Should medical students be taught Parkinson's by Movement Disorders Specialists?

I've been thinking about this topic for a bit after it was discussed as a side point by Dr. Doug Gelb, neurology clerkship director and card-carrying general neurologist from the Universtiy of Michigan. He argued that when choosing a teacher for his courses, he prefers someone who is less specialized in the subject matter than a world's expert in that particular disorder. The background of this is that there is an increasing trend for neurologists to sub-specialize. Especially those people who choose to work in academic centers, it is often seen as your way to distinguish yourself and create a niche from which you can work towards a cleaner path to promotion. I am not immune to this, as I sub-specialized in Parkinson's Disease, and of my residency classmates who went into academics, we all are sub-specialty fellowship trained (albeit an n of 3).

Dr. Gelb purposefully invited lecturers for the clinical aspects of the neuroscience course to speak on areas where they are not fellowship trained (indeed he gave many of the lectures himself). This is a very interesting approach, as the typical medical school model is to get the most senior, and most well-known person in your institution who is willing to talk to do the lecture. The theory is that a person who spends all their time seeing patients in one area, and reading literature in primarily one area will become so engrossed in the small points that it becomes very difficult to see to the broader picture. Hence, even though medical students should focus on differential diagnosis of Parkinson's and early treatment, the lecturer may spend a few cursory slides on this (as it is relatively boring material for them), and then skip to detailed slides of rasagiline as a potential for neuromodulation and the neurophysiology of deep brain stimulation. If you're not a Movement Disorders specialist, you may not really understand why these two topics are very interesting and worthy of multiple slides. That's the point. In this line of reasoning, we are training medical students to be generalists, and they can then specialize and differentiate in residency. Thus, they need to know what a generalist will need to know to be able to care for these patients in their typical practice. The other point he made is that students would rather have a consistent face and style to the lectures by limiting them to a few key faculty, than have a parade of world-renowned gurus each doing a one hour stint of a four to sixteen week course.

I'm not sure I'm ready for all sub-specialists to be banned from the lecture halls. I've seen many lectures by sub-specialists which have really be quite nicely done, and targeted at the appropriate level. In some respects, it's like giving a talk at any level, there is some skill involved, and the skill-set necessary to become well-known in your field and well-published in your field is not the same skill-set necessary to be an effective lecturer. I also think that the specialist is going to be more adept at answering questions that come up from the audience as these can be varying away from the knowledge one learns by seeing a few patients with this condition and ventures more into experience gained only by having been exposed to rare phenomenon. Here a generalist may not have the depth of knowledge, and may be working on older literature or their patient experiences may be skewed due to not seeing the volume.

Hence, I would make two suggestions. One, if a generalist or a specialist gives a talk, it may be a good idea to have your slides reviewed by that person's counterpart to see if there are gaping holes or large volumes of unnecessary minutia. I think if I'm choosing between two skilled teachers, specialists are probably better suited to teach the material. However, if you are faced with a well-trained, excellent speaker who is a generalist, and a specialist who is a great clinician, but not a great teacher, I would choose the generalist. With the caveat, that if the specialist is available, maybe an alternative would be to have the two people team teach the module. This team-teaching model might be ideal in that you could have one or two people be the core faculty who introduce topics and then lend the microphone to various specialists to provide more depth to the discussion.

What do you all think? If you had an equally-good specialist or generalist, whom would you choose.

Disclosures: As a sub-specialist, I understand I may be biased here. Also, I used choosing of lecturer as a model to posit the discussion, but really this could be applied to any formal teaching session or clinical teaching scenario.

What does Mark Zuckerberg have to do with Twitter patient privacy issues?

If any of you have any interest in health care, and have been on Twitter, you all know about the debate which has been swirling about privacy issues and professionalism. Let me start out by stating that I highly doubt this post (or any post) will likely change some people's behaviors. At the end of the day, Twitter is a free space where you are able to to post whatever comes to your mind, so the individual will still have the ultimate choice what goes on their stream. If you missed it, the original post by Dr_V, Bryan Vartebedian, that brewed the 'storm in a tweetcup' (name via @scanman) is found here.

