Saturday, June 30, 2007

Teaching medicine to residents and students

After truly enjoying teaching students, nurses and now residents as long as I have been training and practicing medicine I found that a few thoughts, preferences and priorities seem to be important to me and do not seem to change.

Physicians, and family physicians in particular, have to be competent in a large number of areas and therefore it is vital that the information presented is simple, easy to understand, and memorable. Out of a 40 minute lecture, residents, like everybody else, will likely remember only 2 or 3 facts or sentences. It is necessary that those 3 sentences are the right sentences and the most relevant and most important ones and that they are those that I really want to communicate. These 3 sentences have to be the skeleton or the outline of the topic and should be practical, usable knowledge. Lectures are meant to stimulate, to open the mind for a topic, to make students receptive for a topic, to give students a basic structure, a basic skeleton of a topic. later on they can put the flesh on the skeleton and the guts and the skin. The first thing has to be a clear overview that makes the big idea immediately understandable. A lecture or power point is not meant to provide exhaustive information!

I often start a lecture with “and here is the summary for the post-call-resident” and then say for example: "Dysfunctional uterine bleeding is treated with OCPs. And if the patient is over 35, you also give them OCPs, but you do an EMB first and ask if they smoke”. I summarize the basic message in one sentence, so that everybody remembers this single sentence message.

Or: “birth control pills are all the same. The only difference is that individual patients will react differently. Therefore you should know 3 or 4 basic, generic OCPs and prescribe them. Discourage brand names. Should the patient not tolerate the first OCP, switch to any other generic with a different estrogen dose or with a progestin from a different group – no secret algorithm to it.”

Or “for induction of labor you give 25 mcg of misoprostol until you can fit a finger into a soft cervix, then you switch to pitocin”

Or for introduction of fetal heart rate tracings: “The baseline should be 120-160 or exactly double the adult rate, the jitteriness of the baseline should be 5-25 and corresponds to the blood supply to the fetal brain, accelerations are good (and I give a thumb up) and decelerations are bad (thumb down sign)” And then I go into the details.

I try to teach MTV style meaning a bang or splash here and there is good – and I try to place the bang exactly at one of the three points that I hope they remember forever. I try to make the 3 points memorable with…

a. a joke,

b. an act ….I once had an imaginary interview with Chlamydia, who had a mean voice, was swearing frequently – which I replaced with beeeps. Chlamydia complained about his buddy gonorrhea who causes so many symptoms (fever, pus, pain), and who would get all the good Chlamydia killed because of drawing attention to the infection. Chlamydia called gonorrhea an old fashioned brute and cowboy, who is on his way out and proudly talked about receiving the award for “No 1 Cause of infertility”, then went on to say “it’s because I have stealth” – at this point I suddenly dropped under the table, so that I became invisible, and continued talking….Chlamydia also complained bitterly about the doctor’s who test and treat on suspicion, but was very appreciative of those docs that swabbed the vagina and not the cervical canal! And so on…it was big success….and a lot of fun

c. a video, such as the “dancing baby”

d. a song – if it is bad, it is even more memorable

e. sometimes I try short stories during slide shows, such as the introduction of PCOS as "a special gift from God to family practice", because it is important to recognize the condition early to prevent formation of too much terminal hair, to prevent obesity early oon instead of treating it later, and to be prepared for the treatment of infertility, for the prevention of diabetes, early recognition of HTN and so on. PCOS won’t kill you, but you need long term observation and help, " a gift to family practice". And I mentioned that God was sitting at the laptop running the creation software and creating this as a special goodie for FPs, and when he was done he went to South Beach for a few mojitos…and I had the photo of Ocean drive with the arrow pointing to a dark area "God is there!" and adding that “God is notoriously difficult to catch on camera”. That was the intro for the PCOS talk

I refuse to introduce topics with “this disease is veeery important because it is veeery expensive and xxx billions are spent annually on blablabla….” This is such a horrible introduction. Boring. Xxx billions means nothing to me, absolutely nothing. I can't even imagine a billion dollars, I stop thinking after 20 million, since I would retire and sail around the Caribbean if I had them. And what do the billions matter to your practice? Nothing, nada, zilch, zero. It might matter to federal policy makers. Are those people seeing your power points?

