For medical students the transition to clerkship can be a “shock of practice”. They usually have to get around in a field very strange to them, due to the stress they almost forget everything they have learned the previous 3-4 years. Thanks to Annemarie Cunningham I came across a third year med students blog.
This post will highlight a few of my trepidations; in a follow up post I will share some of the advice for clerkship that I have received from a variety of sources. If you have anything you think I should include please pass it along
Always like a very different view of matter of opinion. Via Annemarie Cunningham discovered a thought provoking blog post: rethinking medical education from The Health Care Blog. Based on all the new medical technologies, super specializations, increasing cost of medical care, and cost of medical education, a new approach to medical education is put forward. This appraoch is mainly focused on shortening the duration of medical education in the US. Nevertheless, these ideas are worth considering also in Europe and the UK.
This blog post proposes the following structure for medical education:
Two years of medical education taken by all students. This common curriculum would consist of 50 percent basic science with an emphasis on competencies that would be useful to every physician. Subsequent exposure to basic science would depend on its relevance to the student’s prospective career, if you are considering medical education check https://www.vocationaltraininghq.com/how-to-become/medical-assistant/ .
One-third of the time would be devoted to an introduction to clinical care of individual patients, making as full use as possible of modern technologies that have been successful in training programs in industry, the armed forces, and other settings. One-sixth of the time would be used to cover key aspects of the health of populations and the organization and delivery of care, with emphasis on a team approach to enhance health. It is important for all physicians, regardless of prospective careers, to understand how each element fits into a health care system or using private services as a hire a certified home health aid company to get the best health services for this.
Upon completion of the two years, each student would select a track which launches him or her into the world of specialization. Here is an example of what the tracks might look like:
Leaders of primary care teams, possibly sub-divided into adult care, pediatric care, and geriatric care.
Clinical specialists in medicine, hospital based and ambulatory.
Clinical specialists in surgery and other procedural specialties.
Possibly another track for those headed for specialities such as radiology and pathology that treat medical and surgical patients.
A track for students whose major interest is research, possibly similar to current MD-PhD programs but with explicit recognition that the trainees are not preparing to be clinicians.
The content of the training program would differ depending on the track. For example, students training to be leaders of primary care teams would be exposed to more statistics, epidemiology, preventive medicine, and management skills than those in the other tracks. They would learn how to deploy nurse practitioners, physician assistants, and other non-physicians most effectively as per Bill Austin.
This means an early choice of specialty for med students have a read about it.
From a content analysis on 10.168 abstracts extracted from the six most influential journals in medical education published since 1988, 29 major themes were identified for research in this field.
In short most of the themes were about the preparation of medical students for professional practice. From the analysis the following topics were the most prominent: student assessment, clinical and communication skills, clinical clerkships, and problem based learning. Declining themes were multiple choice examinations and computer-assisted instruction
The authors conducted this research based on curiosity but also about which topics are increasing and which show a decline in the last 20 years. Were these themes really a priority and which topics haven’t been covered the last years?
Missing was research on optimizing study duration by experimenting with examination systems, is it possible to train doctors in a shorter time, is it possible to involve lesser trained doctors? Do we need academic hospitals in training doctors? They usually only treat complicated highly selected patients, shouldn’t there be more emphasis on primary care during medical clerkship?
Critics on the state of the art in medical education research
The suggestion is that we should be more rigorous than we are. Use less self-report instruments and more measures of actual performance. Experiment rather than observe…….it studies the relative effectiveness of existing approaches rather than to discover new ones
The University of Maastricht published the highest number of publications on medical education and four Dutch authors are amongst the first 6 authors who contributed the most articles to the field of medical education.
Rotgans, J. (2011). The themes, institutions, and people of medical education research 1988–2010: content analysis of abstracts from six journals Advances in Health Sciences Education DOI: 10.1007/s10459-011-9328-x
Because with difficult cases doctors tend to use refelective reasoning for diagnostic decisions. Reflective reasoning is effortful, conscious analysis of features exhibited by a case like during a dog bite incident where you have to act fast to avoid the infection.
When engaged in reflection for solving a case, physicians tend to more carefully consider case findings, search for alternative diagnoses, and examine their own thinking. A recent study indicated that reflective reasoning positively affected diagnoses of complex cases, whereas it made no difference in the diagnosis of simple cases
Nonanalytical thinking is based on the recognition of “illness scripts”. Physicians tend to recognize these patterns of symptoms very easily especially when having more experience. This type of reasoning is very fast but not always accurate. It tends be vulnerable for availability bias. Physicians tend to change to this mode in routine situations.
