The Billy Rubin Blog went mobile this week, as I gave a talk at the Harvard Medical School Academy's annual Medical Education Day. The theme of the day was medical uncertainty, which given my work in Snowball seemed to the organizers to be a perfect fit. Hopefully it was enough of a match that I didn't embarrass myself completely.
The talk is here: https://soundcloud.com/user-713665386/hms-med-ed-day-oct-24-2017. The talk proper starts at 30 seconds. Apologies for the stops and starts; it felt much more fluid in the moment than the slightly herky-jerky quality the address has on playback.
One exchange at the end is worth meditating on--and I include it here as a meditation, a sidenote, for I don't mean for it to indicate that this was anything approaching the most important moment of the hour. But it does allow a second for a departure on the philosophy of medicine.
When I was taking questions at the end, at about the 51:30 mark, a senior clinician wondered about the process of advice from doctors. Here's the exchange (in raw transcript form--the dead-ends make a little more sense as you hear it in the moment):
MD: There's a very specific prime question that I think is legitimate for patients to ask: "Well, what you you do if you were in my shoes?" And this is a very different question from an erudite but simple discussion of a problem, and they are asking for a very specific answer. And I wondered if you give this, believe in it, and if you do, what do you tell your students about answering such questions?
Me: When they [patients] ask, "What would you do if you were me?"
MD: Yes.
Me: So, I know we have one of my former students here who's a psychiatry resident; I would bounce the question right back and say, "Well, I'm not you...so, um, I'm different. I come with certain, you know, fears, hopes...and then you open up a discussion about, really--because when they ask you that question, they're not asking you that question. They're trying to figure out how to prioritize things. That's my sense."
MD: I think they're asking, very specifically, that question. [Audience laughter.]
Me: I don't...I don't agree. I actually think that question is a good deal more complicated than it looks on the surface.
What's fascinating to me about this exchange, in a talk on uncertainty, was the unequivocal confidence this physician had that patients just want to know what their docs would do in the same situation, no further question asked.
My reply in the moment was not perhaps as quick-witted as I would have liked, but I'd add here that medical decisions aren't the same as car repair decisions. I trust what my mechanic tells me, because a car is an expensive but not priceless piece of machinery, important to my life, worth something but something finite. Thus, I can have a straightforward discussion about whether it makes sense to rebuild the engine for $3000 in a twelve-year old Toyota that has 180,000 miles on it and has a reasonable chance of breaking down in other ways, or just trade it in for a new model. Maybe it's more expensive in the short run to get another car, but that comes at the benefit of fewer headaches induced by repeated trips back to the garage.
A good mechanic can lay out the risks versus benefits in a clear way, and based on what they've seen over the years (the number of 12 year-old Toyotas that make it to 15 without constant servicing, for instance), they can say, "it's a good car, I'd hold on to it, but there's a risk," or alternately say, "I'd be rid of the headache." That kind of advice in that kind of situation is genuinely helpful, and more importantly, the terms being discussed are reasonably clear and equivalent to both parties.
But a doctor just casually dropping advice to a patient's family asking a similar question about a loved one struggling for life on the vent in the ICU, and whether the doctor would request to have all lifesaving measures stopped, presupposes any number of areas of understanding that may not be so. What value does the family place upon religion and ethical precepts about the value of life no matter the struggle? Have they had good or bad experiences with the medical system? Are there life events on the horizon that might make a patient or family try to subjugate themselves to the frequently tortuous procedures and treatments medicine can provide, in order to reach such moments? Does the patient or family have regrets about saying goodbye, of having fights years ago in which no reconciliation has ever been broached?
Don't these questions seem rather more important than, "Well, doctor, what would you do?" as if the subject could be so easily compressed to a singularity of physician wisdom?
And if those questions are explored between doctor and patient, or doctor and family, then what need of such an absurd and possibly dangerously oversimplified question?
--Billy
Showing posts with label medical education. Show all posts
Showing posts with label medical education. Show all posts
Saturday, October 28, 2017
Tuesday, February 5, 2013
Conflation Of "Education" With "Lecture" Is, At Best, Questionable Pedagogy
I do not often snoop about the blog pages of the Cato Institute owing to time constraints and a general sense that I won't find much enlightenment there. Hence, my acquaintance with Professor Alex Tabarrok's really interesting essay "Why Online Education Works"--which he wrote back in November 2012--came via a glance at Brad DeLong's blog today. But it's a provocative read, and at least in DeLong's blog, the commentary afterward was fascinating (and, I note with a certain delight, mostly free of the smack talk that so pervades online discussions that touch upon politics...mostly, anyway).
