Tag: medical education

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We need to do it differently

Michael Heung of the University of Michigan tweeted this yesterday

Here is the image again in case Twitter breaks.

This is not an uncommon finding at medical schools around the country. I have been to lectures by Dr. Heung at Kidney Week and he is a gifted teacher. There is nothing wrong with him. The knee-jerk response is to do what Oakland University William Beaumont School of Medicine did and make lectures mandatory. I get a full auditorium for every one of my lectures. It strokes my (already formidible) ego, but I don’t think it is the right response.

The empty lecture hall is because medical students are finding ways to learn that are better for them than sitting in a class room six hours a day. It’s more efficient to stream the lecture at 2x-speed with tabs open to other resources. If this is how they learn best, schools shouldn’t enforce inefficiency by making them attend lectures. Medical school deans should recognize how the material is going to be consumed and then develop curriculum around that consumption.

Every medical student, after paying tens of thousands of dollars for tuition, spends additional thousands of dollars on materials, tutorials, and videos to get ready for the big bad board exam at the end. What is the core competency of medical schools if it is not getting students ready to excel at licensing exams? Every one of those subscriptions is an indictment of the product that medical schools are providing their students.

Here is a list of vendors from the 2018 American Medical Student Association Convention. Check marks indicate vendors that provide services that medical students should be getting from their (wildly expensive) schools.

If we were to start from the position that students are going to consume every lecture on their own time on their own laptop, would we record the same slide show with the same talking head every year? No, that’s an absurd waste of the professor’s time to produce content that is not compelling or a good use of the medium. This is like the first movies, where directors would just film stage productions, ignoring the nature of the novel medium. Instead of seeing the empty lecture halls as a problem it should be viewed as the huge opportunity it is. The students have already moved to the new medium, it is time for medical schools to catch up.

It is time to turn those lecture halls into production studios. It is time to hire professional animators, artists, and video producers, and go from slide shows that need to be performed live every year to tightly produced educational shows that can be created once and shown many times. Let’s teach for the contemporary reality, rather than fight it with rules that serve to waste student’s and teacher’s time.

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What books or resources should I use to learn nephrology?

I received this DM today (my DMs are open. I was nervous about opening DMs but a year later I would rate the experiment as a delightful success. It has opened up Twitter to many new discussions that otherwise would not have occurred).

Hi Dr. Topf, I’m a final year medical student from the UK. I’ve been following you for a while due to my interest in renal medicine. Are there any books/online resources that you would recommend to learn renal physiology? I feel that I lack fundamental principles and concepts which I’d like to improve. Thanks!

Arnav

This is actually a relatively common question and I am going to attempt to write this post so I can link to it in the future.

The answer depends on the goals of the student

Preclinical medical student.

Vander’s Renal Physiology

Slim, readable. Good choice.

The Acid-Base Haggadah

This is designed to be part of a workshop but it can be read on its own.

Medical student or resident on a clinical rotation

This list is for the learner who is looking to know what to do.

Nephrology Secrets

Of course I’m one of the authors and I edited every single word in this book but a year later I still am amazed at how well this review book walks the tightrope of being concise without over simplifying complex topics. I may be biased, but I think this is an excellent book.

NKF Nephrology Primer

Before Secrets this was my go to recommendation, but this book is getting long. I’m beginning to think this may be too long for a student resident on a one month nephrology rotation. That said you can’t find better renal educators that editors than Gilbert and Weiner.

The learner really wants (or needs) to have a mechanistic understanding of why we do what we do then…

Fluid, Electrolyte and Acid Base Companion

It is strange that one of the things I am most proud of in my entire career is a book I wrote as a resident but it is no exaggeration to say this book for transformative for my life. I poured five years of work into this project and i think it stands up. However you should skip the tremendously outdated and overly complex section on the treatment hyponatremia and instead read the European Clinical Practice Guidelines.

Burton Rose’s Clinical Physiology of Acid Base and Electrolyte Disorders.

People look at the copyright on Rose’s electrolyte book and conclude the book is out of date.
It is.
It doesn’t matter.
Rose excels at providing the reader a cohesive mental model of how the kidneys work so that things make sense. Then if you need to learn more and get a more up to date and nuanced view of how the kidney works it is pretty simple to plug those updates into your mental model of the kidney.

The nephrology fellow

Use the following:

  • Nephrology Secrets
  • Burton Rose’s electrolyte book
  • Daugirdas’ Handbook of Dialysis
  • All of the KDIGO clinical practice guidelines
  • A subscription to UpToDate
  • A subscription to Nature Reviews Nephrology
  • Attend every NephJC

Read the first three cover-to-cover and then cover-to-cover again. The KDIGO Guidelines will give you the state-of-the-art for many of the important issues in Nephrology and the full guidelines provide a solid scientific rational for why the guideline are the way they are. You should have more than a superficial familiarity with the guidelines. Use UpToDate and Nature Reviews to go deep on every weird, rare, or interesting patient. Use the last one to stay up to date with clinical research. That’ll do. That’ll do quite nicely.

What did I miss? What are your favorites. Hit me up on #MedTwitter or slide into my DMs.

Some good updates from Twitter

And Mir Tariq Ali reminded me of major omission to my list. I forgot Daugirdas’ Handbook of Dialysis. This is the third book that every nephrology fellow should read cover to cover and then read again.

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Team based learning, reason for optimism about medical education

In general, as I have progressed through my education, I have felt that the quality of education has been on a downward vector.

  • I believe that duty hour work restrictions have diminished continuity of care and reduced the drive for residents to read and learn about their patients, because the patients feel less like “their patients.”
  • I think the emphasis on fraud prevention that has meant that attendings need to see and be present for all of the meaningful aspects of patient encounters has diminished fellow autonomy and delayed the maturation process that senior residents and fellows undergo.
  • I think the addition of alternative medicine curriculum to medical schools is an inexcusable retreat from the goal of medical scientists.

