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. 

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.

Augmented reality for neurological education simulations

I am laying down a challenge for app developers out there who know more about programming than I do.  This challenge comes from a day-long IAMSE meeting course I attended over the weekend on state-of-the art medical simulation tools.  What I saw was some pretty cool simulation is available today to replicate many physical signs and to help train on various procedures.  These simulations have come a long way from when all Harvey could do was teach you how to pick up a murmur consistent with mitral stenosis.  Now you can check blood pressure, pupillary response, breath sounds, and the mannequin can even talk to you.

The trouble (from a neurologist perspective) is that current simulation is great for cardiopulmonary physiology and simulation, but it leaves a void for the neurological exam.  It can teach laproscopic surgery, mimic a prostate nodule on DRE, and a lot of other things.  But aside from pupils and having the machine shake to mimic a seizure (which I haven't seen, but from the description, it sounds like a very large Tickle-Me-Elmo type of convulsion - ie all trunk movement and not much arm or leg movements), the neurological exam is as yet uncovered.  I think a lot of that comes from the fact that the neurological exam will require pretty advanced robotic arms and legs to mimic things like fine finger movements, and strength testing.  Hence, essentially you can equilibrate an essentially comatose person's exam for the most part.

I see an opportunity for augmented reality to step in while the robotic simulation takes time to become more sophisticated and cheaper.  I could imagine using a real person as a simulated patient sitting in a chair, or a simulation mannequin in a gurney, and have the student hold a tablet up to the person so that the view screen is over the torso.  Then an augmented reality protocol could take the image of the arm from the simulation, and overlay a realistic-looking tremor.  Or you could overlay realistic ataxia with heel to shin testing.  Or you could overlay a realistic tongue deviation, tongue fasiculations, or palate deviation.  Thus, you could more efficiently create a high fidelity simulation with neurological deficits.  I've asked my bioengineer friend about this, and he said it could probably be done, it'd just take money to get off the ground.

So, there's my challenge.  Create an augmented reality neurology exam simulation.  I'd be interested to hear if anyone is already developing something like this, or if someone if any app makers would be interested in making this happen.

Social Media: Are med students SoMe-philes or SoMe-phobes?

As with any question about human behavior, I don't think whether students love or hate social media has a definitive answer.  If you talk to students about it, you'll find answers vary from one to the next.  I have talked to many students about this, and I have found the continuum of students thoughts on social media was more varied than I originally anticipated.

The main thing that surprised me at first is that not all med students have active social media accounts.  I had this vision in my head of these students getting through their college years with the prototypical laptop open with multiple chat windows going, Twitter and Facebook windows chock full of 'lol's and 'rofl's, streaming a soccer game from Sweden, video chatting on Skype with a friend at Harvard, and working on a paper on Word researched through a Wikipedia page.  While some of that might be true for some of them.  I've found a healthy percentage (at least 1-2 in 10 in informal talks) do not have any social media accounts including a Facebook account.  This crowd is usually a little sheepish to admit it, but they are a substantial chunk of current medical students.  Also, in a class of about 120, I usually find 2-3 students who have a Twitter account which I thought was a bit lower than I'd expect.  I don't think my initial perceptions are that unique, as in a recent #meded chat on Twitter, this subject came up, and many academic physicians on the chat were surprised by the numbers I just shared with you.  (I haven't yet done a formal survey of med students, but that may not be a bad idea...)

It's easy to assume that the Millenials are the 'digital' generation, so they must all be on social media.  So why are they not there?  I think part of it is that there are genuinely some younger people who still prefer an analogue life.  I don't mean this in a negative sense, but there are people out there (even young people) who are aware of the technologies available, and understand the potential benefits, but don't feel it is worth the time and effort.  Some have even tried it out, and didn't like the experience.

The second reason I hear is that there are a good number who are scared of its potential harm, and feel this risk outweighs the benefit of seeing pictures of their college roommates baby.  You don't have to be in medical school for very long before someone from the front of a lecture hall tells a story of social media gone horribly wrong, and these stories usually end up with suspensions and expulsions of students.

Another thing I've picked up in talking with students is that very few of them realize they can use social media as part of their job as a physician.  They also don't realize its potential positive impact, so few of them are engaged in it.  Many are worried about it.  I've even interacted with a few med students on Twitter who have a nice presence, but were seriously weighing whether to include their blog/Twitter profile on their residency application.

What has your experience been at your medical school?  Do the confines of your school promote social media friendliness or social media angst?