What matters to me is “what percentage of patients that walk through my office door have this” because that determines if I am going to do something about it, how seriously I am going to take it and what I am going to do…

And finally, topics should be taught in a clinically relevant way and not in a pathologically / systematic way. It is depressing when students or residents are shown long lists of differential diagnoses with weighing them according to clinical importance. It is absolutely impossible to remember the 22 causes of amenorrhea when they are presented as a long systematic list. It is an insult to the learner! Presenting a list without weighing the differential diagnoses by frequency of occurrence means that the teacher really does not care about the student and just slaps something on the slide in who-cares-what-you-can-learn-from-it style. Next time you as the student get presented such a list, either booo or make a frown and walk out.

The differential diagnosis of amenorrhea for example should be presented like this (taken from Kistner, Gynecology):


Option 1 – the right way

start quote

Pregnancy, and otherwise:

Hypothalamus / pituitary /stress 50-55%

PCOS 10-15%

Prolactinoma 7-10%

Asherman’s 5-6%

Hypothyroidism 1%

Ovarian failure 1%

end quote

You know immediately what is common and what is rare, you know immediately what to ask for in your history and what to look for in the physical exam.



Option 2 - the wrong way, too much to remember. All that remains after reading that is the impression that the topic is complicated and that you may have to consult a textbook or a specialist whenever a patient presents with that symptom.

It presents far too much information in a very badly structured fashion and confuses much more than it educates. Especially the long version at the bottom is a prime example of not well thought out presentation. Students and residents, do not put up with this kind of thoughtless teaching!

start quote

Causes of amenorrhea

  • Generalized pubertal delay

    • Constitutional delay

    • Hypergonadotropic hypogonadism

      • Turner syndrome

      • Gonadal dysgenesis with mosaic karyotype

      • Pure gonadal dysgenesis (Perrault syndrome, Swyer syndrome)

      • Gonadotropin-resistant ovary syndrome

      • Acquired causes (eg, high-dose alkylating chemotherapy, pelvic radiation, autoimmune oophoritis)

    • Hypogonadotropic hypogonadism

      • Chronic conditions (eg, starvation, excessive exercise, depression, psychological stress, marijuana use, Crohn disease, cystic fibrosis, sickle cell disease, thalassemia major, HIV infection, renal disease, thyroid disease, diabetes mellitus, anorexia nervosa)

      • Slow-growing CNS tumors (eg, adenomas, craniopharyngiomas, meningiomas, pituitary microadenomas)

      • Abnormal hypothalamic development (eg, Kallmann syndrome, Prader-Willi syndrome, and Laurence-Moon-Biedl syndrome)

      • Acquired miscellaneous disorders (eg, infiltration disorders [sarcoidosis, Langerhans cell histiocytosis, syphilis, tuberculomas], ischemia disorders [caused by trauma, aneurysm, obstruction of the aqueduct of Sylvius] and destruction [concentrated, high-dose exposure to radiation])

  • Normal puberty

    • Associated with hyperandrogenicity (eg, PCO syndrome, late-onset 21-hydroxylase deficiency [nonclassic congenital adrenal hyperplasia], immaturity of the hypothalamic-pituitary-ovarian axis, Cushing disease, androgen-producing ovarian or adrenal tumors, ovarian stromal hypertrophy)

    • Associated with absence of hirsutism or virilization (eg, immaturity of the hypothalamic-pituitary-ovarian axis, pregnancy)

    • Hypergonadotropic hypogonadism (eg, ovarian failure, high-dose alkylating chemotherapy, pelvic radiation, autoimmune oophoritis)