But I have recently experienced a vision for the future of medical education at Oakland University William Beaumont Medical school and I am blown away. Don’t worry future doctors are going to be just fine.

OUWB is one of the newest medical schools in the country and has it’s first two classes of medical students enrolled, classes of 2015 and 2016. The second years are finishing up the renal section. It is an integrated unit including histology, pathology, physiology and pathophysiology. I was privileged to have an integral role in developing the curriculum. One of the parts that I spent hours on was developing Team Based Learning modules (TBL).

Typical MD Lab from Scott Hall
(http://conjoint.med.wayne.edu/mdlabs.php)

Team based learning is OUWB’s version of the small group learning sessions that have always been a part of the first two years of medical school. During my years at Wayne State they were called MD Labs. The sessions were sprinkled through out the curricula. I went to a few and they were of widely variable quality. I didn’t go to many, because they didn’t count toward your grade. That told me that The Dean didn’t think they were important enough to count so I took the hint spent my limited hours cranking on stuff that counted.

The TBL is a reinterpretation of those small group sessions that I see as wildly successful. The success is not by accident and comes from the novel structure of the sessions. A TBL is made up of preparation and three segments:

Prep

The preparatory reading is a chapter, or article or handout that covers all of the main ideas of the session. For proteinuria and glomerular disease the students were assigned a chapter in Harrison’s. For CKD and AKI the students were given review articles in BMJ (Hilton R. 2006) and NEJM (Abboud, Henrich 2010). For Sodium and Water, I wrote a 41 page chapter on the subject. Be warned I have been told that it has a lot of typos.


    Individual Readiness Assessment Test (iRAT)

    As soon as the session starts the students have a multiple choice test of 10 questions. All of the answers should be found in the assigned reading. The test score is part of the students grade in the section. This means that all of the students need to do the prep work and all of the students need to show up for the session. Two huge improvements to the Wayne State MD labs.
    Gunning for grades on the iRAT

      Team Readiness Assessment Test (tRAT)

      After completing the fill-in-the-bubble iRAT, the students then work in 5 person teams on the exact same questions they just answered. The teams have scratch off pads that work like instant lottery tickets with the correct answers. When the team answers a question they get instant feedback if they were right or wrong. This is closed book but the students all work together. After the all of the teams complete their tRAT there is a brief discussion of any questions that were troubling. The proctors walk around the room during the exercise and listen to the team discussions to they get a sense of what questions are difficult/poorly written.
      If you scratch off three horse shoes you win $60.
        Look at her notes. Every tricky nephrology
        question starts with “let’s draw a nephron.”

        Application Exercise

        Application questions are complex questions that supposed to integrate physiology and clinical medicine in to a complex multiple choice question. The questions are all open book, and in this age of WiFi, laptops and the WWW, we should really rename open book as open Google. The teams get 15-20 minutes per question and then simultaneously display their answer. Then the proctors lead a discussion on the reasoning behind the answers and different strategies the teams used to get to the answer.

        The things I love about the TBL

        • It is part of the grade. Curriculum directors need to understand that the medical school curriculum has more information than is possible to learn and students are rational actors. They will sacrifice important but uncounted learning opportunities in order to prepare for counted exams. There is no way to make something meaningful without making it part of the grade.
        • The iRAT happens right when the students walk in to the room. I love how this makes it clear that the students are being graded on preparation. The important thing is getting the students to learn the material before the session starts. This paragraph from Regis School of pharmacy states it perfectly:

        “To promote active and collaborative learning, students are sometimes asked to work in groups in class or on projects outside of class. While group work does benefit student learning, unfortunately it is often plagued by “social loafers”, or students who do not pull their weight in terms of helping the group. As a result, many students learn to dislike group work and may seek to avoid it. TBL is different. TBL ensures that each member of the team is held accountable for their own learning outside of class. Students who do not prepare adequately before class will perform poorly on the iRAT and will not be able to contribute in a meaningful manner to the tRAT and application exercises. As a result, most students who would normally remain “social loafers” in a group learning project are instead quickly motivated to do the assigned work out of class in order to perform well on the iRAT. In addition, as teams work together and compete with other teams in the class, loyalty to the team develops among each member. This further motivates the “social loafers” to prepare outside of class so that they can contribute and help the team succeed.“

        In the cut throat world of medical school any system that allowed a “social loafer” to benefit from the group while contributing nothing would be a recipe for a short lived project. The iRAT gives a clear message: come to class prepared, or you will suffer.

        • The application exercises are open google. To me, this was the most interesting part of TBL. Clinical medicine is, of course, open book. Everyday I am consulting Dr. Google, Epocrates and UpToDate. My information gathering strategies were developed on the fly in my clinical practice. No one taught me these types of skills and no where in medical school were there any opportunities to practice hone them. The students of OUWB are working together, comparing notes, seeing which resources work best. I heard students explain the virtues of DynaMed (a POS in my opinion). I spoke with students who distanced themselves from Wikipedia until I told them I was a fan and had no reservations about using the crowd sourced encyclopedia. After hearing me extol its virtues they quickly changed their tune and agreed that it was easy to filter good from bad wiki pages (referenced, with mainstream journals, avoid political topics) and that the good ones never steered them wrong.

        People used, Google, Wikipedia, UpToDate and a strange
        resource called a “book” 

        Summary

        The portable computer revolution of iPads and smart phones allows us to bring the library to the bedside, it is time for medical schools to appreciate and embrace this pivot in the history if medicine. TBLs are the best example I have seen of of this.