Tabarrok mainly argues that the reason why online education will largely displace university brick & mortar education as currently constituted is because it is wildly more efficient. In essence, he believes that one very, very, very large virtual lecture "taught" by one professor is a much less expensive model than lots and lots of smaller lectures taught by many professors. Since traditional universities, with their relatively-smaller-but-still-impersonal lecture-style format, are vastly more expensive than the online model, they will eventually be forced to adapt or face extinction since students will eventually realize that they don't have to bear the crushing debt associated with modern higher education. He uses his own TED talk as an example, as he writes, "the 15 minutes of teaching I did at TED dominates my entire teaching career: 700,000 views at 15 minutes each is equivalent to 175,000 student-hours of teaching, more than I have taught in my entire offline career."
What follows on DeLong's broadsheet is a discussion about how much Tabarrok's observations can be generalized--and thus how valid his basic point may be. For my part, I sit somewhere in the middle of the continuum: I think big universities had better listen up really quick or else find themselves losing students in the coming years to University of Phoenix in large numbers. Sooner or later there are going to be some enterprising "traditional" students who will decide to roll the dice at much cheaper online schools, and they will eventually find "traditional" employers in the workforce who are willing to roll the dice on students with online degrees. And if they discover that these students are just as prepared as ones from State U, the exodus from the traditional schools will accelerate.
That said, I also side with those in the discussion who point out that undergraduate education is much more commonly smaller classes with more individualized attention, and that Tabarrok is sounding the death-knell of a type of University that almost certainly doesn't exist at the smaller, lib-arts school. Moreover, he sidesteps the fact that the majority of an education of an intellectually curious undergraduate happens outside the classroom walls: a university's appeal--and value--lies in "the close, dense concentration of fellow students, and the close, dense concentration of adults interested in said students, and the dense array of programs tailored to students" in the words of one commenter.
Mostly, though, I viewed Tabarrok's points as well as the replies through the lens of my work at a medical school. I am, at present, basically a 60 percent doctor and 40 percent teacher. You can dress it up in fancy titles but I'm a teacher, no different than a senior grad student lecturing to Chem 101 freshmen. That is, with one critical difference: my students are apprentices. The lecture hall is an inpatient hospital room, or an outpatient exam room. There is simply no legitimate way, thus far, to train a physician by anything other than working with them in a nearly one-on-one manner, right in front of the patient (or away from the patient's eyes listening to presentations and discussing medicine). It is an education where doing and theorizing cannot be separated. You can't solely watch TED talks to become a physician. You must learn at the feet of a master (typically, several masters) to develop your craft.
Which is why one terse little quip from a gentleman named Colin, whose twitter handle is mcgilcoli, caught my eye, and serves as a nice title for this post: conflation of "education" with "lecture" is, at best, questionable pedagogy. Whether Tabarrok would agree with that sentiment or not I do not know. However, I am certain that it highlights what we do at a medical school with our 3rd year students all the way through our interns, residents, and fellows. Education is an intensely personal experience in medicine.
I hadn't understood that at all when I got into this business, and it is certainly one of the most rewarding aspects of my career at this point. I don't think they're going to find an online me anytime soon that can replace the flesh-and-bones me in the medical school. Whether they can find a different flesh-and-bones person to replace the flesh-and-bones me is a separate matter. We promise to provide updates on that front to our intrepid readers.
--Billy
Tabarrok mainly argues that the reason why online education will largely displace university brick & mortar education as currently constituted is because it is wildly more efficient. In essence, he believes that one very, very, very large virtual lecture "taught" by one professor is a much less expensive model than lots and lots of smaller lectures taught by many professors. Since traditional universities, with their relatively-smaller-but-still-impersonal lecture-style format, are vastly more expensive than the online model, they will eventually be forced to adapt or face extinction since students will eventually realize that they don't have to bear the crushing debt associated with modern higher education. He uses his own TED talk as an example, as he writes, "the 15 minutes of teaching I did at TED dominates my entire teaching career: 700,000 views at 15 minutes each is equivalent to 175,000 student-hours of teaching, more than I have taught in my entire offline career."