From recent research we learn that in dealing with a so called difficult patients, the doctor tends switch to mostly reflective reasoning with more time spent on diagnosis. The physician does a more careful analysis of findings and alternative diagnosis. Diagnostic accuracy improves with this type of reasoning in these cases. Moreover, physicians shift to reflective diagnostic reasoning when they perceive the case to be solved as problematic irrespective of whether the particular case is really problematic or not. It is impressive to realize how easily doctors are influenced by circumstances instead of being neutral and objective to each case.
Mamede S, Schmidt HG, Rikers RM, Penaforte JC, & Coelho-Filho JM (2008). Influence of perceived difficulty of cases on physicians’ diagnostic reasoning. Academic medicine : journal of the Association of American Medical Colleges, 83 (12), 1210-6 PMID: 19202502
One possible mechanism for diagnostic errors made by physicians is the availability bias. Clinical reasoning is one of the most important achievements after med school. Flaws in clinical reasoning can result in diagnostic errors and medical mistakes. Availability bias is the doctor who diagnoses a certain disease more often since it comes to mind more easily. This is often helpful since things that come to mind easily generally do occur more frequently. For instance a flu pandemic could result in to easily diagnosing the flu instead of probable other diseases, pneumonia in it’s first appearance can be easily overlooked.
That’s also why consulting so called super specialists for a first consult is not without risk. They tend to rely more on nonanalytical reasoning based on pattern recognition, which is mostly a unconscious diagnostic approach.
Counteracting biases based on these mechanisms can be produced by introducing analytical or reflective reasoning. This means going over the case again with careful, effortful consideration of findings in a case supportive for a certain diagnoses.
In a Dutch trial with first year (n=18) and second year internal medicine residents (n=18) an availability bias could be demonstrated. When faced with cases similar to previous ones and using nonanalytic reasoning the second year residents made errors consistent with availability bias. Diagnostic reflection tended to counter this bias.
Participants first evaluated diagnoses of 6 clinical cases (phase 1). Subsequently, they diagnosed 8 different cases through nonanalytical reasoning, 4 of which had findings similar to previously evaluated cases but different diagnoses (phase 2). These 4 cases were subsequently diagnosed again through reflective reasoning (phase 3).
Why is this important?
It’s the first experimental research about availability bias delivering direct evidence of it’s existence. It also shows that reflective reasoning may help counteract this bias. This could easily and preferable be introduced in medical education. Reflective reasoning can improve diagnostic accuracy.
The results suggest that the occurrence and negative effects of availability bias are a function of the
reasoning approach and the expertise level.
This should be tested in another sample with experienced clinicians.
Mamede, S., van Gog, T., van den Berge, K., Rikers, R., van Saase, J., van Guldener, C., & Schmidt, H. (2010). Effect of Availability Bias and Reflective Reasoning on Diagnostic Accuracy Among Internal Medicine Residents JAMA: The Journal of the American Medical Association, 304 (11), 1198-1203 DOI: 10.1001/jama.2010.1276
Recently discovered a new nice blog: Pre-Med Hell. It started in January 2010. One of their first posts was Must Read Books for Pre-Med Students, which was my first acquitance with this blog. Liked their suggestions, more original than The House of God although this book also got a favorable review on this blog. Even bought one of their suggestions: How Doctors Think. Go and have a look at their reviews of books and other posts for pre-med students. If you have some more suggestions for must reads for med students or residents especially psychiatric residents, please let me know in the comments and yes, Mount Misery is already on my list.
Pre Med Hell is a blog run entirely by undergraduate students, the goal of this blog is to provide tips, that have helped other students throught he same process, and also to place a satirical spin on the traditional pre-med lifestyle….We will introduce you to new technologies that will make your life as a pre-med easier. We will interview medical school students, doctors, and other people you may be interested in hearing about. There will be tips on surviving orgo, biochem, phyics, and what have you.
As mentioned in my blog post it’s probably not only the design of the slides but mostly the educational instructions such as building on the knowledge the students already have and encourage the students to prepare for the lecture. This will enable the lecture to focus more on new things they should learn. All these arguments are all more or less good educational practice. Moreover, from my own experience designing and making slides without a lot of bullet points (text) often leads to more educational slides. In order not to get bored myself by the slides and content of the lecture, reinventing the content and preparing useful slides does improve the learning experience for medical students.
I wanted to emphasis that what makes the design work is not the asthetics of the design but more importantly the marriage between the cognitive load theory (minimize audio-visual load imposed by the slide design) and the integration of new knowledge with the old, brought about through two separate processes; for one the lecturer researched and then built apon what students knew already through their curriculum; and secondly, students were encouraged to prepare before comming into the lecture. by off loading numerous bullets of slides we are allowing students to have the time to assimilate what is new with what they already know. I hope that may have shedd some light on our study.
