Category Archives: Medical Education

Deliberate practice in medicine: reflection

During our first semester of med school, when we had our class where we learned to interview patients, we had to write a journal entry after each encounter. It wasn’t due for a few days after class, so mine usually got written in the final minutes before the deadline. The first half, writing the patient history, was easy. Less easy was to come up with some deep thoughts about the patient encounter to fill up the final paragraph. Needless to say, it wasn’t my favorite exercise. It’s hard to force meaning into an encounter when you’re more focused on what questions to ask to fill up the silence.

Reflection gets used that way, and maybe it has it’s place, but reflection as a form of deliberate practice isn’t really about our growth as a person. This guide describes reflection in medical education as “experiential learning” and outlines the following steps in the process: 1. noticing what happened, whether through our own perceptions, feedback from others, or analysis of critical incidents; 2. processing, including learning needs and also the emotional content of a situation; and 3. developing a plan to meet learning needs. (The appendix includes some prompts.) Essentially, reflection as a tool is acting as your own coach.

One of my (multitude) of complaints about medical education is that the time to do this isn’t really built in. You’re either busy with patient care, or you’re not doing something clinical. The problem is it’s hard to remember the details of a situation after you’re not in the midst of it. I think in med school in particular there should be time blocked out so it doesn’t feel like an obligation: you could structure it so you see a clinic patients in the morning, and then have time blocked out to write both a note and also identify a learning need and do some reading. In residency, it’s harder, but as I’m going forward, I notice I do have down time during the day, which I usually use to do some combination of browsing the internet, practicing French vocab, and chatting. It’s much harder to make myself read, and when I do, it’s frequently random. So that’s a challenge to me, I guess…definitely room for improvement.

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What does deliberate practice look like in medicine?

The Olympics are over, but I was interested by this article on Mikaela Shiffrin–the 18-year-old who just became the youngest gold medalist in slalom. Basically unlike a lot of her cohort, who spend a lot of time and energy on entering races, she stayed at home and practice a lot, perfecting her technique. Less fun, probably, but obviously it paid off.

It reminded me a lot of Cal Newport‘s writing. I can’t remember when I discovered his blog, but I found some of his thoughts on specific study skills helpful in med school. More recently–now that he’s out of student-hood, I guess–he’s been writing a lot about the idea of mastery. Basically the idea is, to quote his book’s title, to become so good they can’t ignore you–to stop chasing a job based on what you think you’re excited about, and instead, to do the hard work at becoming excellent at what you are doing.

This resonates with me, I guess, because I took a few years off between college and med school. I wasn’t premed in college, but I did decide around graduation that it might be a good plan for me. In the interim, however, while finishing the prereqs and taking the MCATs, I took a job in a field related to my major. It was…fine. I mean, there were frustrations, but it wasn’t a bad job. And by the time I got around to leaving, I was getting better at it, and doing projects with more independence, and stuff. And so I think back, and wonder, if I’d just stayed there, how would things have turned out? A couple of my other young coworkers did, and are still there, and seem to be doing well. Maybe I should have been seeking mastery all along.

The grass is always greener, of course, and on the whole I’m glad I picked the path I did. But it did get me thinking about how to achieve mastery in medicine. What does it even mean, anyway? Being a clinician-scientist is easier to understand–it’s not really unlike being any other kind of scientist. But what if you just want to be a clinician? How do you get better at it?

I think there are two major components to being a good doctor. (Here I’m leaving out some of the other pieces, like running your office well so that patients aren’t kept waiting overly long, etc.) The first is mastery of a body of knowledge. We have some systems in place to help with this. They may not be ideal, but we have USMLEs and board exams and requirements for CMEs. The second is how you interact with patients–how you dress, your body language, how you phrase questions, how you listen, and show empathy, how you deal with a difficult patient, how you examine people. And I can tell you, from having watched a lot of physician-patient encounters, that most people need work in this area too. It gets de-emphasized, though, even if the powers that be try to test it on Step 2 CS.

So, deliberate practice. I don’t actually think a lot of what’s supposed to be practice works out that way. For one thing, when we admit a patient and write a note, we have talked about it with the attending already (usually), and so I’m writing down someone else’s plan. (Actually, frequently I’m writing my admission notes at the end of the day, and in an effort to get home at a reasonable time, I’m basically transcribing my resident’s note.) For another, a lot of the patient encounter becomes habitual, and like any other habit, we lapse into it unthinkingly, without looking for ways to improve.

So what are some ways to get to mastery in clinical medicine? I’ll be exploring that in more detail this week, but basically I think it requires 1. reflection; 2. thinking about how to handle a specific, commonly encountered situation; and 3. hypothesis testing. And, underlying them all, a commitment to improvement, something which is definitely lacking in many people.