What follows on DeLong's broadsheet is a discussion about how much Tabarrok's observations can be generalized--and thus how valid his basic point may be. For my part, I sit somewhere in the middle of the continuum: I think big universities had better listen up really quick or else find themselves losing students in the coming years to University of Phoenix in large numbers. Sooner or later there are going to be some enterprising "traditional" students who will decide to roll the dice at much cheaper online schools, and they will eventually find "traditional" employers in the workforce who are willing to roll the dice on students with online degrees. And if they discover that these students are just as prepared as ones from State U, the exodus from the traditional schools will accelerate.
That said, I also side with those in the discussion who point out that undergraduate education is much more commonly smaller classes with more individualized attention, and that Tabarrok is sounding the death-knell of a type of University that almost certainly doesn't exist at the smaller, lib-arts school. Moreover, he sidesteps the fact that the majority of an education of an intellectually curious undergraduate happens outside the classroom walls: a university's appeal--and value--lies in "the close, dense concentration of fellow students, and the close, dense concentration of adults interested in said students, and the dense array of programs tailored to students" in the words of one commenter.
Mostly, though, I viewed Tabarrok's points as well as the replies through the lens of my work at a medical school. I am, at present, basically a 60 percent doctor and 40 percent teacher. You can dress it up in fancy titles but I'm a teacher, no different than a senior grad student lecturing to Chem 101 freshmen. That is, with one critical difference: my students are apprentices. The lecture hall is an inpatient hospital room, or an outpatient exam room. There is simply no legitimate way, thus far, to train a physician by anything other than working with them in a nearly one-on-one manner, right in front of the patient (or away from the patient's eyes listening to presentations and discussing medicine). It is an education where doing and theorizing cannot be separated. You can't solely watch TED talks to become a physician. You must learn at the feet of a master (typically, several masters) to develop your craft.
Which is why one terse little quip from a gentleman named Colin, whose twitter handle is mcgilcoli, caught my eye, and serves as a nice title for this post: conflation of "education" with "lecture" is, at best, questionable pedagogy. Whether Tabarrok would agree with that sentiment or not I do not know. However, I am certain that it highlights what we do at a medical school with our 3rd year students all the way through our interns, residents, and fellows. Education is an intensely personal experience in medicine.
I hadn't understood that at all when I got into this business, and it is certainly one of the most rewarding aspects of my career at this point. I don't think they're going to find an online me anytime soon that can replace the flesh-and-bones me in the medical school. Whether they can find a different flesh-and-bones person to replace the flesh-and-bones me is a separate matter. We promise to provide updates on that front to our intrepid readers.
--Billy
Thursday, March 10, 2011
Profile in Courage, Writ Small, But Still
Today was Grand Rounds at my academic medical center. The subject was diabetes and how we--"we" being the medical system as opposed to "we" the individual doctors--can improve outcomes in this disease, which is a killer, and which we (pick whichever "we" you like) stink at treating successfully. The view of the speakers, with which I'm sympathetic, is that we require less gee-whiz bioscience breakthroughs than we do a comprehensive, systematic plan for identifying, following, and ensuring affected patients stay on their meds. None of their suggestions were particularly sexy and didn't involve lots of fancy technology except for using a personal computer. I was persuaded by their assertion that sometimes it's simple but labor-intensive solutions in medicine that are the ones with the best chance of success.
Grand Rounds at my hospital always begins with a physician "presenting a case." Typically this involves a resident summarizing a bare-bones medical history of some patient who has some affliction related to the topic being discussed: gout, Wegener's granulomatosis, multiple myeloma, sepsis, a heart attack, you name it. Often the speaker will make some remark about the case in relation to his or her talk, and then it's on with the show. This kind of case presentation is de rigueur among physicians, and after one has lived & breathed medicine for long enough (i.e. survived the third year of medical school), one becomes so acclimated to the rhetorical form that one can get fairly desensitized to the reality that it's actual human beings that are being spoken of.