Found an interesting article on the use of e-readers in medical education, the Kindle. The Kindle was used by medical students during family medicine clerkship and by family medicine clerkship preceptors. The e-reader was loaded with medical textbooks and other relevant material such as guidelines. The hypotheses was that the information demand during education and working in a clinical setting would favor the use of e-readers. After usage of the devices the students and preceptors were send a link to an online anonymous survey asking them to rate the use of the e-reader in terms of relevance of content, usability, efficiency and appropriateness in various settings. In this group the e-reader was not recommended for direct patient care, mostly due to it’s lack of speed. It was recommended for use in educational settings. Unfortunately the research didn’t compare it to another device or online searching. The iPad was not available in that period. As with all devices, the Kindle might be considered old fashioned especially when it comes to speed and searching.
In another trial the Kindle was tested with fourth year medical students and residents. The Kindles were loaded with relevant medical textbooks. The students and residents were asked to compare the print, online and e-reader versions of the textbooks. The students preferred the computers available throughout the hospital instead of the e-reader in clinical settings. The residents preferred online resources to find clinical answers, not the e-reader.
Participants from both studies rated the selected e-reader as highly portable, overcoming accessibility issues that might arise in clinical settings, but users found limitations in the e-reader’s navigation, lack of color display, and speed. The e-reader processor and wireless connection were slow for use in direct patient care settings, especially when networked computers were available. In the clinical setting, computers were easier to use and faster than the e-reader for answering patient care questions, and participants from both studies reported preferring computer based online resources to those on the e-reader.
In short, e-readers are of limited use in clinical settings. The e-reader is of use in medical education such as reading in guidelines or textbooks in preparing for or after seeing a patient. Shurtz, S., & von Isenburg, M. (2011). Exploring e-readers to support clinical medical education: two case studies Journal of the Medical Library Association : JMLA, 99 (2), 110-117 DOI: 10.3163/1536-5050.99.2.002
Readers from this blog recognize my interest in presentation skills. Not only the presenting but also the design of slides. Often I’ve written about the boring powerpoint slides often used in lectures with endless bullet points and great deal of text. Several authors have explained why these bullet points won’t teach the audience anything. They have argued why simple design principles in developing the slides does improve the retention of information.
how people learn best from words and pictures, based on the theoretical underpinnings of multimedia learning theory, and, accordingly, to understand how to design effective multimedia instructional messages
Multimedia learning is learning from words and pictures. Words can be seen or heard, pictures can be static (pictures, graphs, charts, maps) or moving as in videos or animations.
Moreover, besides the multimedia design the story behind the information also plays an enormous role in the educational effort.
Do these multimedia design principles also apply for learning from lectures in medical education?
In a pre-test post-test controlled design the multimedia design principles were compared with the traditional design in undergraduate medical students. The group of medical students with the modified design group consisted of 91 students, the traditional design group consisted of 39 medical students. Two versions of the same lecture containing identical factual information were delivered.
The students attending the modified design according to multimedia design principles showed significant greater improvements in retention and total scores on their test.
The accompanying comment argues that not the design of the slides but the development of these multimedia slides might have impacted more on the positive effect. It’s more about reflecting on general education issues such as good instructional messages, encouragement to prepare one self and familiarize the subject before attending the lecture, establish what students already know about the subject and build on that, don’t make to many slides for the amount of time. To my opinion, teachers spent more effort in optimizing their slides and story when trying to develop multimedia designed lectures. Bullet points especially in Powerpoint are far more easy and quicker to make. What do you think?
Issa, N., Schuller, M., Santacaterina, S., Shapiro, M., Wang, E., Mayer, R., & DaRosa, D. (2011). Applying multimedia design principles enhances learning in medical education Medical Education, 45 (8), 818-826 DOI: 10.1111/j.1365-2923.2011.03988.x Ellaway, R. (2011). Reflecting on multimedia design principles in medical education Medical Education, 45 (8), 766-767 DOI: 10.1111/j.1365-2923.2011.04064.x
A large iPad like table is used by students to learn human anatomy. Together with other forms of anatomy education a real new way of improving understanding of complicated human anatomy for students. You can watch a video about this computer and examples of it’s use on the Stanford Med School site. The many ways of using this new technique is also described in this blogpost on Stanford Med School
In the ongoing search for how best to explore and learn about the anatomy of the human body, Silicon Valley engineers have now joined a long list of doctors, artists, photographers and other technology innovators by adding a new method of anatomical exploration.
The new virtual dissection table takes advantage of 20th-century technological advancements in imaging, such as X-rays, ultrasound and MRIs, and combines them for use in a 7-foot by 2.5-foot screen. At Stanford, the table is being tested as a way to further enhance that age-old teaching method — the dissection of human cadavers.