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Teaching from textbooks

This Atlantic article isn’t a fan. I’m split on this. In general I think multidisciplinary learning centered around a topical theme engage students more than reading a textbook. The problem arises when there’s a certain body of knowledge that has to be mastered, for example to pass the USMLE. You just have to master a broad range of topics, and I think it can be hard to teach  that effectively without one. Plus, there’s something to be said for having a framework in which to put your existing knowledge. It’s easier to incorporate new facts when you have a skeleton on which to put them. Otherwise there’s a lot of randomness. The flip side of this is that when you have a survey that’s too broad, it also feels random–this was how I felt about introductory biology, for example: at one point you’re learning about organelles, then a neuron, then the heart’s chambers, and it doesn’t all feel like it ties together.

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Evaluating job performance

The Atlantic takes on performance evaluations.

I’ve only had one “real” annual review–from before med school, when I worked for a consulting firm. There was a self-evaluation to fill out, and then I met with my boss, and he told me I was doing fine, which basically consisted of showing up on time and being enthusiastic. On the one hand, really, I was 23 and in an entry-level position. Still, it was not a terribly useful exercise except as a gateway to my 3% raise. Which is pretty much the vibe I get, from my husband and friends with corporate jobs, and from The Office.

In medical training, we instead get feedback. Both as a student and now in residency, we’re supposed to get some kind of feedback at the end of every rotation. This has also been somewhat hit or miss. For one thing, like the article suggests, people tend to think you’re doing a good job if they like you. This was most noticeable to me with certain male attendings who would banter about cars or what have you with my male counterparts, but it’s not a gender thing per say. Medicine tends to attract a lot of type A people who have strong interests and hobbies, and like to talk about them. I remember, for example, being stuck in a conversation between an attending and resident about Nantucket, and how things have changed over the years with all the new money buying up property. And let me just say that I had very little to add to that conversation.

Anyway feedback. So besides whether you bond with the person evaluating you, the other problem with medicine is most of how you spend your time is not observed. There is a move towards watching trainees interact with patients–some of my med school rotations had these index cards we had to get signed off, for example–and the good attendings and residents will let you do some of the talking. But for the most part, even as an intern, most of my H&Ps tend to be with me watching the resident do the interview, which I can guarantee doesn’t add much. So you get evaluated on what they can see–how you present a new patient, how you outline a plan, and, often, how you respond when pimped–which, for those of us who are less verbally agile spur of the moment, does not necessarily correspond to the extent of your medical knowledge.

Not that I’m complaining. I did well during my clinical rotations as a student, so I clearly wasn’t harmed by the whole thing. But neither have I felt like I’ve gotten much feedback that’s been helpful. What I’ve learned has mostly come from: i. from attendings who teach as they discuss the case; ii. from watching really good attendings and residents interact with patients; iii. from watching not very good attendings and residents interact with patients (ie what not to do); iv. from reading, conferences, and the like. Usually the constructive criticism I get falls under the category of “read more”, which is…not that helpful when you’re already tired and overworked. For one, frequently I got that feedback when I hadn’t encountered something yet in training–like starting my OBGYN rotation, when I was told that “I didn’t know as much as would be expected by this time in the year.” Contrast that to one helpful piece of advice as a student, when my resident told me to read the Step 1 and Step 2 review book topics that related to my patients.

What would be helpful? There are a lot of resources out there. Good feedback is frequent, immediately related to something that happened ie “teachable moments”, and gives suggestions for how to act differently next time. Basically, acting as a coach. Atul Gawande wrote a New Yorker article about getting someone to coach him once he’d finished training, as an attending. And that, in spades, is what feedback during medical training would ideally be. And, for that matter, for jobs in general.

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Teaching better sign-out

I was watching this video about signouts (I know, I’m really fun at parties). But anyway I was struck by how little training we get on the communications skills aspect of medicine. At my institution we had maybe 2 talks on how to present a patient’s story formally on rounds, and a few of my residents coached me on it, and that was it – I more or less figured it out. (Not to mention that different attendings want different things from med students). Student notes have to be co-signed by a resident, so I did get some feedback on those, although I have to say, it was pretty inconsistent, in that some interns like to do things one way, and some another. But I didn’t get any formal instruction on how to sign out a patient to whoever is cross-covering, and that’s one of the key skills for patient safety.

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Is Step 2 CS worth the cost?