However, choosing what one puts on the stream got me thinking about one of major issues in the divide between those who are for healthcare professionals posting whatever comes to mind, and those who are against it. It brought me back to an article I read a while ago about Mark Zuckerberg. The link takes you to a similar article (I couldn't find the exact one I read), but the essence is that with the progression of the use of social media, and in particular Facebook, Zuckerberg felt there was no more need nor use for privacy. What I read his remarks to mean is that in the world before Facebook, we went to work as doctors, nurses, PA's, etc, and we shared a social space with those workers which was different from how we were when we were in a space with patients present. We then went home, and had a social space with friends. There were social norms associated with how I was to act as a doctor with my patients (or in earshot of patients), and these were different that if I was in the resident room with the door closed. The language was different, the tone of the conversations was different, and the subject matter was different.

Enter Facebook. Now, I have this social feed that goes not just to targeted groups, but to everybody at once. The old physical barriers of social spaces were broken, and now I share everything with everyone. Everyone has made social gaffes by temporarily forgetting who all is in the 'room' and a Facebook status that would otherwise have been innocuous becomes a social nuclear bomb. There are two ways to go once you have had this experience. One, which Zuckerberg advocates, is to say that the old paradigm of having a compartmentalized existence is essentially a false way of living, and everyone should understand that there really is only one you, thus you should be free to express any thoughts you have to all of your friends. This creates a more real and genuine world over all. Thus, if my patient can look at my social media presence and see that I struggle with daily frustrations just like everyone else, I'll be better to relate with them, and build a better bond in the long term.

The other view, is that these social spaces were created over time for a very good reason, and there really should be boundaries between professional life and private life (and what is said in front of patients and what is said in the resident room). This view argues that the blurring of these lines leads to confusion in the doctor-patient relationship. How can a patient trust me to talk to me about a potentially embarrassing social history point or pain in an unflattering area of the body if they are concerned that I will likely step out of the room and make a disparaging remark about them on their Twitter feed. That remark may then be retweeted to viral levels before I've found my car in the parking lot.

Obviously, this debate is more complex than just this point, but I think a large part of it comes down to whether you agree with Zuckerberg's position or not. Do you feel that your online social media presence on the open web (and Twitter is much more open than Facebook) should be compartmentalized or not? I thought about this as @DrGhaheri had a conversation with @SeattleMamaDoc about how to define the lines of the debate. He had wondered if if was based on political viewpoint, but quickly corrected himself. He tweeted, "not cons/liberal from political standpoint but as a lifestyle. Maybe "proper" and "conservatism" had to do with judgment." I think that the line is not entirely conservative vs. liberal (although each of those views probably lend to having you lean one way or another). I think the answer is more, are you pro-Zuckerberg or anti-Zuckerberg. Feel free to leave your thoughts below.

What is student autonomy?

I just went through a review of our neurology clerkship by the curriculum committee at the school of medicine level. One of the things our particular clerkship has struggled with is that the students have a perception that there is not enough autonomy while they are working on the neurology service. I think we have some obvious barriers to overcome as there are times the residents will see new admissions and consults with the student just along for the ride on the wards, and in the clinic the experience is variable with some faculty having the students shadow (hence why I did my grand rounds last week on teaching techniques to use in the clinic). So, we have some work to do as fourth year students are not used to being put into a shadowing role, and really they shouldn't be at an academic institution.

My pondering since the review is not so much on the specifics of what I can do to improve the student experience, but more a puzzling at what autonomy for a student truly looks like in 2011. My medical school professors related stories of working in public hospitals during their training where they were relatively unsupervised as fourth-year medical students, and truly were first call and had a great amount of responsibility for the patient. This has obviously changed, and I don't think this was the best way to teach the next generation of physicians. In reality, the ultimate autonomy in terms of what happens to the patient and what testing and treatment modalities should be chosen rests on the shoulders of the attending physician. From an ethical and legal perspective, the attending is the one responsible for the outcomes be them good or poor. The dance and the nuance comes with how the responsibility then trickles down through a resident team sometimes overfilled with fellows, senior residents, junior residents, and medical students. Added to this dynamic struggle for decision making power are the constraints of time, billing, and EMR implementation to name just a few.

