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!

AAN annual meeting blog promotion ideas accepted

From AAN Annual Meeting website referenced in text

If you are not a neurologist, you probably weren't aware that the American Academy of Neurology Annual Meeting is this next week in New Orleans, LA.  The meeting brings to together neurologists from around the globe to learn from and connect with colleagues.  A major portion of the meeting for myself is devoted to attending medical education sessions and meetings with other neurology educators.  There will be a full day meeting of clerkships and residency directors as well as a half-day session on education topics and a poster and platform presentations.

As I go to the meeting, I'd like to be able to not only learn some things from the meeting, but also do some shameless self-promotion for my blog.  As my blog is fairly newly established, I don't really feel like it is at a stage where I could have made a poster or abstract about its relative worth to the community of educators.  As such, I may have missed an obvious outlet for creating interest and awareness in my blog.  I was wondering if others who have blogs could comment on creative ways to let people at meetings like this know that your blog exists while being relatively subtle.  I'm thinking the strategy of going to the open mic and asking a question about an unrelated presentation that ends with the statement, "...I'm very interested in this as I'd like to include it in my medical education blog found on neuronerd.com."  Are there ways of spreading blog love at meetings?  Thanks for the advice.

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. 

Life - Do med students have one? Work-life balance across generations

I gave a journal club last week discussing some general ideas about generational differences between the three main groups trying to work together in medical education: Boomers, Gen X, and Gen Y (or whatever it is your preferred term for this generation is).  As I was looking into the topic to prepare for this talk, one of the themes that kept popping up was the work-life balance theme.  In general, the common wisdom is that the Boomers value hard work, and are willing to sacrifice family life for career advancement.  Gen X and Gen Y tend to have less of a focus on work as a source of primary identity, and see much more value in maintaining balance between career and home.  The purpose of this blog post is not to decide whether this is indeed true or not.

What I'd like to spend a moment discussing is how this generational difference is creating conflict in the halls of medical schools.  Medical students are primarily Gen Y (although there are some Gen X in the mix).  Faculty who now populate Dean's office level positions are primarily Boomers, and course/clerkship directors are now Boomers with some Gen X filling the junior ranks.  So, what happens is that the Boomers remember their medical school life which was ruled by the Greatest Generation (even more value on work due to their experiences in the Great Depression).  The biggest place I've seen this conflict play out is in requests for time off or for changing a date to take a test.  The Boomers were given very little room to change their schedule.  I've talked to many of them, and the stories were essentially that if you wanted to take a day off during the clinical years for anything other than being near-death, there would be severe consequences (like repeating the entire clerkship).  Things were a little better for me, but not a lot.  I remember having friends in medical school who had a lot of trouble getting time off to attend weddings or family reunions.  There was minor grumbling, but we all decided it was a transient time, and this was preparing us somehow for the trials of residency.  And we kept telling ourselves that things would eventually get better.  We also had the usual weeks of vacation around the Holidays and Spring Break for some time off.  Everyone also had some lighter rotations, and the fourth-year comes with a much more flexible schedule.

Then along comes Gen Y.  They are much more vocal about their need for time off, and much more vocal about providing feedback on things that they are not in agreement with.  And they are now complaining primarily to the Boomers, who primarily don't want to hear about it.  I'm not so sure.  Maybe it's my Gen X roots showing or maybe I'm still close enough to being a student that I remember the bind it puts you in if your schedule is completely inflexible.  So, I'm wondering if maybe school policies for personal days off should be revisited.  I'm thinking most of the policies were set in place for a very different world, and haven't been changed much for 20-30 years.  With the advent of technology, it is possible to make up some assignments which may not have been possible to make up in the past.  There's also a different cultural norm emerging (or maybe I just think this should happen), and missing a wedding because you are assigned to spend a day in clinic is not an acceptable trade-off.

As a disclaimer - I've been told by several fourth-year students that as a clerkship director, I run a 'tight ship'.  To my mind I'm just doing what the school time off policy is telling me to do.  Our school policy is that student have 2 days off per year which can be used for attending a professional meeting or if they are ill/ have a family emergency.  All other time off is at the discretion of the clerkship director, and must be made up.  I'm not sure I have a perfect answer as to how to change the current policy, but maybe working with appropriate representatives from Gen Y, Gen X, and Boomers we can work together to figure something out.

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?