  • Anomalies of the genital tract

    • Müllerian agenesis (eg, Mayer-Rokitansky-Kuster-Hauser syndrome) breast present

    • Congenital or acquired anatomic obstruction (eg, imperforate hymen, transverse vaginal septum, Asherman syndrome, endometrial destruction due to severe infection or surgery)

    • Androgen insensitive syndrome-absent uterus with normal breast development

end quote


Now you know, now you have a good overview of the issue, now it is all clear, this is what you are going to remember, right? Although this is pretty good if you know about the topic already and it is a very good summary. but not appropriate for a power point lecture.


Option 3 - better, but not good yet. The following list is shorter and a little better, but there still is no order and no frequency of occurrence etc.



start quote

Differential Diagnoses:

Pregnancy
Breastfeeding related
Menopause
Norplant related.
Hypothalamic.Suppression of the hypothalamic-pituitary-ovarian axis.

Exercise induced.
Eating disorder such as anorexia nervosa

Endocrine such as hypothyroidism.
Polycystic ovarian disease
Pituitary or ovarian tumor.
Rarely, Mullerian duct agenesis or other chromosomal or developmental defect.

A young woman who has is Tanners Stage 1 at age 14 or who has had no period by age 16 needs to be referred to an OB-GYN for work up.

end quote

Comment: Mentioning Breastfeeding and Norplant is probably useless, since they areboth pretty obvious to the patient. Why put it in the list? A list is supposed to guide me in a situation where I do not know right away what is going on and where I am trying to find a solution, solve a problem. I know if a patient is breastfeeding or has a Norplant (or nowadays a Mirena), or I find out at the time of the physical exam.



Option 4 - the disaster: Systematic, in a pathophysiological / pathological order that is nice for pre-med, when you think and consider and ruminate about the basic mechanisms of disease, but which is a plain disaster in clinical teaching. If someone shows a slide of such a list, you should walk out of the room. it is a waste of time to show such things and it is an embarrassment for a teacher to be caught overloading students with things they will never be able to remember! The idea of a lecture is to provide a useful take home message. The take home message of slides like this is "Wow, this is so complicated, I will never be able to learn it".

I am muddling the point a bit by comparing the first list, which does not contain the DD of primary amenorrhea with the other ones that contain primary and secondary amenorrhea, but I hope to make a point. You need to show the relevant ones first, and place the DDs in order or frequency, in order of clinical importance. You cannot get lost with chasing the rare and improbable, you need to know the two, three or four most probable causes, and you need to know them by heart.


Start quote and feel free to very quickly scroll down once you get the idea

CAUSES OF AMENORRHEA

Primary amenorrhea:

(1) No period by age 14 in the absence of growth or development of

secondary sexual characteristics.

(2) No period by age 16 regardless of the presence of normal growth

And development with the appearance of secondary sexual characteristics.

Secondary amenorrhea

Can be a transient, intermittent or a permanent condition.

The result of dysfunction of the hypothalamus, pituitary, ovaries, uterus, or

vagina.

GESTATIONAL CAUSES

Pregnancy

ANATOMIC CAUSES

CONGENITAL ABNORMALITIES –

Imperforate hymen

Abnormal Mullerian development – Rokitansky-Kuster-Hauser syndrome

Testicular feminization syndrome

5-alpha-reductase deficiency

Early failure prior to testicular development

Late failure

vanishing testes syndrome

Testis Determine Factor Gene deletion.

ACQUIRED ANATOMIC LESIONS

Asherman's syndrome:

ENDOCRINE

OVARIAN DISORDERS – The major ovarian causes of amenorrhea are

hyperandrogenism, from internal or external sources, and ovarian failure due to

normal or early menopause.

