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 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.

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.