not convinced that their all going to buy the first 3 books that are already on my list.

From theater seating to studios - Medical education reform of learning spaces

I took the above picture from a blog outlining recent University of Virginia School of Medicine's curricular changes.  These changes in part integrate learning theory ideas that participatory learning creates better retention than passive learning (read small group discussions are better than large group lectures), and also incorporates the use of new technology seamlessly into the curriuculum.  This includes a physical learning space change from a tiered lecture hall to a learning studio with multiple tables to foster small group discussion.

The medical school I am at (OHSU) is looking to build a new medical education building.  The current plans call for learning studios for the first and second year courses as opposed to the traditional theater-style lecture hall we now have.  I had asked in my last post for some feedback on curricular reform, but I think I may not have given a focused enough question to get a good discussion going.  So, this time I'll be more to the point on what I'm REALLY interested in here.  So, what I'd like to know is:

1) Has your medical school (or other higher education institution) already switched to the learning studio format for large group presentations in the first and second year or are you planning on switching soon?
2)  What have been successes/hurdles if you have implemented this style of learning space? 
                    -  Our course directors have specific concerns about the amount of faculty development needed to   pull this off given our current heavy reliance on lecture)
                    - Are there innovative teaching methods you have implementing using this type of space which is not possible with a traditional lecture hall?

I'm personally thinking this will fit my emerging person style of large group lectures quite well, as I've moved much more to giving introductory statements, and having learners figure out the rest as they work through a case study or an example.  I appreciate your comments (as does our basic science sub-committee)!