Hyperandrogenism

PCOS

Premature Ovarian Failure

Idiopathic

autoimmune

poly-glandular autoimmune syndrome (type 1 and 2)

anti-thyroid antibodies

anti-adrenal antibodies

karyotypic abnormalities

radiation or chemotherapy

Turner's syndrome – 45X,O karyotype

HYPOTHALAMIC AND PITUITARY DISEASE

Functional hypothalamic amenorrhea due to Exercise, Nonspecific stresses (emotional, illness)

GnRH deficiency - idiopathic hypogonadotropic hypogonadism -

Other hypothalamic and pituitary lesions

Infiltrative diseases: result in diminished GnRH release, low or

normal serum gonadotropin levels

i. Histiocytosis X

ii. Gumma

b. Hemochromatosis: hemosiderin toxicity for the gonadotrope

c. Tumors:

i. Craniopharyngioma

ii. Meningiomas

iii. Gliomas

iv. Metastatic tumors

v. Chordomas

d. Sheehan's Syndrome

end of looong quote

Please note: this is actually a good and appropriate textbook section, but unfortunately I see these things in lectures! This is not meant as any kind of criticism towards the author, this is only meant as an illustration of how not to teach! Back to imagining that this was a lecture....

Wow, I am so impressed by this presentation! The author must be a genius! I bow in reverence! What a great teacher!

You know what? I regularly either fell asleep during these lectures or wrote down a lot of things that I never look at later or I picked up one or two tidbits that I could never use later on because they were out of context.

If you really succeed in memorizing the last list, then what are you going to do? Are you going to test for histiocytosis X each time a patient presents with amenorrhea? How many Histiocytosis patients have you seen in your life? And you test for Hemochromatosis? And for Chordomas – wait, I have to look up to remember what that even is….

Lectures are not supposed to exhaust or to overload your listeners and YOU are not supposed to show off pretending that you are a genius and know infinitely much more than your audience. Be down to earth, be normal, be a friend, lecture like you would teach a good friend!


Here is a book that might be worth reading:

"Made to Stick": Why Some Ideas Survive and Others Die, By Chip Heath and Dan Heath, Random House, 289 pp., $29.95.

Coauthors (and brothers) Chip and Dan Heath – a Stanford Business School professor and an education entrepreneur respectively – spent a decade disassembling and trying to understand the inner workings of memorable, persuasive ideas, no matter what kind of packages they came in. They studied political speeches, urban legends, news reports, management directives, and marketing messages like Subway's – not to mention culture-crossing proverbs, the various fables of Aesop, and the many soups of chicken (for the soul). It didn't matter whether the ideas themselves were good or bad, just that they'd "stuck." Each of these ideas could be described using one or more of just these six attributes: simple, unexpected, concrete, credible, emotional, and story-containing. We can't always pack all that into a lecture, but some or most of it.

Keeping this is mind it will go a long way to being a great and successful teacher.

2 comments:

mabrahamsmd said...

As a frequent "favorite" presentor to medical students, I applaud your comments, since I too have discovered the magic of presenting facts in unexpected, friendly, pallitable tidbits. Unfortunately, this was the exception throughout my own training, and I still regularly walk out on lectures by "big" names that are amaziningly unattenable. Unfortunately again, those lecturers have no idea what you are talking about. The funniest thing is when they say "For the sake of the medical students..." I will go review something basic, when it is in fact the residents and attendings who also need the review. A good lecture appeals to and entertains the entire audience.

ObGynThoughts said...

Dear Dr. Abrahams:
thank you so much for your encouraging comments! I am very glad that you agree with me.
I think it would be an advantage for everybody to have dedicated pure teachers, colleagues that really know how to capture an audience, how to get a point across, how to make things memorable. Teaching is often the undesirable stepchild in University, done on the side, as a not so loved additional burden for those whose days are filled with clinical practice and research.
I favor dedicated teachers and I would love a kind of YouTube project that brings together videos of the very best teachers nationwide into one "best university".
Your Matthias Muenzer, MD