I don't mean to imply that physicians speak about patients in a de-humanizing way when a case is presented--that's never acceptable--only that the process of summary and discussion of history, physical exam, and laboratory findings in the dry, sterile, & detached form of the "case presentation" is second-nature to physicians, and must be creepy as hell to patients if they had to listen to themselves being discussed. Sometimes I try to teach residents and students at the bedside in the old-fashioned manner, but I always make sure to alert patients that such feelings might overtake them as I "do some doctor-talk with my colleagues." I do everything I can think of to make that moment as comfortable as possible for patients, but ultimately my suspicion is that all my efforts, at best, help blunt the sense of creepiness rather than remove it altogether.
So you can imagine what it must have felt like for the gal today to have her case of diabetes discussed in the amphitheater filled with well over 100 physicians in attendance, watching the medical facts of her life, neatly summarized into three Power Point slides, as she sat in the fifth row. I've been part of this community for more than ten years now and I still get nervous when facing the White Coat Army en banc; I can only imagine how intimidating that must have felt for her. Then, at the end of the presentation, the presenter noted to the crowd that the patient was in attendance, and asked her if she had any thoughts to add. Again, with what I would describe as remarkable poise, she eloquently explained some of the life circumstances that made her choose treatment options that, without that critical context, would puzzle and frustrate physicians.
She not only did this, but managed to deliver an observation with a small barb attached to the end of it: "I see that many of you here are eating really nice lunches here today, really healthy food. Well, my family has to live month-to-month because of our income, and I can tell you that a pound of pasta and some tomato sauce goes a lot further than some other food." It was a complex observation, but the sheer nerve & determination it took to march into what could very well have felt like a Lion's Den, and deliver that speech with such clarity, was quite a thing to watch. (Disclosure: lunches are not sponsored by anyone at our medical center. Mostly this woman was referring to tasty-but-modestly-sized deli sandwiches using fresh ingredients and a fruit salad.)
It's very unusual to invite patients to hear their own cases discussed in this kind of format, weirder still to give them a platform for a few minutes to speak about their challenges. Certainly in this setting it was a brilliant idea to include such a patient in the dialogue: my school gets an "A" not merely for effort but execution as well! Though at the end of the day, when the speaker concluded the lecture and the audience gave its polite applause per the cultural conventions of Grand Rounds, no one thought to give a special thanks for this woman. On that count, I think the organizers earned a D-minus.
Grand Rounds at my hospital always begins with a physician "presenting a case." Typically this involves a resident summarizing a bare-bones medical history of some patient who has some affliction related to the topic being discussed: gout, Wegener's granulomatosis, multiple myeloma, sepsis, a heart attack, you name it. Often the speaker will make some remark about the case in relation to his or her talk, and then it's on with the show. This kind of case presentation is de rigueur among physicians, and after one has lived & breathed medicine for long enough (i.e. survived the third year of medical school), one becomes so acclimated to the rhetorical form that one can get fairly desensitized to the reality that it's actual human beings that are being spoken of.
I don't mean to imply that physicians speak about patients in a de-humanizing way when a case is presented--that's never acceptable--only that the process of summary and discussion of history, physical exam, and laboratory findings in the dry, sterile, & detached form of the "case presentation" is second-nature to physicians, and must be creepy as hell to patients if they had to listen to themselves being discussed. Sometimes I try to teach residents and students at the bedside in the old-fashioned manner, but I always make sure to alert patients that such feelings might overtake them as I "do some doctor-talk with my colleagues." I do everything I can think of to make that moment as comfortable as possible for patients, but ultimately my suspicion is that all my efforts, at best, help blunt the sense of creepiness rather than remove it altogether.
So you can imagine what it must have felt like for the gal today to have her case of diabetes discussed in the amphitheater filled with well over 100 physicians in attendance, watching the medical facts of her life, neatly summarized into three Power Point slides, as she sat in the fifth row. I've been part of this community for more than ten years now and I still get nervous when facing the White Coat Army en banc; I can only imagine how intimidating that must have felt for her. Then, at the end of the presentation, the presenter noted to the crowd that the patient was in attendance, and asked her if she had any thoughts to add. Again, with what I would describe as remarkable poise, she eloquently explained some of the life circumstances that made her choose treatment options that, without that critical context, would puzzle and frustrate physicians.