In the light of all of this, I would like to look at a specific case of student autonomy as an example. In our ward, patients are admitted overnight by a resident (and sometimes a student) covering multiple neurology services at our university hospital and the VA. Thus, it is likely the resident team and students have not seen the patient when they were admitted, and are picking them up fresh in the morning. What does autonomy look like in this situation for the student? I would posit that a fourth year student should at a minimum see the patient independently or directly observed by the resident, and should be allowed to formulate their own interpretation of the history and physical and outline an initial plan of care. This can then be honed and refined by the resident and fellow team, and ultimately approved or modified by the attending. The reality is that (at least on our service), the student is often reading from a printed copy of the note written by the on-call resident the night before as they have been trained not to write notes in the chart. The assessment and plan has likewise also been laid out by the on-call resident. Thus, just by looking over the notes to prepare themselves to see the patient, all the work has essentially been done for the student, and they are essentially verifying findings on examination, and deciding if the plan overnight is reasonable. They are also serving to update the condition of the patient from the previous night through to the morning.

So, how do we improve this paradigm? Should we send the student in without looking at the notes? This seems a bit artificial to me, and if time is a factor, is not very efficient either. Should we print out the note up to the physical examination and assessment and plan? Again it is a bit artificial, but at least now the student has a chance to try to formulate a plan independently. Or is it enough to have the student and resident work together to refine the plan as laid out by the on-call resident? Or is it just as valuable to learn from seeing what others have done, and then seeing how that plan works over the course of the patient's hospitalization. When I'm attending, I try to get around this a little by asking the students who haven't seen this particular patient to formulate their own localization of the lesion, differential diagnosis, and plan. But that doesn't get to the student that is following the patient. What do they gain through this experience? Maybe it is enough to have seen the physical findings and think through the differential diagnosis albeit in retrospect and with some heavy prompting from the already completed note.

Not sure I have a great answer yet, and I was hoping to gain from your experience. How also does this model change from third to fourth year, and then into residency? I look forward to your comments.

Strategies to more effectively teach in the ambulatory clinic

Here's a grand rounds I gave this week for the OHSU Department of Neurology on some tips I've found useful for teaching in clinic. We go over barriers to teaching in clinic, and some strategies to overcome those barriers. Our clinics are set up so that students spend roughly a half-day with each provider over the course of a week which gives some background to our unique issues. I do feel many of these points are useful in many settings. I do briefly discuss the 'One Minute Preceptor' toward the end, and I realized I didn't reference the paper in this talk. That original paper is - Naher, et. al. J Am Board Fam Pract. 1992 Jul-Aug;5(4):419-24.

Feel free to leave comments below on idea you have used to improve your effectiveness while teaching in ambulatory clinic setting.

Do providers focus too much on ourselves when we learn about breaking bad news?

I'm a facilitator for a small group of medical students in the first-year principles of clinical medicine course. Yesterday's session was on some practical pointers on what to do when you have to deliver bad news to a patient. The presentation was much like others that I have been through where the lecturer discussed what we as providers need to do to make this difficult process as easy as possible for both us and the patient. There was emphasis on making sure the setting is appropriate (ie finding a quiet space where you can sit with no distractions), and delivering the news with appropriate empathy. He covered the importance of clear communication free of medicalese with frequent checks to see how well the patient and family members are receiving the news. He also talked about how some times what we view as a pretty routine discussion like admitting a small child for dehydration secondary to diarrhea, may be very scary, and the family may view this as very bad news. He talked about bringing closure to the discussion, and trying to instill some hope even in very dire circumstances. I left thinking it was a very solid presentation.

Then, when we got to our small groups, our discussion of the large group began with a comment from one of the medical students that I thought was very insightful. His point was that the lecturer spent a lot of time talking about us as the healthcare provider, and how it is uncomfortable for us to deliver the news, and ways to make this easier for us. The student then went on to say that the patient was really only referred to in how our behavior will need to change in reaction to the patient. He felt like the presentation appeased our need to feel better, and although making us feel better about the encounter will often also allow the patient and family to have a better experience, they are not always the same thing. As I reflected on this viewpoint, I think it is true. Every lecture I've been to on 'breaking bad news' couches the discussion based on the premise that this is uncomfortable to me. I'm not saying there is no mention of how the patient is involved in the process, but it's just always presented with the provider in the center of the news, and the patient being peripheral and receiving the news. Our student stated that it's not really our news, and we should not be central as the news truly belongs to the patient. Another student responded that this approach would help engender a team approach where the provider and patient are working together to navigate the illness with which they all must deal, and thus, makes it less of an 'us versus them' interaction between provider and patient.

I liked this discussion. I'm not sure it's going to change what I do when I talk to patients myself, but it may change how I'd give a lecture about this topic in the future. What do you all think?