Evidence based medicine in second year courses: Too much too soon or just in time?

Once again sitting in the back of the neuroscience and behavior class, and I've noticed another interesting phenomenon as the course as gone on.  As we cover stroke, the clinical presenters are presenting much more clinical trial data than the other clinicians did (including myself for example as I the presentation on Parkinson's disease).  Part of this is due to the veritable glut of evidence from strokologists.  As stroke is very common, it is not hard to get large trials together, and the stroke literature is now quite robust.  And, rightfully so, the stroke physicians are proud of their work, and want to communicate the data.

This raises a bit of a tension in the second-year neuroscience class.  This tension is that these students were introduced to vascular anatomy yesterday, and stroke pathophysiology earlier in the morning.  So how soon is too soon to talk about EBM?  The focus of the course is more on learning the basic science, and getting an introduction to differetial diagnosis and treatment.  Hence, when I talked about the clinical context of Parkinson's disease, I presented a lot about the clinical syndrome, and the differential diagnosis, and initial treatment options with pharmacologic information.  As I'm a clinician, the pharmcology focused on adminstration route and side effects.  But I didn't really show any primary literature in my slides.  The stroke people showed a lot of primary literature - SPARKLE, CLOSURE, CREST, ECASS, NINDS tPA trial, the list of acronyms paraded across the screen.

So the tension lies in the fact that students do need to know that there is evidence which supports our clinical decisions.  This evidence is often cited when I do ward attending rounds with the residents and the fourth-year students.  But how much belongs in the first and second year coursework?  When does it become overload when the student is still trying to grasp the basic concepts of pathophysiology?  I'm not sure I have answers to these questions.  As my lectures tend to show, I'm more for presenting basic data, and pivotal trial data in measured doses at this stage in training, and allow the learners to delve more deeply into EBM during the clinical years, and into their residency training.  What do you think?

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.

Lessons learned from video conferencing didactic sessions

I've been using two different video conferences platforms over the last few years to beam our didactic sessions on the neurology clerkship to students who are at remote sites - in our case community sites in Bend, and Eugene.  I've had mixed success, and wanted to see if other people have found ways to improve the use of the technology to overcome some of the hurdles I've found.  Our didactic sessions are really set up to be a series of cases which the facilitator works through with the students.  They are usually an hour, and are intended to be very interactive with the students working together as a group to learn about various disease states from a case described by a facilitator.

Here are some things I've learned:

1)  Tech savviness is good.  I'm MUCH more likely to succeed at getting the student to keep coming back to the didactic sessions, and find that they are satisfied with the experience if that student has some technical savvy.  If the student is relatively not as literate with navigation of the web or more in depth programming than a word processor, it is more likely to fail technically.  Also, there is a much lower tolerance if problems start with the less savvy student bailing out earlier.  We're now using Abobe Connect and had used Microsoft LiveMeeting in the past.  Both are decent, but both have a bit of a learning curve, which less computer literate students aren't often willing to overcome.

2)  Better microphones = better experience.  Much more involvement when I spent more money (around $100) on a nice area mic that covers the whole conference room than trying to squeak by with cheaper mics.

3)  Works better with help.  I don't always have help, but I think the whole experience works better if you have some tech help who can monitor the feed, and problem solve for you if issues arrive.  When I'm the only tech help, I try a few things, but often just tell the student to try again the next time, as I can't hijack the whole lecture to spend even 5 minutes finding out what's wrong.  I'm not saying I have help now...

4)  Video feed can just provide a distraction.  Students have said that if the only thing they can see is my head, but there are lots of people talking at a table, it can almost take away from the experience.  I'm going to just sending the slides/whiteboard to try to get around that.  I don't have a whole table cam, and don't have help to run an external camcorder to focus on the person whose talking.  Haven't found a great way around that.

5)  Bigger computers are better.  I recently switched to using my newer, faster, sleeker laptop from an older one we had stowed in the conference room.  Audio has been our main tech issue, and it seemed to run better with the combination of a better computer and a hardwired line on the presenter's side.  We don't always have students hard wired in, but it is harder for them to do that as they have a netbook with them, and are not always in a predictible spot to participate in the lecture.  With that limitation, I'm not sure how to get around the student side of the problem.

What are your insights or experiences?  Have you found other ways to get around the problems I've had?  I hope to be able to improve my abilities to run this over time (as I'm hoping the software will become more reliable, and the hardware will become cheaper and smarter).