She not only did this, but managed to deliver an observation with a small barb attached to the end of it: "I see that many of you here are eating really nice lunches here today, really healthy food. Well, my family has to live month-to-month because of our income, and I can tell you that a pound of pasta and some tomato sauce goes a lot further than some other food." It was a complex observation, but the sheer nerve & determination it took to march into what could very well have felt like a Lion's Den, and deliver that speech with such clarity, was quite a thing to watch. (Disclosure: lunches are not sponsored by anyone at our medical center. Mostly this woman was referring to tasty-but-modestly-sized deli sandwiches using fresh ingredients and a fruit salad.)
It's very unusual to invite patients to hear their own cases discussed in this kind of format, weirder still to give them a platform for a few minutes to speak about their challenges. Certainly in this setting it was a brilliant idea to include such a patient in the dialogue: my school gets an "A" not merely for effort but execution as well! Though at the end of the day, when the speaker concluded the lecture and the audience gave its polite applause per the cultural conventions of Grand Rounds, no one thought to give a special thanks for this woman. On that count, I think the organizers earned a D-minus.
Tuesday, March 3, 2009
Is Pharmacology at Harvard Medical School Being Taught By Drug Companies, or Professors?
The good name of Harvard Medical School has been a bit sullied these days. The NY Times details the general ickitude in an article about a couple of bold medical students who came forward with the idea that perhaps it was not right to learn about drugs from people who made money--and one can only assume lots of it--moonlighting as speakers touting the wonders of the very drugs about which they were supposed to teach with disinterest. One choice tidbit: one of the students meekly asked a pharm professor about the side effects of cholesterol drugs, and apparently got "belittled" in reply. A fellow med student named Matt Zerden did some online checking afterward and discovered that said professor was a paid consultant to 10 drug companies, including five makers of cholesterol treatments. Bravo, future Doc Zerden and your fellow activists! The article notes that the American Medical Student Association has given Harvard an "F" for how poorly it monitors and controls the relationship between its faculty and big pharma, though its Ivy-league cousin the University of Pennsylvania got an "A." The silver lining may be that the new dean, Dr. Jeffrey S. Flier, wants to make some changes and has convened a committee to re-examine Harvard's policies. Billy's Blog promises to hope for the best and report on any changes should they become known to him.
Better still is that the Harvard student activists, while holding a demonstration to call attention to the problems inherent in such laissez-faire policies, were photographed by an employee of Pfizer in what appears to be a creepy kind of surveillance project. Senator Charles Grassley (R-Iowa), who is investigating the relationships between the pharmaceutical industry and physicians, is looking into the shenanigans. Go Chuck! (I have delivered my one endorsement for a Republican in the year 2009.)
One last recommendation for the truly interested is to check out the comments section to the main article (on Harvard's ethics issues, the first link above). The "Editor's Selections" include at least two hum-dingers, with a reasoning process that would bring a smile to Rush Limbaugh's face (see comment #11 from RichardN, Idaho, and #16 from Dr. O, Michigan). Apparently the Editors feel a need to represent letters both pro and con, regardless of how well the comments are written. The "Readers Recommendations" I find to be more telling of what a highly literate, sophisticated group like NYT readers think of the comments, and--no surprise, this--the above comments don't arouse much sympathy.
--br
Better still is that the Harvard student activists, while holding a demonstration to call attention to the problems inherent in such laissez-faire policies, were photographed by an employee of Pfizer in what appears to be a creepy kind of surveillance project. Senator Charles Grassley (R-Iowa), who is investigating the relationships between the pharmaceutical industry and physicians, is looking into the shenanigans. Go Chuck! (I have delivered my one endorsement for a Republican in the year 2009.)
One last recommendation for the truly interested is to check out the comments section to the main article (on Harvard's ethics issues, the first link above). The "Editor's Selections" include at least two hum-dingers, with a reasoning process that would bring a smile to Rush Limbaugh's face (see comment #11 from RichardN, Idaho, and #16 from Dr. O, Michigan). Apparently the Editors feel a need to represent letters both pro and con, regardless of how well the comments are written. The "Readers Recommendations" I find to be more telling of what a highly literate, sophisticated group like NYT readers think of the comments, and--no surprise, this--the above comments don't arouse much sympathy.
--br
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