What medical education can learn from "Moneyball"

I've been waiting a bit to write this post, as I'm not sure exactly which way to take it.  Let me start by stating that I'm a really big baseball fan, and have been since second grade when my dad first took me on the El in Chicago to see the Cubs play in Wrigley.  I still get chills walking into that place.  This love of baseball drives me read the occasional baseball book.  So, while I haven't seen the recent movie, I read the Michael Lewis book, "Moneyball," a few years ago.  And I really liked it on many levels.

In the realm of medical education, I liked the idea of trying to measure something that is inherently immeasurable.  In some respects, trying to pick a good candidate from a pool of medical school applicants or trying to assign a grade to a student on a clinical rotation is not unlike what the old-time scouts in "Moneyball" were doing.  They would look at a player batting, pitching, or fielding, and go with an overall geschalt of whether that player was 'big-league material'.  They were also basing their decisions on statistics which had been around forever, and no one had ever really questioned whether they worked or not to predict who is or who is not going to be a good performer.

Then, Billy Beane and his team of statisticians looked beyond the traditional numbers and redefined what to look for in a player prospect by largely ignoring the players current body habitus or mechanics and focusing solely on the numbers.  They also redefined what success was by finding the the number of runners on base per game correlated to wins more tightly than other statistics.  Thus, on-base percentage, and slugging percentage (which measures walks with extra-base hits) was more important for how an individual would contribute to the team than total runs batted in or home runs.  (Sorry if I just lost the non-baseball fans out there).

This process can have applications to lots of venues.  I think medical school needs to re-look at how we are evaluating our students and decide if we need to go through a similar process.  Are there statistics available to us now which may not have been available 20 to 30 years ago that we could use to identify medical students who are not likely to do well in practice.  We're pretty solid at identifying people with knowledge gaps as our system of standardized testing takes care of that.  But, is that what really makes a good physician?  It's a part of it for sure, but it is not all of it.  There's a lot more to clinical reasoning, and professionalism than just knowledge base.  Can we find ways of identifying ways to capture those measures, or are we going to be stuck with the old scouting reports and crossing our fingers to see what happens?  I don't have any solid answers yet, but I'm willing to help look.

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?

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.

Teaching second year students with tag teams

In my view from the back of the neuroscience course, I saw some good stuff today.  We had a four-hour block of time to introduce muscle, neuro-muscular junction, peripheral nerve, and motor neuron physiology and pathophysiology.  For each of these lectures, I invited a pathologist and a neurologist to share the lecture time.  They had not done this before, so there were a few moments where it wasn't clear who was going to present what.  Overall, the pathologists presented the pathological changes in the structure, then the clinicians gave a presentation of what that looks like in patients affected by these diseases.  What I noticed that I thought was super cool, was that in the middle of each talk, the clinician or the pathologist would look over at the other person with a look like, "am I explaining this right?"  The other presenter, then usually stepped in, and gave a nice presentation of the area that was fuzzy for the first lecturer.

I like this model for several reasons.  First, it helps avoid some of the inevitable statements like, "I have no idea what you've been exposed to before about this, but..." or "Have you all seen this before or not?"  Second, it allows points which need clarification to be clarified right at that moment.  Third, I think it helps emphasize to the students that medicine truly is becoming too complex for one person to feel like they can master every thing.  Yes, you can still aspire to be a well-rounded physician, but any field of study moves to fast for you to practically stay up on everything.  Thus, you need to learn to rely on the knowledge and experience of your colleagues.  I think it also practically has the advantage of having clinicians and more basic science facutly mingle a little.

Wondering if others have more experience with a similar model in the basic science curriculum of your medical school?  Please share your thoughts and ideas here.

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.