NEJM has an article about the cost of the clinical skills portion of Step 2, response here. Basically the test, which is taken as a medical student and required to become licensed as a physician in the US, costs more than a thousand dollars, and even more if you’re not fortunate to attend school in one of the 5 measly cities in which it is administered and have to travel to a testing site. The test, which is pass/fail, consists of a bunch of stations with actors pretending to be patients with common problems: sore throat, back pain, anxiety, etc. You rotate through the stations, talk to and examine the patients, and then document your findings, and you’re evaluated on specific things that the powers that be have determined are important: if memory serves, they include asking the right questions, washing your hands, picking the right parts of the body to examine and doing it correctly, as well as certain patient-centered communication skills such as recapping what they’ve said so far. They also evaluate your English language skills (obviously a gimme for American students but this exam is also taken by people who went to med school in other countries and want to practice in this country).

It’s actually kind of fun, at least by the standards of taking a test. The issue is, it’s super easy to pass–98% of US students pass the first time, and 91% of the remaining 2% pass on retry. (Foreign grads do less well, but still almost 80% pass the first time.) And unlike the other medical licensing exams, it’s pass/fail, so there’s no way to differentiate who does well and who just squeaked by. So the argument is, why do we have a test that’s crazy expensive and doesn’t tell us that much? Having had to fork over my ridiculously large chunk of change, I totally get this argument. Eliminating it would be one less source of stress for students.

Except. There is the truism about what gets tested, gets learned. And even if most of my classmates didn’t necessarily study for CS in particular, we did more broadly, because preparing for it was incorporated throughout the curriculum. Medical schools want to stay accredited, and so they are motivated to change the curriculum to make sure their students pass. The patient simulation exercises that we do are actually helpful: unlike the majority of clinical time as a student, when you are either talking to patients unsupervised or watching as your resident or attending does the talking, you get to practice interacting with patients and get immediate feedback about how to improve from your instructor, classmates, and the “patients” themselves. That’s why unlike, say, professional meetings, simulation improves clinical performance and may even impact patient safety

Would schools do these simulations anyway? Maybe, since there’s good evidence that they’re an effective teaching tool. On the other hand, they’re expensive, and med schools aren’t always the most profitable of endeavors. So from that perspective, maybe keeping CS around for a while isn’t such a bad idea.

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Rethinking med school from the ground up, part I

Most med schools in the US look basically the same. The first two years are mostly coursework, not too different from college. You sit in lecture and learn about how the body works, all the muscles and bones and blood and guts, and then you go to the anatomy lab and see it for yourself. You memorize biochemical pathways. You learn about the common diseases and some uncommon ones too, the latter mostly chosen because they illustrate a point about genetics or protein synthesis or whatever. And you have some exposure to the business of being a doctor, learning how to take a history and examine people.

Then, the last two years, you have a totally separate experience. You spend all your time in the hospital or in clinic, seeing patients along with residents and attending physicians. You rotate through many of the different parts of the hospital. You see babies born and sick kids and appendicitis and cancer. You decided what type of doctor you want to be, based on your personality and what you like to do and which specialty you got along with best, and you apply for residency.

There are variants, but this is how the majority of American medical students learn to be doctors. It’s been this way since 1910, when Abraham Flexner published his report on medical education. At that time, medical training wasn’t standardized, and many schools were turning out wildly substandard graduates. And without internship and residency being a requirement, med school was all you got – everything else you learned on the job, on real people, without oversight. Or didn’t, as the case may be. The Flexner report led to the standard 2+2 curriculum, and it worked pretty well – a couple years to learn the science of the body, and then a couple years of apprenticeship.

Except. Then it got codified and engraved in stone. And in the meantime, the world changed. Medical knowledge expanded by a gazillion-fold. We started doing internship and then residency and then fellowship and then post-fellowship fellowship (I’m looking at you, electrophysiology) to be able to master even one small niche. We got (or are finally straggling towards) EMR and UpToDate and internet streaming of lectures. We got a whole slew of education research on teaching and learning.

So why hasn’t medical education kept up? Blame the hierarchical, traditional mindset that comes with an apprenticeship model, where I do something this way because that’s how I was taught. The numbers of times I have heard that phrase over the past few years. It reminds me of the story about how when a woman got married, her husband asked her why she always cut the end off the roast. “Because that’s how my mother did it”, she says, so they ask her mom, who says that’s how HER mother did it, so they ask Grandma, who tells them it’s because her roast pan was too small. Individual idiosyncrasies get passed down from attendings to one generation of residents to the next. And when you reach attending status yourself you’re expected to pick through what you were taught, and know what to discard and what to keep.

Medical education is not broken, exactly. We still turn out pretty decent doctors every year. But there’s definitely room for improvement, not just around the margins, but in the fundamentals of the system. And it matters for all of us, because better doctors are better for patients.

That’s what this blog is about: changing the fundamentals of the system. Rethinking how we train physicians, how we interact with patients and with each other, how hospitals work and how they can work better with new technology–not just for better diagnostics and therapeutics, but to change the way medicine is practiced. Because we all know that the US healthcare system could do better. And that starts with us, in medicine. Better doctors are better for patients.

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